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Yourman L, Pollner A, Khatibi J, Ramos V, Melkote V, O'Gorman A, Begler E, Lum HD. Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic. Am J Hosp Palliat Care 2024:10499091241233687. [PMID: 38896819 DOI: 10.1177/10499091241233687] [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: 06/21/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic necessitated the transition from in person to virtual advance care planning (ACP) engagement efforts. This pilot initiative evaluated virtual group visits (GVs) and in-person GVs for ACP to determine their feasibility and effectiveness. METHODS Participants included patients in a Geriatric Medicine clinic who were referred by their primary care physician to an ACP GVs intervention. The ACP GVs had 2 sessions, led by clinicians with ACP expertise who facilitated a discussion on patients' values, goals, and preferences. Participants were provided with technical assistance to support use of the virtual platform. Evaluation included an ACP readiness survey, post-session feedback, GV observations, and electronic health record review at baseline and a 6 month follow-up for goals of care documentation and advance directives. RESULTS Seventy patients attended 46 ACP GVs from August 2019 to February 2022, including 16 in-person GVs and 54 virtual GVs. At a 6 month follow-up, for virtual GVs participants (n = 54), goals of care documentation increased from 31% to 93%, and advance directives increased from 22% to 30%. For in-person GVs participants (n = 16), goals of care documentation increased from 25% to 100%, and advance directives increased from 69% to 75%. All surveyed patients in both formats would recommend ACP GVs. CONCLUSION ACP GVs are feasible and effective for supporting ACP, demonstrating an increase in both goals of care conversations and advance directives completion.
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Affiliation(s)
- Lindsey Yourman
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Internal Medicine, University of California at San Diego School of Medicine, La Jolla, San Diego, CA, USA
| | | | | | - Vanessa Ramos
- Health Sciences, University of California, San Diego, San Diego, CA, USA
| | | | | | - Erika Begler
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Roberts RL, Cherry KD, Mohan DP, Statler T, Kirkendall E, Moses A, McCraw J, Brown III AE, Fofanova TY, Gabbard J. A Personalized and Interactive Web-Based Advance Care Planning Intervention for Older Adults (Koda Health): Pilot Feasibility Study. JMIR Aging 2024; 7:e54128. [PMID: 38845403 PMCID: PMC11089888 DOI: 10.2196/54128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/28/2024] [Accepted: 03/14/2024] [Indexed: 06/10/2024] Open
Abstract
Background Advance care planning (ACP) is a process that involves patients expressing their personal goals, values, and future medical care preferences. Digital applications may help facilitate this process, though their use in older adults has not been adequately studied. Objective This pilot study aimed to evaluate the reach, adoption, and usability of Koda Health, a web-based patient-facing ACP platform, among older adults. Methods Older adults (aged 50 years and older) who had an active Epic MyChart account at an academic health care system in North Carolina were recruited to participate. A total of 2850 electronic invitations were sent through MyChart accounts with an embedded hyperlink to the Koda platform. Participants who agreed to participate were asked to complete pre- and posttest surveys before and after navigating through the Koda Health platform. Primary outcomes were reach, adoption, and System Usability Scale (SUS) scores. Exploratory outcomes included ACP knowledge and readiness. Results A total of 161 participants enrolled in the study and created an account on the platform (age: mean 63, SD 9.3 years), with 80% (129/161) of these participants going on to complete all steps of the intervention, thereby generating an advance directive. Participants reported minimal difficulty in using the Koda platform, with an overall SUS score of 76.2. Additionally, knowledge of ACP (eg, mean increase from 3.2 to 4.2 on 5-point scale; P<.001) and readiness (eg, mean increase from 2.6 to 3.2 on readiness to discuss ACP with health care provider; P<.001) significantly increased from before to after the intervention. Conclusions This study demonstrated that the Koda Health platform is feasible, had above-average usability, and improved ACP documentation of preferences in older adults. Our findings indicate that web-based health tools like Koda may help older individuals learn about and feel more comfortable with ACP while potentially facilitating greater engagement in care planning.
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Affiliation(s)
| | | | | | - Tiffany Statler
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Eric Kirkendall
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Adam Moses
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Jennifer McCraw
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | - Andrew E Brown III
- Wake Forest Center for Healthcare Innovation, Winston-Salem, NC, United States
| | | | - Jennifer Gabbard
- Section of Gerontology and Geriatric Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, United States
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Singh S, Jones L, Grant M, Freeland D. Federal Advance Care Planning Policy Primer - Key Aspects, Barriers, and Opportunities. Am J Hosp Palliat Care 2024; 41:348-354. [PMID: 37207663 DOI: 10.1177/10499091231175641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
Advance care planning (ACP) is a nuanced process where patients identify their goals and consider their preferences for medical care over time. Recent systematic reviews have shown mixed findings about the association of ACP with the provision of goal-concordant care, completion of advance directives, and health care utilization. Despite a lack of consistent benefit, patients and clinicians value ACP and policy makers at the state and federal level have been moving ACP policies forward. All fifty states have policies regarding advance directives, and federal policy has had important implications on promoting awareness of ACP and its corresponding legal documents such as advance directives. However, challenges to effectively incentivize and facilitate the delivery of high-quality ACP exist. This paper provides an overview of key federal policy aspects and barriers that affect ACP use including: limitations of Medicare ACP billing codes, disparities in telemedicine access, difficulties with interoperability of advance directives, and underutilization of ACP as a mandatory measure in federal programs. This paper highlights key opportunities to improve federal ACP policy. Because ACP is an essential part of high-quality care and is deeply embedded in state and federal policies, it is imperative that clinicians are knowledgeable about these issues so they may more effectively engage in ACP policy.
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Affiliation(s)
- Sarguni Singh
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - LaCinda Jones
- Senior Social Worker, Department of Veterans Affairs, Seattle, WA, USA
| | - Marian Grant
- Senior Regulatory Advisor, Coalition to Transform Advanced Care, Washington, DC, USA
| | - Deborah Freeland
- Division of Geriatric Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA
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Matthieu MM, Taylor LD, Adkins DA, Williams JS, Hu B, Oliver CM, McCullough JA, Mallory MJ, Smith ID, Painter JT, Ounpraseuth ST, Garner KK. Adopting the RE-AIM analytic framework for rural program evaluation: experiences from the Advance Care Planning via Group Visits (ACP-GV) national evaluation. FRONTIERS IN HEALTH SERVICES 2024; 4:1210166. [PMID: 38590731 PMCID: PMC10999534 DOI: 10.3389/frhs.2024.1210166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 02/27/2024] [Indexed: 04/10/2024]
Abstract
Introduction To support rigorous evaluation across a national portfolio of grants, the United States Department of Veterans Affairs (VA) Office of Rural Health (ORH) adopted an analytic framework to guide their grantees' evaluation of initiatives that reach rural veterans and to standardize the reporting of outcomes and impacts. Advance Care Planning via Group Visits (ACP-GV), one of ORH's Enterprise-Wide Initiatives, also followed the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. ACP-GV is a national patient-centered intervention delivered in a large, veterans integrated healthcare system. This manuscript describes how RE-AIM was used to evaluate this national program and lessons learned from ORH's annual reporting feedback to ACP-GV on their use of the framework to describe evaluation impacts. Methods We used patient, provider, and site-level administrative health care data from the VA Corporate Data Warehouse and national program management databases for federal fiscal years (FY) spanning October 1, 2018-September 30, 2023. Measures included cumulative and past FY metrics developed to assess program impacts. Results RE-AIM constructs included the following cumulative and annual program evaluation results. ACP-GV reached 54,167 unique veterans, including 19,032 unique rural veterans between FY 2018 to FY 2023. During FY 2023, implementation adherence to the ACP-GV model was noted in 91.7% of program completers, with 55% of these completers reporting a knowledge increase and 14% reporting a substantial knowledge increase (effectiveness). As of FY 2023, 66 ACP-GV sites were active, and 1,556 VA staff were trained in the intervention (adoption). Of the 66 active sites in FY 2023, 27 were sites previously funded by ORH and continued to offer ACP-GV after the conclusion of three years of seed funding (maintenance). Discussion Lessons learned developing RE-AIM metrics collaboratively with program developers, implementers, and evaluators allowed for a balance of clinical and scientific input in decision-making, while the ORH annual reporting feedback provided specificity and emphasis for including both cumulative, annual, and rural specific metrics. ACP-GV's use of RE-AIM metrics is a key step towards improving rural veteran health outcomes and describing real world program impacts.
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Affiliation(s)
- Monica M. Matthieu
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
- School of Social Work, Saint Louis University, Saint Louis, MO, United States
| | - Laura D. Taylor
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, United States
| | - David A. Adkins
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - J. Silas Williams
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - Bo Hu
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - Ciara M. Oliver
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - Jane Ann McCullough
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, United States
| | - Mary J. Mallory
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, United States
| | - Ian D. Smith
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
| | - Jacob T. Painter
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, United States
- Division of Pharmaceutical Evaluation & Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Songthip T. Ounpraseuth
- Department of Biostatistics, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Kimberly K. Garner
- U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, United States
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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Parajuli J, Larson KL. Changing Life Plans: When to Engage Caregivers of Older Adults With Cancer in Advance Care Planning. J Hosp Palliat Nurs 2024; 26:29-35. [PMID: 37697472 DOI: 10.1097/njh.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
Advance care planning (ACP) is a continuous process where individuals discuss and document their end-of-life preferences with trusted caregivers and health care providers. Caregivers are pivotal to include in ACP discussions because they assist loved ones to navigate serious medical illness. The purpose of this study was to examine caregivers' engagement in ACP decision making with their loved ones with cancer. A qualitative descriptive design was used, informed by Engel's biopsychosocial model, with a convenience sample of 14 caregivers in North Carolina. Virtual interviews were conducted using a semistructured interview guide. Using prevalence logic, the overarching theme of "Changing Life Plans" was explained by two subthemes, "Learning the Diagnosis" and "Keeping Them on Track." The timing and location of ACP conversations were important considerations. Over half of the participants (64%) had no knowledge or had misconceptions about ACP, and 5 had accurate knowledge. Nurses could develop partnerships with community leaders trained in palliative care principles to begin conversations early with community members. Advocacy groups might hold events, such as the Hello Game, in community settings to facilitate early ACP conversations.
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Matthieu MM, Church KA, Taylor LD, Oliver CM, McCullough JA, Adkins DA, Mallory MJ, Garner KK. Integrating the Age-Friendly Health Systems Movement in Veterans Health Administration: National Advance Care Planning via Group Visits and the 4Ms Framework. HEALTH & SOCIAL WORK 2023; 48:277-280. [PMID: 37608558 DOI: 10.1093/hsw/hlad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Monica M Matthieu
- PhD, is a research social worker, U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Health Services Research and Development (HSR&D) Center of Innovation: Center for Mental Healthcare & Outcomes Research, 2200 Fort Roots Drive, North Little Rock, AR 72114, USA
| | - Kimberly A Church
- MS, is the national lead, Age-Friendly Health Systems, Veterans Health Administration, U.S. Department of Veterans Affairs, Office of Geriatrics and Extended Care, Washington, DC, USA
| | - Laura D Taylor
- MSW, was Advance Care Planning via Group Visits (ACP-GV) program manager, U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, North Little Rock, AR, USA
| | - Ciara M Oliver
- BS, is technical writer, U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, North Little Rock, AR, USA
| | - Jane Ann McCullough
- MSW, is ACP-GV national program coordinator, U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, North Little Rock, AR, USA
| | - David A Adkins
- MHA, is health science specialist, U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, North Little Rock, AR, USA
| | - Mary J Mallory
- BS, is ACP-GV national program assistant, U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, North Little Rock, AR, USA
| | - Kimberly K Garner
- is VISN 16 rehabilitation and extended care lead, U.S. Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, North Little Rock, AR, USA
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Özkaytan Y, Schulz-Nieswandt F, Zank S. Acute Health Care Provision in Rural Long-Term Care Facilities: A Scoping Review of Integrated Care Models. J Am Med Dir Assoc 2023; 24:1447-1457.e1. [PMID: 37488029 DOI: 10.1016/j.jamda.2023.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVES We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation. DESIGN Systematic scoping review. SETTING AND PARTICIPANTS Residential LTCFs in rural areas worldwide. METHODS The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary. RESULTS A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth. CONCLUSIONS AND IMPLICATIONS This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.
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Affiliation(s)
- Yasemin Özkaytan
- Faculty of Human Sciences, Graduate School GROW-Gerontological Research on Well-being, University of Cologne, Cologne, Germany.
| | - Frank Schulz-Nieswandt
- Department of Social Policy and Methods of Qualitative Social Research, Faculty of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Susanne Zank
- Faculty of Human Sciences, Rehabilitative Gerontology, University of Cologne, Cologne, Germany
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Nortje N, Zachariah F, Reddy A. Advance Care Planning conversations: What constitutes best practice and the way forward: Advance Care Planning-Gespräche: Was Best Practice ausmacht und wie es weitergehen kann. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 180:8-15. [PMID: 37438167 DOI: 10.1016/j.zefq.2023.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/07/2023] [Accepted: 05/08/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) conversations are a cornerstone of modern health care and need to be supported. However, research indicates that the uptake thereof is limited, regardless of various campaigns. ACP conversations are complex and specific elements thereof should be discussed at various timepoints during the illness trajectory. OBJECTIVE This narrative review delineates what ACP conversation should entail, and a way forward. METHODS A PEO (Population, Exposure, Outcome) search was performed using relevant keywords, and 615 articles were identified. Through screening and coding, this number was reduced to 24 articles. All the authors were involved in the final selection of the articles. RESULTS Various themes developed throughout the review which include timing early on in the disease trajectory; incorporating beliefs and culturally relevant contexts; conversations needing to be iterative and short; involving surrogates and family; applying various media formats. DISCUSSION ACP conversations are relevant. ACP is not static and needs to be dynamic as patients' illness trajectories and goals change. The care team needs to guard themselves against having ACP conversations to satisfy a metric and should instead be guided by the patient's expressed values and wishes. A system-wide operational plan will help alleviate common barriers in having appropriate ACP conversations.
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Affiliation(s)
- Nico Nortje
- Section of Integrated Ethics, Department of Critical Care Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA; Department of Dietetics and Nutrition, University of the Western Cape, Bellville, South Africa.
| | - Finly Zachariah
- Department of Supportive Care Medicine, City of Hope, CA, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Oh DHW, Conell C, Lyon L, Ramalingam ND, Virk L, Gonzalez R. The Association of Chinese Ethnicity and Language Preference with Advance Directive Completion Among Older Patients in an Integrated Health System. J Gen Intern Med 2023; 38:1137-1142. [PMID: 36357725 PMCID: PMC10110817 DOI: 10.1007/s11606-022-07911-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/28/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Little is known about possible differences in advance directive completion (ADC) based on ethnicity and language preference among Chinese Americans on a regional level. OBJECTIVE To understand the association of ethnicity and language preference with ADC among Chinese Americans. DESIGN Retrospective cohort analysis with direct standardization. PARTICIPANTS A total of 31,498 Chinese and 502,991 non-Hispanic White members enrolled in Kaiser Permanente Northern California during the entire study period between 2013 and 2017 who were 55 or older as of January 1, 2018. MAIN MEASURES We compared the proportion of ADC among non-Hispanic White and Chinese patients, and also analyzed the rates according to language preference within the Chinese population. We calculated ADC rates with direct standardization using covariates previously found in literature to be significant predictors of ADC such as age and utilization. KEY RESULTS Among Chinese members, 60% preferred English, 16% preferred another language without needing an interpreter, and 23% needed an interpreter. After standardizing for age and utilization, non-Hispanic Whites were more than twice as likely to have ADC as Chinese members (20.6% (95% confidence interval (CI): 20.5-20.7%) vs. 10.0% (95% CI: 9.6-10.3%), respectively). Among Chinese members, there was an inverse association between preference for a language other than English and ADC (13.3% (95% CI: 12.8-13.8%) if preferring English, 6.1% (95% CI: 5.4-6.7%) if preferring non-English language but not needing an interpreter, and 5.1% (95% CI: 4.6-5.6%) if preferring non-English language and needing an interpreter). CONCLUSIONS Chinese members are less likely to have ADC relative to non-Hispanic White members, and those preferring a language other than English are most affected. Further studies can assess reasons for lower ADC among Chinese members, differences in other Asian American populations, and interventions to reduce differences among Chinese members especially among those preferring a language other than English.
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Affiliation(s)
- David Hyung Won Oh
- Department of Internal Medicine, Kaiser Permanente Oakland Medical Center, 275 W. McArthur Blvd, Oakland, CA 94611 USA
| | - Carol Conell
- Division of Research, Kaiser Permanente, Oakland, CA USA
| | - Liisa Lyon
- Division of Research, Kaiser Permanente, Oakland, CA USA
| | - Nirmala D. Ramalingam
- Graduate Medical Education, Kaiser Permanente Oakland Medical Center, Oakland, CA USA
| | - Loveleena Virk
- Department of Internal Medicine, Kaiser Permanente Oakland Medical Center, 275 W. McArthur Blvd, Oakland, CA 94611 USA
| | - Ruben Gonzalez
- Napa-Solano Family Medicine Residency Program, Kaiser Permanente, Vallejo, CA USA
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Sakamoto A, Inokuchi R, Iwagami M, Sun Y, Tamiya N. Association between advanced care planning and emergency department visits: A systematic review. Am J Emerg Med 2023; 68:84-91. [PMID: 36958094 DOI: 10.1016/j.ajem.2023.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Advance care planning can help provide optimal medical care according to a patient's wishes as a part of patient-centered discussions on end-of-life care. This can prevent undesired transfers to emergency departments. However, the effects of advance care planning on emergency department visits and ambulance calls in various settings or specific conditions remain unclear. AIM To evaluate whether advanced care planning affected the frequency of emergency department visits and ambulance calls. DESIGN Systematic review. This study was registered in PROSPERO (CRD42022340109). We assessed risk of bias using RoB 2.0, ROBINS-I, and ROBINS-E. DATA SOURCES We searched the PubMed, Cochrane CENTRAL, and EMBASE databases from their inception until September 22, 2022 for studies comparing patients with and without advanced care planning and reported the frequency of emergency department visits and ambulance calls as outcomes. RESULTS Eight studies were included. Regarding settings, two studies on patients in nursing homes showed that advanced care planning significantly reduced the frequency of emergency department visits and ambulance calls. However, two studies involving several medical care facilities reported inconclusive results. Regarding patient disease, a study on patients with depression or dementia showed that advanced care planning significantly reduced emergency department visits; in contrast, two studies on patients with severe respiratory diseases and serious illnesses showed no significant reduction. Seven studies showed a high risk of bias. CONCLUSIONS Advanced care planning may lead to reduced emergency department visits and ambulance calls among nursing home residents and patients with depression or dementia. Further research is warranted to identify the effectiveness of advanced care planning in specific settings and diseases.
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Affiliation(s)
- Ayaka Sakamoto
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Ryota Inokuchi
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan.
| | - Masao Iwagami
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Yu Sun
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
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11
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Yang J, Kim HJ, Heo S, An M, Park S, Ounpraseuth S, Kim J. Factors associated with attitudes toward advance directives in nurses and comparisons of the levels between emergency nurses and palliative care nurses. Jpn J Nurs Sci 2023; 20:e12508. [PMID: 36054594 DOI: 10.1111/jjns.12508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/19/2022] [Accepted: 08/01/2022] [Indexed: 01/05/2023]
Abstract
AIM Little is known about attitudes toward advance directives and factors associated with them among emergency and palliative care nurses who often or daily face end-of-life circumstances. Thus, we aimed to compare the levels of attitudes toward advance directives, communication skills, knowledge about end-of-life care (knowledge), and awareness of the concept of a good death (good death awareness) between emergency and palliative care nurses, and to examine factors associated with attitudes toward advance directives in the total sample. METHODS In this cross-sectional, correlational study, data were collected from 153 nurses (59 emergency and 94 palliative care nurses) at three tertiary hospitals using online or offline surveys and were analyzed using t-tests and multiple linear regression analysis. RESULTS The levels of attitudes, communication skills, knowledge, and good death awareness were moderate in both groups. Attitudes in emergency compared to palliative care nurses were less positive (46.78 vs. 48.38; p = .044), and knowledge was significantly lower (13.64 vs. 15.00; p = .004). Communication skills and good death awareness between the two groups were similar. In the total sample, emergency practice (B = -1.59, p = .024), and lower levels of good death awareness (B = 0.30, p < .001), communication skills (B = 0.18, p = .001), and education (B = -2.84, p = .015) were associated with less positive attitudes (F = 9.52, p < .001; R2 = 0.35). CONCLUSIONS The findings demonstrate the need for improvements in attitudes, knowledge, communication skills, and good death awareness in both groups, especially emergency nurses. Two modifiable targets of interventions to improve nurses' attitudes were also noted.
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Affiliation(s)
- Jisun Yang
- Gachon University, College of Nursing, Incheon, South Korea
| | - Hee Jung Kim
- Gachon University, College of Nursing, Incheon, South Korea
| | - Seongkum Heo
- Mercer University, Georgia Baptist College of Nursing 3001 Mercer University Drive, Atlanta, Georgia, USA
| | - Minjeong An
- College of Nursing, Chonnam National University, Gwangju, South Korea
| | - SeongHu Park
- College of Nursing Sciences, Sungshin Women's University, Seoul, South Korea
| | - Songthip Ounpraseuth
- University of Arkansas for Medical Sciences, College of Public Health, Little Rock, Arkansas, USA
| | - JinShil Kim
- Gachon University, College of Nursing, Incheon, South Korea
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12
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Korfage IJ, Polinder S, Preston N, van Delden JJ, Geraerds SAJ, Dunleavy L, Faes K, Miccinesi G, Carreras G, Moeller Arnfeldt C, Kars MC, Lippi G, Lunder U, Mateus C, Pollock K, Deliens L, Groenvold M, van der Heide A, Rietjens JA. Healthcare use and healthcare costs for patients with advanced cancer; the international ACTION cluster-randomised trial on advance care planning. Palliat Med 2022; 37:707-718. [PMID: 36515362 DOI: 10.1177/02692163221142950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advance care planning supports patients to reflect on and discuss preferences for future treatment and care. Studies of the impact of advance care planning on healthcare use and healthcare costs are scarce. AIM To determine the impact on healthcare use and costs of an advance care planning intervention across six European countries. DESIGN Cluster-randomised trial, registered as ISRCTN63110516, of advance care planning conversations supported by certified facilitators. SETTING/PARTICIPANTS Patients with advanced lung or colorectal cancer from 23 hospitals in Belgium, Denmark, Italy, the Netherlands, Slovenia and the UK. Data on healthcare use were collected from hospital medical files during 12 months after inclusion. RESULTS Patients with a good performance status were underrepresented in the intervention group (p< 0.001). Intervention and control patients spent on average 9 versus 8 days in hospital (p = 0.07) and the average number of X-rays was 1.9 in both groups. Fewer intervention than control patients received systemic cancer treatment; 79% versus 89%, respectively (p< 0.001). Total average costs of hospital care during 12 months follow-up were €32,700 for intervention versus €40,700 for control patients (p = 0.04 with bootstrap analyses). Multivariable multilevel models showed that lower average costs of care in the intervention group related to differences between study groups in country, religion and WHO-status. No effect of the intervention on differences in costs between study groups was observed (p = 0.3). CONCLUSIONS Lower care costs as observed in the intervention group were mainly related to patients' characteristics. A definite impact of the intervention itself could not be established.
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Affiliation(s)
- Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nancy Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Johannes Jm van Delden
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Sandra A Jlm Geraerds
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Kristof Faes
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Guido Miccinesi
- Clinical Epidemiology, Oncological network, prevention and research Institute (ISPRO), Florence, Italy
| | - Giulia Carreras
- Clinical Epidemiology, Oncological network, prevention and research Institute (ISPRO), Florence, Italy
| | - Caroline Moeller Arnfeldt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, The Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Marijke C Kars
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | | | - Urska Lunder
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Ceu Mateus
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, The Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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13
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Gabbard J, Strahley AE, Pajewski NM, Callahan KE, Foley KL, Brown A, Moses A, Kirkendall E, Williamson JD, Brooten J, Marterre B, Sutfin EL. Development of an Advance Care Planning Portal-Based Tool for Community-Dwelling Persons Living With Cognitive Impairment: The ACPVoice Tool. Am J Hosp Palliat Care 2022:10499091221134030. [PMID: 36239407 PMCID: PMC10102257 DOI: 10.1177/10499091221134030] [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: 11/15/2022] Open
Abstract
Background: Patient portals can be an innovative and efficient way to engage patients in advance care planning (ACP). However, comprehension and judgment in older adults with cognitive impairment presents several barriers and challenges to engaging in new technology. Our objective was to develop an ACP portal-based tool (ACPVoice) for community-dwelling persons living with cognitive impairment (PLCI) by engaging end-users in the design process. Methods: Two rounds of cognitive interviews were conducted to identify and resolve cognitive issues related to comprehension, judgment, response, and to assess content validity. Purposive sampling was used with the goal of enrolling 15 different participants (five with mild cognitive impairment and five dyads (those with mild dementia and their care partner) in each round to assess respondents' understanding of questions related to advance care planning to be administered via the patient portal. Results: Twenty PLCI (mean age 78.4, 10 females [50%]) and ten care partners (mean age 60.9, 9 females [90%]) completed cognitive interviews between May 2021 and October 2021. The mean Mini-Mental State Examination score for PLCI was 25.6 (SD 2.6). Unclear wording and undefined vague and/or unfamiliar terms were the major issues identified. Revisions to item wording, response options, and instructions were made to improve question comprehension and response as well as navigational ease. Conclusion: Minor changes to the wording, format, and response options substantially improved respondents' ability to interpret the item content of the ACPVoice tool. Dissemination and implementation of the ACPVoice tool could help to engage community-dwelling PLCI in ACP discussions.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ashley E Strahley
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nicholas M Pajewski
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Biostatistics and Data Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Implementation Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kristie L Foley
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Implementation Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew Brown
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Adam Moses
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Section on General Internal Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Eric Kirkendall
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Department of Pediatrics, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Justin Brooten
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Department of Emergency Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Buddy Marterre
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Erin L Sutfin
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
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14
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Kozlov E, Llaneza DH, Trevino K. Older patients' and their caregivers' understanding of advanced care planning. Curr Opin Support Palliat Care 2022; 16:33-37. [PMID: 34864762 PMCID: PMC9214415 DOI: 10.1097/spc.0000000000000583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the recent literature (2019-2021) on older patients' and their caregivers' understanding of advance care planning. RECENT FINDINGS Recent studies highlight the continued gaps in knowledge about advance care planning for older adults with cancer and their caregivers both domestically and abroad. The recent literature also revealed that there is a lack of research methodology to assess knowledge of advance care planning reliably and validly in older adults with cancer and their caregivers given the lack of uniform scales to measure knowledge of advance care planning. SUMMARY Older adults with cancer are at an elevated risk of death from their illness, and it is essential they understand how advance care planning can improve their quality of life, facilitate goal congruent care and ultimately decrease medical expenditures at end of life. In order to engage in a process such as advance care planning, patients must know what it is and how it can be helpful to them. The lack of understanding about advance care planning presents a significant barrier to patients engaging in the process. Public health campaigns to increase advance care planning knowledge are needed to ensure that older adults with cancer and their caregivers understand how this service can be helpful to them as they approach end of life.
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Affiliation(s)
- Elissa Kozlov
- Rutgers University, School of Public Health, Department of Health, Behavior, Society, and Policy
| | - Danielle H. Llaneza
- University of Houston, Department of Psychological, Health, and Learning Sciences
| | - Kelly Trevino
- Memorial Sloan Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences
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15
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Editorial: Supportive and palliative care for older adults with cancer. Curr Opin Support Palliat Care 2022; 16:1-2. [DOI: 10.1097/spc.0000000000000586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Bernacki GM, McDermott CL, Matlock DD, O'Hare AM, Brumback L, Bansal N, Kirkpatrick JN, Engelberg RA, Curtis JR. Advance Care Planning Documentation and Intensity of Care at the End of Life for Adults With Congestive Heart Failure, Chronic Kidney Disease, and Both Illnesses. J Pain Symptom Manage 2022; 63:e168-e175. [PMID: 34363954 PMCID: PMC8814047 DOI: 10.1016/j.jpainsymman.2021.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 02/03/2023]
Abstract
CONTEXT Heart failure (HF) and chronic kidney disease (CKD) are associated with high morbidity and mortality, especially in combination, yet little is known about the impact of these conditions together on end-of-life care. OBJECTIVES Compare end-of-life care and advance care planning (ACP) documentation among patients with both HF and CKD to those with either condition. METHODS We conducted a retrospective analysis of deceased patients (2010-2017) with HF and CKD (n = 1673), HF without CKD (n = 2671), and CKD without HF (n = 1706), excluding patients with cancer or dementia. We compared hospitalizations and intensive care unit (ICU) admissions in the last 30 days of life, hospital deaths, and ACP documentation >30 days before death. RESULTS 39% of patients with HF and CKD were hospitalized and 33% were admitted to the ICU in the last 30 days vs. 30% and 28%, respectively, for HF, and 26% and 23% for CKD. Compared to patients with both conditions, those with only 1 were less likely to be admitted to the hospital [HF: adjusted odds ratio (aOR) 0.72, 95%CI 0.63-0.83; CKD: aOR 0.63, 95%CI 0.53-0.75] and ICU (HF: aOR 0.83, 95%CI 0.71-0.94; CKD: aOR 0.68, 95%CI 0.56-0.80) and less likely to have ACP documentation (aOR 0.53, 95%CI 0.47-0.61 and aOR 0.70, 95%CI 0.60-0.81). CONCLUSIONS Decedents with both HF and CKD had more ACP documentation and received more intensive end-of-life care than those with only 1 condition. These findings suggest that patients with co-existing HF and CKD may benefit from interventions to ensure care received aligns with their goals.
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Affiliation(s)
- Gwen M Bernacki
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Cardiology, Department of Medicine, University of Washington (G.M.B., J.N.K.), Seattle, WA; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System (G.M.B., A.M.H. ), Seattle, WA.
| | - Cara L McDermott
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA
| | - Daniel D Matlock
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine (D.D.M.), Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center (D.D.M.), Denver, CO
| | - Ann M O'Hare
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System (G.M.B., A.M.H. ), Seattle, WA; Division of Nephrology, Department of Medicine, University of Washington (A.M.O., N.B.), Seattle; Kidney Research Institute, University of Washington (A.M.O., N.B.)
| | - Lyndia Brumback
- Department of Biostatistics, University of Washington (L.B.), Seattle
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington (A.M.O., N.B.), Seattle; Kidney Research Institute, University of Washington (A.M.O., N.B.)
| | - James N Kirkpatrick
- Division of Cardiology, Department of Medicine, University of Washington (G.M.B., J.N.K.), Seattle, WA; Department of Bioethics and Humanities, University of Washington (J.N.K., R.A.E.), Seattle, WA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington (R.A.E., J.R.C.), Seattle, WA; Department of Bioethics and Humanities, University of Washington (J.N.K., R.A.E.), Seattle, WA
| | - Jared Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington (G.M.B., C.L.M., J.R.C.), Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington (R.A.E., J.R.C.), Seattle, WA
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17
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Advance Directive Documentation in a Huntington’s Disease Clinic: A Retrospective Chart Review. Tremor Other Hyperkinet Mov (N Y) 2022; 12:4. [PMID: 35136703 PMCID: PMC8815436 DOI: 10.5334/tohm.676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/13/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Advance care planning (ACP) benefits patients and caregivers, yet it is underutilized and little is known about ACP in Huntington’s disease (HD) clinics. This study sought to determine the percentage of charts with AD documentation within an HD clinic. Methods: A retrospective chart review was conducted on a randomly selected sample of charts within an HD clinic. HD patients ≥18 y/o with a positive genetic test (≥40 CAG repeats) seen between January 2018 and June 2021 were included. Charts were reviewed for documentation of ADs either in provider notes or in the electronic medical records (EMR). Results: Ninety-one charts were reviewed (n = 91). Twenty-two charts (24.2%) mentioned a completed AD within a provider’s note; however, only nine (9.9%) had an AD available in the EMR. Cognitive status, primary insurance type, presence of dysphagia, and stage of disease were associated with documentation of completed ADs within a provider’s note. Discussion: The rate of completed ADs mentioned in a provider’s note (24.2%) was significantly lower than rates of AD completion in a previous study within the HD population (38%). Additional studies focused on improving rates AD completion are needed. Highlights Most patients with Huntington’s disease do not have documentation of completed advance directives (ADs) within their medical chart. In a retrospective chart review 24.2% of patients seen in a specialty HD clinic had documentation of ADs in a provider’s note and 9.9% had ADs available within the EMR.
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18
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Patel R, Torke A, Nation B, Cottingham A, Hur J, Gruber R, Sinha S. Crucial Conversations for High-Risk Populations before Surgery: Advance Care Planning in a Preoperative Setting. Palliat Med Rep 2021; 2:260-264. [PMID: 34927151 PMCID: PMC8675221 DOI: 10.1089/pmr.2021.0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 01/18/2023] Open
Abstract
Background: High-risk patients undergoing elective surgery are at risk for perioperative complications, including readmissions and death. Advance care planning (ACP) may allow for preparation for such events. Objectives: (1) To assess the completion rate of advance directives (ADs) and their association with one year readmissions and mortality (2) to examine clinical events for decedents. Design: This is an observational cohort study conducted through chart review. Setting/Subjects: Subjects were 400 patients undergoing preoperative evaluation for elective surgery at two hospitals in the United States. Measurements: The prevalence of ADs at the time of surgery and at one year, readmissions, and mortality at one year were determined. Results: Three-hundred ninety patients were included. In total, 102 (26.4%) patients were readmitted, yet did not complete an AD. Seventeen (4.4%) patients filed an AD during follow-up. Nineteen patients died and mortality rate was 4.9%. There was a significant association between completing an AD before death. Of the decedents, seven (37%) underwent resuscitation, but only four had ADs. Conclusions: Many high-risk surgical patients would benefit from ADs before clinical decline. Preoperative clinics present a missed opportunity to ensure ACP occurs before complications arise.
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Affiliation(s)
- Roma Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexia Torke
- IU Health Physicians, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Division of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA.,Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana, USA.,Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana, USA
| | - Barb Nation
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,IU Health Physicians, Indianapolis, Indiana, USA
| | - Ann Cottingham
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana, USA.,Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jennifer Hur
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel Gruber
- Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Shilpee Sinha
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,IU Health Physicians, Indianapolis, Indiana, USA.,Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA
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19
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Whitehead P, Frechman E, Johnstone-Petty M, Kates J, Tay DL, DeSanto K, Fink RM. A scoping review of nurse-led advance care planning. Nurs Outlook 2021; 70:96-118. [PMID: 34627618 DOI: 10.1016/j.outlook.2021.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 08/03/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Advance care planning (ACP) supports persons at any age or health status to determine their values, goals, and preferences regarding future medical care. The American Nurses Association endorses nurses to facilitate ACP to promote patient- and family-centered care. PURPOSE This project reviewed and synthesized literature on nurse-led ACP training models. METHODS A scoping review used the Arksey and O'Malley Framework to identify: (a) ACP training model type, (b) nurse-led ACP recipients, (c) ACP in special populations, (d) ACP outcomes. FINDINGS Of 33 articles reviewed, 19 included 11 established models; however, the primary finding was lack of a clearly identified evidence-based nurse-led ACP training model. DISCUSSION Nurses are integral team members, well positioned to be a bridge of communication between patients and care providers. This is a call to action for nurse leaders, researchers, educators to collaborate to identify and implement an evidence-based, effective nurse-led ACP training model.
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Affiliation(s)
- Phyllis Whitehead
- Palliative Medicine/Pain Management, Carilion Roanoke Memorial Hospital, Virginia Tech Carilion, School of Medicine, Roanoke, VA.
| | - Erica Frechman
- Palliative Care Atrium Health, PhD Candidate Nursing Science, Vanderbilt University School of Nursing, Nashville, TN
| | - Marianne Johnstone-Petty
- Palliative Care Department, Interprofessional Palliative Care Education, Providence Medical Group, Anchorage, AK
| | - Jeannette Kates
- College of Nursing, Thomas Jefferson University, Philadelphia, PA
| | - Djin L Tay
- College of Nursing, University of Utah, Salt Lake City, UT
| | - Kristen DeSanto
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Regina M Fink
- School of Medicine and College of Nursing, Interprofessional MSPC & Palliative Care Certificate Programs, University of Colorado Anschutz Medical Campus, Aurora, CO
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20
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Nicholas R, Nicholas E, Hannides M, Gautam V, Friede T, Koffman J. Influence of individual, illness and environmental factors on place of death among people with neurodegenerative diseases: a retrospective, observational, comparative cohort study. BMJ Support Palliat Care 2021:bmjspcare-2021-003105. [PMID: 34489324 DOI: 10.1136/bmjspcare-2021-003105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/11/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND In long-term neurological conditions, location of death is poorly understood but is seen as a marker of quality of dying. OBJECTIVE To examine individual, illness and environmental factors on place of death among people with multiple sclerosis (MS) and Parkinson's disease (PD) in isolation or in combination and compare them with people without either condition. METHODS Retrospective, observational, comparative cohort study of 582 people with MS, 579 people with PD and 95 controls from UK Multiple Sclerosis and Parkinson's Disease Tissue Bank. A subset of people with MS and PD were selected for analysis of individual clinical encounters 2 years before death and further subset of all groups for analysis of impact of advance care planning (ACP) and recognition of dying. RESULTS People with MS died more often (50.8%) in hospital than those with PD (35.3%). Examining individual clinical encounters over 2 years (4931 encounters) identified increased contact with services 12 months before death (F(1, 58)=69.71, p<0.0001) but was not associated with non-hospital deaths (F(1, 58)=1.001, p=0.321). The presence of ACPs and recognition of dying were high among people with MS and PD and both associated with a non-hospital death. ACPs were more likely to prevent hospital deaths when initiated by general practitioners (GPs) compared with other professional groups (χ2=68.77, p=0.0007). CONCLUSIONS For people with MS and PD, ACPs contribute to reducing dying in hospital. ACPs appear to be most effective when facilitated by GPs underlining the importance of primary care involvement in delivering holistic care at the end of life.
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Affiliation(s)
- Richard Nicholas
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Emma Nicholas
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Mike Hannides
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Vishal Gautam
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Center, University of Göttingen, Göttingen, Germany
| | - Jonathan Koffman
- Department of Palliative Care, Policy and Rehabiltation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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21
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Jeong S, Cleasby P, Ohr SO, Barrett T, Davey R, Oldmeadow C. Efficacy of Normalisation of Advance Care Planning (NACP) for people with chronic diseases in hospital and community settings: a quasi-experimental study. BMC Health Serv Res 2021; 21:901. [PMID: 34470636 PMCID: PMC8408987 DOI: 10.1186/s12913-021-06928-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/18/2021] [Indexed: 01/21/2023] Open
Abstract
Background Advance Care Planning (ACP) has emerged to improve end-of-life processes and experiences. However, the available evidence presents the gloomy picture of increasing number of older people living with chronic diseases and the mismatch between their preferences for and the actual place of death. The study aimed to investigate the efficacy of normalisation of an Advance Care Planning (NACP) service delivered by specially trained Registered Nurses (RNs) in hospital and community settings. Methods A quasi-experimental study was conducted involving 16 sites (eight hospital and eight community sites) in Australia. Patients who were aged ≥18 years, who had at least one of nine chronic conditions, and who did not have an Advance Care Directive (ACD) were offered the NACP service. ACP was normalised as part of routine service on admission. The intervention, NACP, was a series of facilitated conversations about the components of ACP. The primary outcomes which included the completion of ACDs, and/or appointment of an Enduring Guardian (EG), were assessed in both intervention and control sites at pre and post intervention stages. Numbers of patients who completed an ACD or appointed an EG were described by count (percentage). ACD completion was compared between intervention and control sites using a logistic mixed effects regression model. The model includes fixed effects for treatment group, period, and their interaction, as well as random site level intercepts. Secondary model included potentially confounding variables as covariates, including age, sex and chronic diseases. Results The prevalence of legally binding ACDs in intervention sites has increased from five to 85 (from 0.85% in pre to 17.6% in post), whereas it has slightly decreased from five to 2 (from 1.2% in pre and to 0.49% in post) in control sites (the difference in these changes being statistically significant p < 0.001). ACD completion rate was 3.6% (n = 4) in LHD1 and 1.2% (n = 3) in LHD2 in hospital whereas it was 53% (n = 26) in LHD1 and 80% (n = 52) in LHD2 in community. Conclusions The study demonstrated that NACP service delivered by ACP RNs was effective in increasing completion of ACDs (interaction odds ratio = 50) and was more effective in community than hospital settings. Involvement of various healthcare professionals are warranted to ensure concordance of care. Trial registration The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246) on 03/10/2018. The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06928-w.
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Affiliation(s)
- Sarah Jeong
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.
| | - Peter Cleasby
- Division of Aged, Subacute and Complex Care, PO Box 6088, Central Coast Local Health District, Long Jetty, NSW, 2261, Australia
| | - Se Ok Ohr
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia.,Hunter New England Nursing and Midwifery Research Centre, Hunter New England Local Health District, James Fletcher Campus, Gate Cottage, 72 Watt St, Newcastle, NSW, 2300, Australia
| | - Tomiko Barrett
- Department of Aged Care Services, Wyong Hospital, PO Box 4200, Central Coast Local Health District, Lakehaven, NSW, 2263, Australia
| | - Ryan Davey
- School of Nursing and Midwifery, University of Newcastle, 10 Chittaway Road, Ourimbah, NSW, 2258, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, Lot 1, Kookaburra Circuit, New Lambton Heights, Newcastle, NSW, 2305, Australia
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Haverhals LM, Gilman C, Manheim C, Bauers C, Kononowech J, Levy C. Implementation of VA's Life-Sustaining Treatment Decisions Initiative: Facilitators and Barriers to Early Implementation Across Seven VA Medical Centers. J Pain Symptom Manage 2021; 62:125-133.e2. [PMID: 33157178 DOI: 10.1016/j.jpainsymman.2020.10.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/05/2020] [Accepted: 10/27/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT In 2017, Veterans Health Administration (VHA) National Center for Ethics in Health Care began system-wide implementation of the Life-Sustaining Treatment Decisions Initiative (LSTDI). The LSTDI is a national VHA policy and practice to promote conducting goals of care conversations and documenting veterans' preferences for life-sustaining treatments (LSTs). OBJECTIVES The aim of this article is to describe facilitators and barriers to early implementation of the LSTDI within one VHA Veterans Integrated Service Network. METHODS From September 2016 to December 2018, we conducted site visits and semistructured phone interviews with implementation coordinators who championed the LSTDI rollout at seven VHA medical centers. We applied the Consolidated Framework for Implementation Research (CFIR) to assess facilitators and barriers to implementing the LSTDI and assigning interview data to specific CFIR constructs and CFIR valence ratings. We simultaneously benchmarked VHA medical centers' implementation progress as outlined by the National Center for Ethics in Health Care implementation guidebook. RESULTS We divided sites into three descriptive groups based on implementation progress: successfully implemented (n = 2); moving forward, but delayed (n = 3); and implementation stalled (n = 2). Five CFIR constructs emerged as facilitators or barriers to implementation of the LSTDI: 1) self-efficacy of implementation coordinators; 2) leadership engagement; 3) compatibility with pre-existing workflows; 4) available resources; and 5) overall implementation climate. CONCLUSION Although self-efficacy proved key to overcoming obstacles, degree of perceived workflow compatibility of the LSTDI policy, available resources, and leadership engagement must be adequate for successful implementation within the implementation time line. Without these components, successful implementation was hindered or delayed.
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Affiliation(s)
- Leah M Haverhals
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
| | - Carrie Gilman
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Chelsea Manheim
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Courtney Bauers
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Cari Levy
- Division of Health Care Policy and Research, VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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23
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Siconolfi D, Bandini J, Chen E. Individual, interpersonal, and health care factors associated with informal and formal advance care planning in a nationally-representative sample of midlife and older adults. PATIENT EDUCATION AND COUNSELING 2021; 104:1806-1813. [PMID: 33573918 PMCID: PMC8205937 DOI: 10.1016/j.pec.2020.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/30/2020] [Accepted: 12/23/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Assess correlates of advance care planning (ACP) among midlife and older adults in the United States, with attention to informal planning (e.g., conversations) and formal planning (e.g., legal documentation such as a living will). METHODS Data were collected from a nationally-representative U.S. sample of adults ages 55-74. RESULTS Informal ACP was positively associated with greater confidence, history of life-threatening illness, designation as health care decision maker for someone else, knowing at least one negative end-of-life (EOL) story in one's personal network, a desire to ease surrogates' decision making, and having a health care provider who had broached ACP. Formal ACP was positively associated with greater confidence, designation as a health care decision maker, having a provider who had broached ACP, and primarily receiving medical care from a doctor's office, and marginally negatively associated with health worry. CONCLUSIONS There are relevant correlates of advance care planning at the individual, interpersonal, and health care levels, with implications for increasing uptake of ACP. PRACTICE IMPLICATIONS A desire to mitigate proxies' decision-making burden was a significant motivator for ACP conversations. Awareness of negative EOL experiences may also motivate these conversations. Health care providers have a powerful role in formal and informal ACP uptake.
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Affiliation(s)
- Daniel Siconolfi
- RAND Corporation, 4570 Fifth Ave, Suite 600, Pittsburgh, PA, 15213, USA.
| | - Julia Bandini
- RAND Corporation, 20 Park Plaza, Suite 920, Boston, MA, 02116, USA.
| | - Emily Chen
- RAND Corporation, 1200 South Hayes St, Arlington, VA, 22202, USA.
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24
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Parackal A, Ramamoorthi K, Tarride JE. Economic Evaluation of Palliative Care Interventions: A Review of the Evolution of Methods From 2011 to 2019. Am J Hosp Palliat Care 2021; 39:108-122. [PMID: 34024147 DOI: 10.1177/10499091211011138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND End-of-life care is a driver of increasing healthcare costs; however, palliative care interventions may significantly reduce these costs. Economic evaluations that measure the incremental cost per quality adjusted life years (QALY) are warranted to inform cost-effectiveness of the intervention relative to a comparator and permit evaluation of investment against other therapeutic interventions. Evidence from the literature up to 2011 indicates a scarcity of cost-utility studies in palliative care research. AIM This literature review evaluates economic studies published between 2011 and 2019 to determine whether the methods of economic evaluations have evolved since 2011. DESIGN AND DATA SOURCES A literature search was completed using CENTRAL, OVID MEDLINE, EMBASE and other sources for publications between 2011 and 2019. Study characteristics, methodology and key findings of publications that met the inclusion criteria were reviewed. Quality of studies were assessed using indicators developed by authors of the previous literature review. RESULTS 46 papers were included for qualitative synthesis. Among them only 6 studies conducted formal cost-effectiveness evaluations-of these 5 measured QALYs and 1 employed probabilistic analyses. In addition, with the exception of 1 costing analysis, all other economic evaluations undertook a healthcare payer perspective. Quality of evidence were comparable to the previous literature review published in 2011. CONCLUSION Despite the small increase in the number of cost-utility studies, the methods of palliative care economic evaluations have not evolved significantly since 2011. More probabilistic cost-utility analyses of palliative care interventions from a societal perspective are necessary to truly evaluate the value for money.
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Affiliation(s)
- Anna Parackal
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Karishini Ramamoorthi
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, Ontario, Canada.,McMaster Chair, Health Technology Management, McMaster University, Hamilton, Ontario, Canada.,Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada.,Programs for Assessment to Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
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25
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Walter KL, Joehl HE, Alrifai T, Varghese TG, Tyler MJ. A Quality Improvement Initiative to Increase Completion and Documentation of Advanced Directives in the ICU at a U.S. Community Teaching Hospital. Crit Care Explor 2021; 3:e0413. [PMID: 33977277 PMCID: PMC8104255 DOI: 10.1097/cce.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Advance directives can help guide care in the ICU. As a healthcare quality improvement initiative, we sought to increase the percentage of patients with a healthcare power of attorney and/or practitioner orders for life-sustaining treatment in our ICU and to increase medical resident experience with advance directives through routine screening and documentation of advance directives in the ICU. Design: Prospective analysis. Setting: Urban U.S. community teaching hospital. Patients: All patients admitted to the ICU from September 2018 to February 2019. Interventions: Internal medicine residents in the ICU received a lecture about advance directives and instructions to screen their patients for advance directives. For willing and decisional patients, residents facilitated the creation of a healthcare power of attorney and/or practitioner orders for life-sustaining treatment. Residents were anonymously surveyed at the beginning and end of the ICU rotation about their experience and level of comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment completion. Measurements and Main Results: Three-hundred seventy-five patients were admitted to the ICU during the study period. Healthcare power of attorney documents were generated by 34% of all ICU patients without a prior healthcare power of attorney, increased from a baseline rate of 10% (p < 0.001). The number of practitioner orders for life-sustaining treatment documents for patients with code status of “no cardiopulmonary resuscitation” did not increase significantly. The percentage of residents who facilitated completion of a healthcare power of attorney document increased significantly from 56% to 100% (p < 0.001), whereas their practitioner orders for life-sustaining treatment experience did not change significantly by the end of their ICU rotation. On a Likert scale of 0–10, mean resident comfort increased significantly both with healthcare power of attorney documentation, rising from 6.14 to 8.84 (p = 0.005) and with practitioner orders for life-sustaining treatment form completion, increasing from 6.00 to 7.84 (p = 0.008). Conclusions: Training ICU medical residents to routinely screen for and facilitate completion of advance directives significantly increased the percentage of ICU patients with a healthcare power of attorney and significantly improved medical resident comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment form completion.
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Affiliation(s)
- Kristin L Walter
- Department of Medicine, AMITA Health St. Joseph Hospital Chicago, Chicago, IL
| | - Hillarie E Joehl
- Division of Palliative Medicine, AMITA Health St. Joseph Hospital Chicago, Chicago, IL
| | - Taha Alrifai
- Department of Medicine, AMITA Health St. Joseph Hospital Chicago, Chicago, IL
| | - Thomas G Varghese
- Department of Medicine, AMITA Health St. Joseph Hospital Chicago, Chicago, IL
| | - Matthew J Tyler
- Division of Palliative Medicine, AMITA Health St. Joseph Hospital Chicago, Chicago, IL
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26
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Gabbard J, Pajewski NM, Callahan KE, Dharod A, Foley KL, Ferris K, Moses A, Willard J, Williamson JD. Effectiveness of a Nurse-Led Multidisciplinary Intervention vs Usual Care on Advance Care Planning for Vulnerable Older Adults in an Accountable Care Organization: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:361-369. [PMID: 33427851 PMCID: PMC7802005 DOI: 10.1001/jamainternmed.2020.5950] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Advance care planning (ACP), especially among vulnerable older adults, remains underused in primary care. Additionally, many ACP initiatives fail to integrate directly into the electronic health record (EHR), resulting in infrequent and disorganized documentation. OBJECTIVE To determine whether a nurse navigator-led ACP pathway combined with a health care professional-facing EHR interface improves the occurrence of ACP discussions and their documentation within the EHR. DESIGN, SETTING, AND PARTICIPANTS This was a randomized effectiveness trial using the Zelen design, in which patients are randomized prior to informed consent, with only those randomized to the intervention subsequently approached to provide informed consent. Randomization began November 1, 2018, and follow-up concluded November 1, 2019. The study population included patients 65 years or older with multimorbidity combined with either cognitive or physical impairments, and/or frailty, assessed from 8 primary care practices in North Carolina. INTERVENTIONS Participants were randomized to either a nurse navigator-led ACP pathway (n = 379) or usual care (n = 380). MAIN OUTCOMES AND MEASURES The primary outcome was documentation of a new ACP discussion within the EHR. Secondary outcomes included the usage of ACP billing codes, designation of a surrogate decision maker, and ACP legal form documentation. Exploratory outcomes included incident health care use. RESULTS Among 759 randomized patients (mean age 77.7 years, 455 women [59.9%]), the nurse navigator-led ACP pathway resulted in a higher rate of ACP documentation (42.2% vs 3.7%, P < .001) as compared with usual care. The ACP billing codes were used more frequently for patients randomized to the nurse navigator-led ACP pathway (25.3% vs 1.3%, P < .001). Patients randomized to the nurse navigator-led ACP pathway more frequently designated a surrogate decision maker (64% vs 35%, P < .001) and completed ACP legal forms (24.3% vs 10.0%, P < .001). During follow-up, the incidence of emergency department visits and inpatient hospitalizations was similar between the randomized groups (hazard ratio, 1.17; 95% CI, 0.92-1.50). CONCLUSIONS AND RELEVANCE A nurse navigator-led ACP pathway integrated with a health care professional-facing EHR interface increased the frequency of ACP discussions and their documentation. Additional research will be required to evaluate whether increased EHR documentation leads to improvements in goal-concordant care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03609658.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M Pajewski
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ajay Dharod
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Section on General Internal Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kristie L Foley
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Keren Ferris
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adam Moses
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Willard
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
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27
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Verma M, Taddei T, Volk M, Navarro V. Advance Care Planning: A Convincing Argument to Make It Part of Liver Transplant Evaluation. Liver Transpl 2021; 27:461-462. [PMID: 32978855 DOI: 10.1002/lt.25901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 09/02/2020] [Indexed: 01/13/2023]
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28
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Bouttell J, Gonzalez N, Geue C, Lightbody CJ, Taylor DR. Cost impact of introducing a treatment escalation/limitation plan during patients' last hospital admission before death. Int J Qual Health Care 2020; 32:694-700. [PMID: 33210722 DOI: 10.1093/intqhc/mzaa132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/31/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE A recent study found that the use of a treatment escalation/limitation plan (TELP) was associated with a significant reduction in non-beneficial interventions (NBIs) and harms in patients admitted acutely who subsequently died. We quantify the economic benefit of the use of a TELP. DESIGN NBIs were micro-costed. Mean costs for patients with a TELP were compared to patients without a TELP using generalized linear model regression, and results were extrapolated to the Scottish population. SETTING Medical, surgical and intensive care units of district general hospital in Scotland, UK. PARTICIPANTS Two hundred and eighty-seven consecutive patients who died over 3 months in 2017. Of these, death was 'expected' in 245 (85.4%) using Gold Standards Framework criteria. INTERVENTION Treatment escalation/limitation plan. MAIN OUTCOME MEASURE Between-group difference in estimated mean cost of NBIs. RESULTS The group with a TELP (n = 152) had a mean reduction in hospital costs due to NBIs of GB £220.29 (US $;281.97) compared to those without a TELP (n = 132) (95% confidence intervals GB £323.31 (US $413.84) to GB £117.27 (US $150.11), P = <0.001). Assuming that a TELP could be put in place for all expected deaths in Scottish hospitals, the potential annual saving would be GB £2.4 million (US $3.1 million) from having a TELP in place for all 'expected' deaths in hospital. CONCLUSIONS The use of a TELP in an acute hospital setting may result in a reduction in costs attributable to NBIs.
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Affiliation(s)
- Janet Bouttell
- University of Glasgow, Institute of Health and Wellbeing, Health Economics and Health Technology Assessment, Glasgow, Scotland, UK
| | - Nelson Gonzalez
- Western University Canada and London Health Sciences Center London, Ontario, Canada UK
| | - Claudia Geue
- University of Glasgow, Institute of Health and Wellbeing, Health Economics and Health Technology Assessment, Glasgow, Scotland, UK
| | - Calvin J Lightbody
- University Hospital Hairmyres, NHS Lanarkshire, East Kilbride, Scotland, UK
| | - Douglas Robin Taylor
- University Hospital Wishaw, NHS Lanarkshire, Wishaw, Scotland, UK.,Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, UK
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29
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Iglesias K, Busnel C, Dufour F, Pautex S, Séchaud L. Nurse-led patient-centred intervention to increase written advance directives for outpatients in early-stage palliative care: study protocol for a randomised controlled trial with an embedded explanatory qualitative study. BMJ Open 2020; 10:e037144. [PMID: 32958487 PMCID: PMC7511622 DOI: 10.1136/bmjopen-2020-037144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Discussing the evolution of life-threatening diseases and end-of-life issues remains difficult for patients, relatives and professionals. Helping people discuss and formalise their preferences in end-of-life care, as planned in the Go Wish intervention, could reduce health-related anxiety in the advance care planning (ACP) and advance directive (AD) process. The aims of this study are (1) to test the effectiveness of the Go Wish intervention among outpatients in early-stage palliative care and (2) to understand the role of defence mechanisms in end-of-life discussions among nurses, patients and relatives. METHODS AND ANALYSIS A mixed-methods study will be performed. A cluster randomised controlled trials with three parallel arms will be conducted with 45 patients with chronic progressive diseases impacting life expectancy in each group: (1) Group A, Go Wish intervention for patients and their relatives; (2) Group A, Go Wish intervention for patients alone and (3) Group B, for patients (with a waiting list), who will receive the standardised information on ADs (usual care). Randomisation will be at the nurse level as each patient is referred to one of the 20 participating nurses (convenience sample of 20 nurses). A qualitative study will be conducted to understand the cognitive and emotional processes and experiences of nurses, patients and relatives confronted with end-of-life discussions. The outcome measurements include the completion of ADs (yes/no), anxiety, quality of communication about end-of-life care, empowerment, quality of life and attitudes towards ADs. ETHICS AND DISSEMINATION The study protocol has been approved by the Human Research Ethics Committee of the Canton of Geneva, Switzerland (no. 2019-00922). The findings will be disseminated to practice (nurses, patients and relatives), to national and international scientific conferences, and peer-reviewed journals covering nursing science, psychology and medicine. TRIAL REGISTRATION NUMBER NCT04065685.
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Affiliation(s)
- Katia Iglesias
- School of Health Sciences (HEdS-FR), HES-SO University of Applied Sciences and Arts Western Switzerland, Friourg, Switzerland
| | - Catherine Busnel
- Geneva Institution for Homecare and Assistance (imad), Geneva, Switzerland
| | - Florian Dufour
- School of Management and Engineering Vaud (HEIG-VD), HES-SO University of Applied Sciences and Arts Western Switzerland, Yverdon, Switzerland
| | - Sophie Pautex
- Division of Palliative Medicine, Department of rehabilitation and geriatrics, University Hospitals Geneva, Geneva, Switzerland
| | - Laurence Séchaud
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
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30
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Matthieu MM, Ounpraseuth ST, Painter J, Waliski A, Williams JS, Hu B, Smith R, Garner KK. Evaluation of the national implementation of the VA Diffusion of Excellence Initiative on Advance Care Planning via Group Visits: protocol for a quality improvement evaluation. Implement Sci Commun 2020; 1:19. [PMID: 32885180 PMCID: PMC7427851 DOI: 10.1186/s43058-020-00016-6] [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] [Received: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 12/02/2022] Open
Abstract
Background Traditionally, system leaders, service line managers, researchers, and program evaluators hire specifically dedicated implementation staff to ensure that a healthcare quality improvement effort can “go to scale.” However, little is known about the impact of hiring dedicated staff and whether funded positions, amid a host of other delivered implementation strategies, are the main difference among sites with and without funding used to execute the program, on implementation effectiveness and cost outcomes. Methods/design In this mixed methods program evaluation, we will determine the impact of funding staff positions to implement, sustain, and spread a program, Advance Care Planning (ACP) via Group Visits (ACP-GV), nationally across the entire United States Department of Veterans Affairs (VA) healthcare system. In ACP-GV, veterans, their families, and trained clinical staff with expertise in ACP meet in a group setting to engage in discussions about ACP and the benefits to veterans and their trusted others of having an advance directive (AD) in place. To determine the impact of the ACP-GV National Program, we will use a propensity score-matched control design to compare ACP-GV and non-ACP-GV sites on the proportion of ACP discussions in VHA facilities. To account for variation in funding status, we will document and compare funded and unfunded sites on the effectiveness of implementation strategies (individual and combinations) used by sites in the National Program on ACP discussion and AD completion rates across the VHA. In order to determine the fiscal impact of the National Program and to help inform future dissemination across VHA, we will use a budget impact analysis. Finally, we will purposively select, recruit, and interview key stakeholders, who are clinicians and clinical managers in the VHA who offer ACP discussions to veterans, to identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread. Discussion As an observational evaluation, this protocol will contribute to our understanding of implementation science and practice by examining the natural variation in implementation and spread of ACP-GV with or without funded staff positions.
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Affiliation(s)
- Monica M Matthieu
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College for Public Health and Social Justice, School of Social Work, Saint Louis University, Saint Louis, MO USA
| | - Songthip T Ounpraseuth
- College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Jacob Painter
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Angie Waliski
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - James Silas Williams
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA
| | - Bo Hu
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Robin Smith
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA
| | - Kimberly K Garner
- HSR&D Center of Innovation Center for Mental Healthcare & Outcomes Research, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114 USA.,College of Medicine, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR USA.,Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Little Rock, AR USA
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Influence of advance directives on reducing aggressive measures during end-of-life cancer care: A systematic review. Palliat Support Care 2020; 19:348-354. [PMID: 32854813 DOI: 10.1017/s1478951520000838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Although the literature recognizes the participation of patients in medical decisions as an important indicator of quality, there is a lack of consensus regarding the influence of advance directives (ADs) on reducing aggressive measures during end-of-life care involving cancer patients. OBJECTIVE A systematic review was conducted to analyze the influence of ADs on reducing aggressive end-of-life care measures for cancer patients. METHOD We searched the Medline, Embase, Web of Science, and Lilacs databases for studies published until March 2018 using the following keywords, without language restrictions: "advance directives," "living wills," "terminal care," "palliative care," "hospice care," and "neoplasms." Article quality was assessed using study quality assessment tools from the Department of Health and Human Services (NHLBI). RESULTS A total of 1,489 studies were identified; 7 met the inclusion criteria. The studies were recently published (after 2014, 71.4%). Patients with ADs were more likely to die at the site of choice (n = 3) and received less chemotherapy in the last 30 days (n = 1). ADs had no impact on intensive care unit admission (n = 1) or hospitalization (n = 1). One study found an association between ADs and referral to palliative care, but other did not find the same result. SIGNIFICANCE OF RESULTS Of the seven articles found, four demonstrated effects of ADs on the reduction in aggressive measures at the end of life of cancer patients. Heterogeneity regarding study design and results and poor methodological quality are challenges when drawing conclusions.
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Lum HD, Dukes J, Daddato AE, Juarez-Colunga E, Shanbhag P, Kutner JS, Levy CR, Sudore RL. Effectiveness of Advance Care Planning Group Visits Among Older Adults in Primary Care. J Am Geriatr Soc 2020; 68:2382-2389. [PMID: 32726475 DOI: 10.1111/jgs.16694] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 06/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Group visits can support health behavior change and self-efficacy. In primary care, an advance care planning (ACP) group visit may leverage group dynamics and peer mentorship to facilitate education and personal goal setting that result in ACP engagement. OBJECTIVE To determine whether the ENgaging in Advance Care Planning Talks (ENACT) group visits intervention improves ACP documentation and readiness in older adults. METHODS This randomized clinical trial was conducted among geriatric primary care patients from the University of Colorado Hospital Seniors Clinic, Aurora, CO, from August 2017 to November 2019. Participants randomized to ENACT group visits (n = 55) participated in two 2-hour sessions with discussions of ACP topics and use of ACP tools (i.e., Conversation Starter Kit, Medical Durable Power of Attorney form, and PREPARE videos). Participants randomized to the control arm (n = 55) received the Conversation Starter Kit and a Medical Durable Power of Attorney form by mail. The primary outcomes included presence of ACP documents or medical decision-maker documentation in the electronic health record (EHR) at 6 months, and a secondary outcome was ACP readiness (validated four-item ACP Engagement Survey) at 6 months. RESULTS Participants were a mean of 77 years old, 60% female, and 79% white. At 6 months, 71% of ENACT participants had an advance directive in the EHR (26% higher) compared with 45% of control arm participants (P < .001). Similarly, 93% of ENACT participants had decision-maker documentation in the EHR (29% higher) compared with 73% in the control arm (P < .001). ENACT participants trended toward higher readiness to engage in ACP compared with control (4.56 vs 4.13; P = .16) at 6 months. CONCLUSION An ACP group visit increased ACP documentation and readiness to engage in ACP behavior change. Primary care teams can explore implementation and adaptation of ACP group visits into routine care, as well as longer-term impact on patient health outcomes. J Am Geriatr Soc 68:2382-2389, 2020.
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Affiliation(s)
- Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,Geriatric Research Education and Clinical Center, Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Joanna Dukes
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Andrea E Daddato
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Gerontology, University of Massachusetts Boston, Boston, Massachusetts, USA
| | - Elizabeth Juarez-Colunga
- Division of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jean S Kutner
- Division of General Internal Medicine , Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cari R Levy
- Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Eastern Colorado Health Care System, Aurora, Colorado, USA.,Division of Health Care Policy and Research, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rebecca L Sudore
- Division of Geriatric Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Kendell C, Kotecha J, Martin M, Han H, Jorgensen M, Urquhart R. Patient and caregiver perspectives on early identification for advance care planning in primary healthcare settings. BMC FAMILY PRACTICE 2020; 21:136. [PMID: 32646380 PMCID: PMC7350686 DOI: 10.1186/s12875-020-01206-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 06/23/2020] [Indexed: 12/03/2022]
Abstract
Background As part of a broader study to improve the capacity for advance care planning (ACP) in primary healthcare settings, the research team set out to develop and validate a computerized algorithm to help primary care physicians identify individuals at risk of death, and also carried out focus groups and interviews with relevant stakeholder groups. Interviews with patients and family caregivers were carried out in parallel to algorithm development and validation to examine (1) views on early identification of individuals at risk of deteriorating health or dying; (2) views on the use of a computerized algorithm for early identification; and (3) preferences and challenges for ACP. Methods Fourteen participants were recruited from two Canadian provinces. Participants included individuals aged 65 and older with declining health and self-identified caregivers of individuals aged 65 and older with declining health. Semi-structured interviews were conducted via telephone. A qualitative descriptive analytic approach was employed, which focused on summarizing and describing the informational contents of the data. Results Participants supported the early identification of patients at risk of deteriorating health or dying. Early identification was viewed as conducive to planning not only for death, but for the remainder of life. Participants were also supportive of the use of a computerized algorithm to assist with early identification, although limitations were recognized. While participants felt that having family physicians assume responsibility for early identification and ACP was appropriate, questions arose around feasibility, including whether family physicians have sufficient time for ACP. Preferences related to the content of and approach to ACP discussions were highly individualized. Required supports during ACP include informational and emotional supports. Conclusions This work supports the role of primary care providers in the early identification of individuals at risk of deteriorating health or death and the process of ACP. To improve ACP capacity in primary healthcare settings, compensation systems for primary care providers should be adjusted to ensure appropriate compensation and to accommodate longer ACP appointments. Additional resources and more established links to community organizations and services will also be required to facilitate referrals to relevant community services as part of the ACP process.
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Affiliation(s)
- Cynthia Kendell
- Cancer Outcomes Research Program, Department of Surgery, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
| | - Jyoti Kotecha
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mary Martin
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Han Han
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Margaret Jorgensen
- Cancer Outcomes Research Program, Department of Surgery, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Robin Urquhart
- Cancer Outcomes Research Program, Department of Surgery, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.,Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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Electronic medical orders for life-sustaining treatment in New York State: Length of stay, direct costs in an ICU setting. Palliat Support Care 2020; 17:584-589. [PMID: 30636653 DOI: 10.1017/s1478951518000822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In the United States, approximately 20% patients die annually during a hospitalization with an intensive care unit (ICU) stay. Each year, critical care costs exceed $82 billion, accounting for 13% of all inpatient hospital costs. Treatment of sepsis is listed as the most expensive condition in US hospitals, costing more than $20 billion annually. Electronic Medical Orders for Life-Sustaining Treatment (eMOLST) is a standardized documentation process used in New York State to convey patients' wishes regarding cardiopulmonary resuscitation and other life-sustaining treatments. No study to date has looked at the effect of eMOLST as an advance care planning tool on ICU and hospital costs using estimates of direct costs. The objective of our study was to investigate whether signing of eMOLST results in any reduction in length of stay and direct costs for a community-based hospital in New York State. METHOD A retrospective chart review was conducted between July 2016 and July 2017. Primary outcome measures included length of hospital stay, ICU length of stay, total direct costs, and ICU costs. Inclusion criteria were patients ≥65 years of age and admitted into the ICU with a diagnosis of sepsis. An independent samples t test was used to test for significant differences between those who had or had not completed the eMOLST form. RESULT There were no statistical differences for patients who completed or did not complete the eMOLST form on hospital's total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU. SIGNIFICANCE OF RESULTS Completing an eMOLST form did not have any effect on reducing total direct cost, ICU cost, total length of hospital stay, and total hours spent in the ICU.
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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: 12] [Impact Index Per Article: 3.0] [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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Content analysis of Advance Directives completed by patients with advanced cancer as part of an Advance Care Planning intervention: insights gained from the ACTION trial. Support Care Cancer 2019; 28:1513-1522. [PMID: 31278462 PMCID: PMC6989617 DOI: 10.1007/s00520-019-04956-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 06/19/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Writing an Advance Directive (AD) is often seen as a part of Advance Care Planning (ACP). ADs may include specific preferences regarding future care and treatment and information that provides a context for healthcare professionals and relatives in case they have to make decisions for the patient. The aim of this study was to get insight into the content of ADs as completed by patients with advanced cancer who participated in ACP conversations. METHODS A mixed methods study involving content analysis and descriptive statistics was used to describe the content of completed My Preferences forms, an AD used in the intervention arm of the ACTION trial, testing the effectiveness of the ACTION Respecting Choices ACP intervention. RESULTS In total, 33% of 442 patients who received the ACTION RC ACP intervention completed a My Preferences form. Document completion varied per country: 10.4% (United Kingdom), 20.6% (Denmark), 29.2% (Belgium), 41.7% (the Netherlands), 61.3% (Italy) and 63.9% (Slovenia). Content analysis showed that 'maintaining normal life' and 'experiencing meaningful relationships' were important for patients to live well. Fears and worries mainly concerned disease progression, pain or becoming dependent. Patients hoped for prolongation of life and to be looked after by healthcare professionals. Most patients preferred to be resuscitated and 44% of the patients expressed maximizing comfort as their goal of future care. Most patients preferred 'home' as final place of care. CONCLUSIONS My Preferences forms provide some insights into patients' perspectives and preferences. However, understanding the reasoning behind preferences requires conversations with patients.
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Prater LC, Wickizer T, Bower JK, Bose-Brill S. The Impact of Advance Care Planning on End-of-Life Care: Do the Type and Timing Make a Difference for Patients With Advanced Cancer Referred to Hospice? Am J Hosp Palliat Care 2019; 36:1089-1095. [DOI: 10.1177/1049909119848987] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician. Methods: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life. Results: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001). Conclusions: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.
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Affiliation(s)
- Laura C. Prater
- Department of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thomas Wickizer
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Julie K. Bower
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Seuli Bose-Brill
- Department of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Kim H, Keating NL, Perloff JN, Hodgkin D, Liu X, Bishop CE. Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations. J Am Geriatr Soc 2019; 67:961-968. [DOI: 10.1111/jgs.15914] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/14/2018] [Accepted: 02/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Hyosin Kim
- The Heller School for Social Policy and ManagementBrandeis University Waltham Massachusetts
| | - Nancy L. Keating
- Department of Health Care PolicyHarvard Medical School Boston Massachusetts
- Division of General Internal MedicineBrigham and Women's Hospital Boston Massachusetts
| | - Jennifer N. Perloff
- The Heller School for Social Policy and ManagementBrandeis University Waltham Massachusetts
| | - Dominic Hodgkin
- The Heller School for Social Policy and ManagementBrandeis University Waltham Massachusetts
| | - Xiaodong Liu
- Department of PsychologyBrandeis University Waltham Massachusetts
| | - Christine E. Bishop
- The Heller School for Social Policy and ManagementBrandeis University Waltham Massachusetts
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Fliedner MC, Mitchell G, Bueche D, Mettler M, Schols JMGA, Eychmueller S. Development and Use of the 'SENS'-Structure to Proactively Identify Care Needs in Early Palliative Care-An Innovative Approach. Healthcare (Basel) 2019; 7:E32. [PMID: 30791565 PMCID: PMC6473309 DOI: 10.3390/healthcare7010032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/20/2019] [Accepted: 02/15/2019] [Indexed: 11/16/2022] Open
Abstract
Anticipatory planning for end of life requires a common language for discussion among patients, families, and professionals. Studies show that early Palliative Care (PC) interventions based on a problem-oriented approach can improve quality of life, support decision-making, and optimize the timing of medical treatment and transition to hospice services. The aim of this quality-improvement project was to develop a pragmatic structure meeting all clinical settings and populations needs. Based on the Medical Research Council (MRC) framework, a literature review identifying approaches commonly used in PC was performed. In addition, more than 500 hospital-based interprofessional consultations were analyzed. Identified themes were structured and compared to published approaches. We evaluated the clinical usefulness of this structure with an online survey among professionals. The emerged 'SENS'-structure stands for: Symptoms patients suffer from; End-of-life decisions; Network around the patient delivering care; and Support for the carer. Evaluation among professionals has confirmed that the 'SENS'-structure covers all relevant areas for anticipatory planning in PC. 'SENS' is useful in guiding patient-centered PC conversations and pragmatic anticipatory planning, alongside the regular diagnosis-triggered approach in various settings. Following this approach, 'SENS' may facilitate systematic integration of PC in clinical practice. Depending on clearly defined outcomes, this needs to be confirmed by future randomized controlled studies.
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Affiliation(s)
- Monica C Fliedner
- University Centre for Palliative Care, University Hospital Bern, 3010 Bern, Switzerland.
- Department of Health Services Research, School CAPHRI (Care and Public Health Research Institute), Maastricht University, Duboisdomein 30, 6229 GT Maastricht, The Netherlands.
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane 4072, Australia.
| | - Daniel Bueche
- Centre for Palliative Care, Kantonsspital St.Gallen, CH-9007 St.Gallen, Switzerland.
| | - Monika Mettler
- Centre for Palliative Care, Kantonsspital St.Gallen, CH-9007 St.Gallen, Switzerland.
| | - Jos M G A Schols
- Department of Health Services Research, School CAPHRI (Care and Public Health Research Institute), Maastricht University, Duboisdomein 30, 6229 GT Maastricht, The Netherlands.
| | - Steffen Eychmueller
- University Centre for Palliative Care, University Hospital Bern, 3010 Bern, Switzerland.
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Leiter RE, Yusufov M, Hasdianda MA, Fellion LA, Reust AC, Block SD, Tulsky JA, Ouchi K. Fidelity and Feasibility of a Brief Emergency Department Intervention to Empower Adults With Serious Illness to Initiate Advance Care Planning Conversations. J Pain Symptom Manage 2018; 56:878-885. [PMID: 30223014 PMCID: PMC6289886 DOI: 10.1016/j.jpainsymman.2018.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 12/13/2022]
Abstract
CONTEXT Emergency department (ED) visits provide opportunities to empower patients to discuss advance care planning with their outpatient clinicians, but systematically developed, feasible interventions do not currently exist. Brief negotiated interview (BNI) interventions, which allow ED clinicians to efficiently motivate patients, have potential to meet this need. OBJECTIVES We developed a BNI ED intervention to empower older adults with life-limiting illness to formulate and communicate medical care goals to their primary outpatient clinicians. This study assessed the fidelity and feasibility of this intervention in a high-volume ED. METHODS We enrolled adult patients with serious illnesses (advanced cancer, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease on dialysis, predicted survival <12 months) in an urban, tertiary care academic medical center ED. All participants received the BNI intervention. We video-recorded the encounters. Two reviewers assessed the recordings for intervention fidelity based on adherence to the BNI steps (Part I) and communication skills (Part II). RESULTS We reviewed 46 video recordings. The mean total adherence score was 21.07/27 (SD 3.68) or 78.04%. The Part I mean adherence score was 12.07/15 (SD 2.07) or 80.47%. The Part II mean adherence score was 9.0/12 (SD 2.51) or 75%. The majority (75.6%) of recordings met the prespecified threshold for high intervention fidelity. CONCLUSION ED clinicians can deliver a BNI intervention to increase advance care planning conversations with high fidelity. Future research is needed to study the intervention's efficacy in a wider patient population.
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Affiliation(s)
- Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Miryam Yusufov
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mohammad Adrian Hasdianda
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren A Fellion
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Audrey C Reust
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA; Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA; Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
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