Goals-of-Care Consultations Are Associated with Lower Costs and Less Acute Care Use among Propensity-Matched Cohorts of African Americans and Whites with Serious Illness

Relationships between socioeconomic status and cardiovascular outcomes in patients with complete heart block

BACKGROUND

Literature illustrates an association between adverse outcomes and lower socioeconomic status (SES) in patients with critical cardiovascular presentations; however. limited data exist on complete heart block (CHB) outcomes in the context of SES.

OBJECTIVES

The purpose of this study was to assess the association of SES (using zip code income quartiles) with the outcomes of CHB cases.

METHODS

We queried the 2016-2019 Nationwide Inpatient Sample and identified CHB as the primary diagnosis. We compared in-hospital outcomes based on zip code mean income quartiles (≤2 [< $59,000] vs ≥3). The primary outcome was mortality. Secondary outcomes included total and early permanent pacemaker (PPM) and temporary pacemaker (TPM) use, cardiogenic shock, palliative care involvement, mechanical ventilation use, length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders.

RESULTS

Of 150,265 CHB hospitalizations, 76,635 (51%) involved patients with a lower income quartile. Lower quartiles were associated with lower odds of early PPM use (adjusted odds ratio [aOR] 0.86; 95% confidence interval [CI] 0.81-0.90) and higher odds of in-hospital mortality (aOR 1.23; 95% CI 1.05-1.46), total TPM use (aOR 1.08; 95% CI 1.02-1.14), palliative care (aOR 1.2; 95% CI 1.02-1.43), mechanical ventilation use (aOR 1.11; 95% CI 1.01-1.23), cardiogenic shock (aOR 1.15; 95% CI 1.01-1.31), and longer LOS (4 days vs 3.6 days; P <.001) compared to patients in higher quartiles.

CONCLUSION

Patients with lower income admitted for CHB were less likely to receive an early PPM and had higher adverse outcomes compared to patients with higher income.

Patient, Caregiver, and Clinician Perceptions of Palliative Care that Influence Access and Use: A Qualitative Meta-Synthesis

Objective: Benefits of integration of palliative care early in the trajectory of a patient's serious illness are well established in the literature. Yet, barriers to palliative care access in the US continue to exist. The purpose of this study is to synthesize existing qualitative data of patient, caregiver, and clinician perceptions of palliative care (PC) that influence PC access and use in the US. Methods: A formal qualitative meta-synthesis was completed. The meta-synthesis included 1) a systematic literature search of qualitative studies conducted from 2016 to 2021, 2) a critical appraisal of the included studies, and 3) a reciprocal translation of the study's findings through an interpretive thematic analysis. Results: Seven articles met inclusion criteria resulting in a sample size of patients (n=18), caregivers (n=15), and clinicians (n=118). Three themes emerged with associated subthemes: knowledge and opinions of PC (subthemes of patient and caregiver knowledge and awareness and clinician knowledge and beliefs); care coordination and collaboration (subthemes of communication and trust); and social and structural drivers (subthemes of socioeconomic demographics and time and resources). Conclusions: This qualitative meta-synthesis identifies barriers and facilitators to palliative care access and use. The study findings illuminate the commonalities and differences of the perceptions of the three key stakeholder groups. In addition, this qualitative meta-synthesis reveals the complexities within the US healthcare system, and the challenges patients and their caregivers face accessing PC.

Cost of Hospitalization Associated with Inpatient Goals-of-Care Program Implementation at a Comprehensive Cancer Center: A Propensity Score Analysis

The impact of goals-of-care programs on acute hospitalization costs is unclear. We compared the hospitalization cost in an 8-month period before implementation of a multimodal interdisciplinary goals-of-care program (1 May 2019 to 31 December 2019) to an 8-month period after program implementation (1 May 2020 to 31 December 2020). Propensity score weighting was used to adjust for differences in potential covariates. The primary outcome was total direct cost during the hospital stay for each index hospitalization. This analysis included 6977 patients in 2019 and 5964 patients in 2020. The total direct cost decreased by 3% in 2020 but was not statistically significant (ratio 0.97, 95% CI 0.92, 1.03). Under individual categories, there was a significant decrease in medical oncology (ratio 0.58, 95% CI 0.50, 0.68) and pharmacy costs (ratio 0.86, 95% CI 0.79, 0.96), and an increase in room and board (ratio 1.06, 95% CI 1.01, 1.10). In subgroup analysis, ICU patients had a significant reduction in total direct cost after program implementation (ratio 0.83, 95% CI 0.72, 0.94). After accounting for the length of ICU admission, we found that the total direct cost per hospital day was no longer different between 2019 and 2020 (ratio 0.986, 95% CI 0.92, 1.05), suggesting that shorter ICU admissions likely explained much of the observed cost savings. This study provides real-world data on how "in-the-moment" GOC conversations may contribute to reduced hospitalization costs among ICU patients.

Examining the needs of survivors of critical illness through the lens of palliative care: A qualitative study of survivor experiences

OBJECTIVE

To examine the needs of adult survivors of critical illness through a lens of palliative care.

RESEARCH METHODOLOGY

A qualitative study of adult survivors of critical illness using semi-structured interviews and framework analysis.

SETTING

Participants were recruited from the post-intensive care unit clinic of a mid-Atlantic academic medical center in the United States.

FINDINGS

Seventeen survivors of critical illness aged 34-80 (median, 66) participated in the study. The majority of patients were female (64.7 %, n = 11) with a median length of index ICU stay of 12 days (interquartile range [IQR] 8-19). Interviews were conducted February to March 2021 and occurred a median of 20 months following the index intensive care stay (range, 13-33 months). We identified six key themes which align with palliative care principles: 1) persistent symptom burden; 2) critical illness as a life-altering experience; 3) spiritual changes and significance; 4) interpreting/managing the survivor experience; 5) feelings of loss and burden; and 6) social support needs.

CONCLUSION

Our findings suggest that palliative care components such as symptom management, goals of care discussions, care coordination, and spiritual and social support may assist in the assessment and treatment of survivors of critical illness.

Characteristics of Patients with Cancer Readmitted Within 30 Days to an Acute Palliative Care Unit

OBJECTIVE(S)

For patients with cancer, the emergence of acute palliative care units (APCU) may hold promise in curtailing hospital readmissions. The study aims to describe the characteristics of patients readmitted to an APCU.

METHODS

This retrospective study examined patients with cancer readmitted within 30 days to an APCU. Readmissions were further classified as either potentially preventable or non-preventable.

RESULTS

Out of 734 discharges from July 1, 2014 to July 1, 2015, 69 (9%) readmissions were identified and analyzed. For index admissions, median length of stay was five days, and one (1%) was discharged home with hospice care. For readmissions, median time from index admission to readmission was nine days, median length of stay was six days, three (4%) patients died, and 20 (30%) went home with hospice. Ten (14.5%) readmissions were deemed potentially preventable (95% CI 7.2-25.0%). Race/ethnicity-White/Black/Hispanic/Others-was 60%, 10%, 20% and 10%, respectively, among potentially preventable readmissions and 76%, 22%, 2% and 0%, respectively, among potentially non-preventable readmissions (P = .012). Potentially preventable readmissions were more likely to have venous thromboembolism (40% vs. 12%, P = .046) and more reasons for readmission (median 2 vs. 1, P = .019).

CONCLUSIONS

Among patients with cancer readmitted to an APCU, one out of seven was potentially preventable and a far larger proportion was discharged with hospice care compared to the index admission. Recognition of disease course, meaningful goals of care discussions and timely transition to hospice care may reduce rehospitalization in this population.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

BACKGROUND

Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.

METHODS

PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations.

DISCUSSION

The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

Hospice Enrollment, Future Hospitalization, and Future Costs Among Racially and Ethnically Diverse Patients Who Received Palliative Care Consultation

BACKGROUND

Palliative care consultation to discuss goals-of-care ("PCC") may mitigate end-of-life care disparities.

OBJECTIVE

To compare hospitalization and cost outcomes by race and ethnicity among PCC patients; identify predictors of hospice discharge and post-discharge hospitalization utilization and costs.

METHODS

This secondary analysis of a retrospective cohort study assessed hospice discharge, do-not-resuscitate status, 30-day readmissions, days hospitalized, ICU care, any hospitalization cost, and total costs for hospitalization with PCC and hospitalization(s) post-discharge among 1,306 Black/African American, Latinx, White, and Other race PCC patients at a United States academic hospital.

RESULTS

In adjusted analyses, hospice enrollment was less likely with Medicaid (AOR = 0.59, P = 0.02). Thirty-day readmission was less likely among age 75+ (AOR = 0.43, P = 0.02); more likely with Medicaid (AOR = 2.02, P = 0.004), 30-day prior admission (AOR = 2.42, P < 0.0001), and Black/African American race (AOR = 1.57, P = 0.02). Future days hospitalized was greater with Medicaid (Coefficient = 4.49, P = 0.001), 30-day prior admission (Coefficient = 2.08, P = 0.02), and Black/African American race (Coefficient = 2.16, P = 0.01). Any future hospitalization cost was less likely among patients ages 65-74 and 75+ (AOR = 0.54, P = 0.02; AOR = 0.53, P = 0.02); more likely with Medicaid (AOR = 1.67, P = 0.01), 30-day prior admission (AOR = 1.81, P = 0.0001), and Black/African American race (AOR = 1.40, P = 0.02). Total future hospitalization costs were lower for females (Coefficient = -3616.64, P = 0.03); greater with Medicaid (Coefficient = 7388.43, P = 0.01), 30-day prior admission (Coefficient = 3868.07, P = 0.04), and Black/African American race (Coefficient = 3856.90, P = 0.04). Do-not-resuscitate documentation (48%) differed by race.

CONCLUSIONS

Among PCC patients, Black/African American race and social determinants of health were risk factors for future hospitalization utilization and costs. Medicaid use predicted hospice discharge. Social support interventions are needed to reduce future hospitalization disparities.

Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans

Racial disparities, including decreased hospice utilization, lower quality symptom management, and poor-quality end-of-life care have been well documented in Black Americans. Improving health equity and access to high-quality serious illness care is a national palliative care (PC) priority. Accomplishing these goals requires clinician reflection, engagement, and large-scale change in clinical practice and health-related policies. In this article, we provide an overview of key concepts that underpin racism in health care, discuss common serious illness disparities in Black Americans, and propose steps to promote the delivery of antiracist PC.

Narrative Approach to Goals of Care Discussions: Adapting the 3-Act Model Training to an Online Format

CONTEXT

The three-Act Model, a narrative approach to goals of care (GOC) discussions centered on patients' individual stories, has proven to be effective as measured by objective skill improvement among medical trainees. This study describes the adaptation of the in-person curriculum to a streamlined, online format, in the setting of the Covid19 pandemic. We hypothesized that high levels of skill proficiency and learner satisfaction observed in previous in-person cohorts would be sustained amongst trainees in the online setting.

OBJECTIVE

Our primary aim was to assess the skills proficiency of a cohort of internal medicine interns undergoing online training for GOC discussions with the three-Act Model. Our secondary goal was to assess learners' satisfaction with the prerecorded didactic video and online role plays.

METHODS

Our team used REDCap for the data collection, and as the user-facing hub for learners to access didactic video content and for submitting surveys. We used Zoom to host synchronous discussions and role-play sessions. Trainers used the previously validated Goals of Care Assessment Tool (GCAT) to objectively rate intern proficiency in two role plays each.

RESULTS

Twenty-one internal medicine interns began the training; 20 completed the training and were assessed using the GCAT. All but one intern who completed the training (19 of 20, 95%) achieved proficiency in leading a GOC discussion as measured objectively using the GCAT. Learner satisfaction was high: 1) 100% of respondents recommended the training to others as a "good" (26.7%) or "outstanding" experience (73.3%); 2) 93.3% were "satisfied" or "very satisfied" using a online, distance-learning format for the prerecorded didactic component; 3) 80% were "satisfied" or "very satisfied" using an online, distance-learning format for the role-play component; and 4) 93.3% were content with the number of role plays. The amount of time dedicated to this training decreased compared to prior years when done in person (six hours) - to four hours and 40 minutes for learners and under four hours for trainers.

CONCLUSION

After completing the adapted online three-Act Model training, nearly all learners were scored to be proficient in GOC communication skills and reported high satisfaction with the online curriculum. Achieving high quality more efficiently represents genuine educational value. Further, these online teaching results show that the three-Act Model training can be delivered to geographically distanced learners.

Adapting Palliative Care Skills to Provide Substance Use Disorder Treatment to Patients With Serious Illness

BACKGROUND

The majority of Palliative Care (PC) clinicians report recently caring for a person with a Substance Use Disorder (SUD). The impact of an untreated SUD is associated with significant suffering but many PC clinicians report a lack of confidence in managing this population.

OBJECTIVE

This paper aims to demonstrate existing PC skills that can be adapted to provide primary SUD treatment.

METHODS

A comprehensive literature review was conducted on quality PC domains and core SUD treatment principles. To demonstrate the shared philosophy and skills of PC clinicians and SUD treatment, the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care and resources outlining core Addiction Medicine and Nursing Competencies were used.

RESULTS

There is an abundance of overlapping domains in PC and SUD treatment. This paper focuses on the domains of communication, team-based care, quality of life considerations, addressing social determinants of health, and adherence to ethical principles. In each section, the shared domain in PC and SUD treatment is discussed and steps to expand PC clinician's skills are provided.

CONCLUSION

PC clinicians may be among the last healthcare touchpoint for persons with SUD, by naming the shared skills required in PC and evidenced-based SUD treatment, we challenge the field to undertake primary SUD treatment as part of its constant pursuit to better serve people living with serious illness.

Goals-of-Care Consultation Associated With Increased Hospice Enrollment Among Propensity-Matched Cohorts of Seriously Ill African American and White Patients

CONTEXT

African Americans are less likely to receive hospice care and more likely to receive aggressive end-of-life care than whites. Little is known about how palliative care consultation (PCC) to discuss goals of care is associated with hospice enrollment by race.

OBJECTIVES

To compare enrollment in hospice at discharge between propensity-matched cohorts of African Americans with and without PCC and whites with and without PCC.

METHODS

Secondary analysis of a retrospective cohort study at a high-acuity hospital; using stratified propensity-score matching for 35,154 African Americans and whites aged 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at end of study, and did not die during index hospitalization (hospitalization during which first PCC occurred).

RESULTS

Compared with African Americans without PCC, African Americans with PCC were 15 times more likely to be discharged to hospice from index hospitalization (2.4% vs. 36.5%; P < 0.0001). Compared with white patients without PCC, white patients with PCC were 14 times more likely to be discharged to hospice from index hospitalization (3.0% vs. 42.7%; P < 0.0001).

CONCLUSION

In propensity-matched cohorts of seriously ill patients, PCC to discuss goals of care was associated with significant increases in hospice enrollment at discharge among both African Americans and whites. Research is needed to understand how PCC influences decision making by race, how PCC is associated with postdischarge hospice outcomes such as disenrollment and hospice lengths of stay, and if PCC is associated with improving racial disparities in end-of-life care.