1
|
Hauschildt KE, Vick JB, Ashana DC. Racial, Ethnic, and Socioeconomic Differences in Critical Care Near the End of Life: A Narrative Review. Crit Care Clin 2024; 40:753-766. [PMID: 39218484 DOI: 10.1016/j.ccc.2024.05.007] [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: 09/04/2024]
Abstract
Patients from groups that are racially/ethnically minoritized or of low socioeconomic status receive more intensive care near the end of life, endorse preferences for more life-sustaining treatments, experience lower quality communication from clinicians, and report worse quality of dying than other patients. There are many contributory factors, including system (eg, lack of intensive outpatient symptom management resources), clinician (eg, low-quality serious illness communication), and patient (eg, cultural norms) factors. System and clinician factors contribute to disparities and ought to be remedied, while patient factors simply reflect differences in care and may not be appropriate targets for intervention.
Collapse
Affiliation(s)
- Katrina E Hauschildt
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, #520, Baltimore, MD 21205, USA
| | - Judith B Vick
- Durham VA Health Care System; Department of Medicine, Duke University School of Medicine; National Clinician Scholars Program, Duke Clinical and Translational Science Institute, 701 West Main Street, Durham, NC 27701, USA
| | - Deepshikha Charan Ashana
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Hanes House, 315 Trent Drive, Durham, NC 27705, USA.
| |
Collapse
|
2
|
Perone AK. Navigating Religious Refusal to Nursing Home Care for LGBTQ+ Residents: Comparisons Between Floor Staff and Managers. J Gerontol B Psychol Sci Soc Sci 2024; 79:gbae122. [PMID: 39023035 DOI: 10.1093/geronb/gbae122] [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] [Received: 02/05/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVES Religious exemptions (exceptions to nondiscrimination laws for individual religious/moral beliefs) in health care have surged, negatively affecting LGBTQ+ older adults in nursing homes with some of the highest caregiving needs. Given job differences between floor staff and managers, this study asks: How does meaning-making differ between nursing home floor staff and managers when staff refuse to care for LGBTQ+ residents? To answer this question, this study uses social coherence as a conceptual framework to understand the process of reflection that staff employ when a colleague invokes a religious exemption to care. METHODS This qualitative comparative study uses in-depth semistructured interviews to compare responses from nursing home floor staff and managers (n = 80). Qualitative content analysis incorporated inductive and deductive coding approaches. RESULTS Staff invoked 5 frames to reach social coherence: fairness, resident safety and comfort, individual religious beliefs, job obligations, and laws/policies. Floor staff and managers invoked the same 2 reasons (fairness, resident safety and comfort) to reach social coherence. However, floor staff differed from managers by also invoking individual religious beliefs and job obligations; whereas managers turned to laws and policies to reconcile tensions between religious rights and LGBTQ+ resident rights to care. DISCUSSION In an increasingly polarized world, findings from this study illuminate nuances (and potential new areas of allyship) in how floor staff and managers understand and use various frames when deciding whether or not to accommodate a colleague who refuses care to an LGBTQ+ resident because of religious or moral reasons.
Collapse
Affiliation(s)
- Angela K Perone
- School of Social Welfare, University of California, Berkeley, California, USA
| |
Collapse
|
3
|
Cid M, Quan Vega ML, Yang Z, Guglielminotti J, Li G, Hua M. Disparities in end-of-life care for minoritized racial and ethnic patients during terminal hospitalizations in New York State. J Am Geriatr Soc 2024; 72:2690-2699. [PMID: 38982870 PMCID: PMC11368611 DOI: 10.1111/jgs.19046] [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] [Received: 03/20/2024] [Revised: 05/15/2024] [Accepted: 05/24/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Racial and ethnic minorities often receive care at different hospitals than non-Hispanic white patients, but how hospital characteristics influence the occurrence of disparities at the end of life is unknown. The aim of this study was to determine if disparities in end-of-life care were present among minoritized patients during terminal hospitalizations, and if these disparities varied with hospital characteristics. METHODS We identified hospitalizations where a patient died in New York State, 2016-2018. Using multilevel logistic regression, we examined whether documented end-of-life care (do-not-resuscitate status (DNR), palliative care (PC) encounter) differed by race and ethnicity, and whether these disparities differed based on receiving care in hospitals with varying characteristics (Black or Hispanic-serving hospital; teaching status; bed size; and availability of specialty palliative care). RESULTS We identified 143,713 terminal hospitalizations in 188 hospitals. Across all hospitals, only Black patients were less likely to have a PC encounter (adjusted odds ratio (aOR) 0.83 [0.80-0.87]) or DNR status (aOR 0.91 [0.87-0.95]) when compared with non-Hispanic White patients, while Hispanic patients were more likely to have DNR status (aOR 1.07 [1.01-1.13]). In non-teaching hospitals, all minoritized groups had decreased odds of PC (aOR 0.80 [0.76-0.85] for Black, aOR 0.91 [0.85-0.98] for Hispanic, aOR 0.93 [0.88-0.98] for Others), while in teaching hospitals, only Black patients had a decreased likelihood of a PC encounter (aOR 0.88 [0.82-0.93]). Also, Black patients in a Black-serving hospitals were less likely to have DNR status (aOR 0.80 [0.73-0.87]). Disparities did not differ based on whether specialty PC was available (p = 0.27 for PC encounter, p = 0.59 for DNR status). CONCLUSION During terminal hospitalizations, Black patients were less likely than non-Hispanic White patients to have documented end-of-life care. This disparity appears to be more pronounced in non-teaching hospitals than in teaching hospitals.
Collapse
Affiliation(s)
- Miguel Cid
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Main Lin Quan Vega
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Zhixin Yang
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jean Guglielminotti
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Guohua Li
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| |
Collapse
|
4
|
Kimpel CC, Dietrich MS, Lauderdale J, Schlundt DG, Maxwell CA. Using the Age-Friendly Environment Framework to Assess Advance Care Planning Factors Among Older Adults With Limited Income: A Cross-Sectional, Descriptive Survey Study. THE GERONTOLOGIST 2024; 64:gnae059. [PMID: 38813768 PMCID: PMC11192857 DOI: 10.1093/geront/gnae059] [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] [Received: 01/26/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The World Health Organization created the Age-Friendly Environment (AFE) framework to design communities that support healthy aging and equitable decision making. This framework's resource domains may account for disparately lower advance care planning (ACP) among older adults with limited incomes compared to those with high incomes. We aimed to describe and examine associations of AFE factors with ACP. RESEARCH DESIGN AND METHODS We recruited and conducted cross-sectional surveys among older adults with limited incomes in 7 community-based settings in Nashville, TN. ACP and AFE item scales were dichotomized and analyzed with unadjusted phi correlation coefficients. RESULTS Survey participants (N = 100) included 59 women, 70 Black/African American, and 70 ≥60 years old. Most participants agreed that their community was age friendly (≥58%) and varied in ACP participation (22%-67%). Participants who perceived easy travel and service access and sufficient social isolation outreach were more likely to have had family or doctor quality-of-life discussions (phi = 0.22-0.29, p < .05). Having a healthcare decision maker was positively associated with age-friendly travel, housing, and meet-up places (phi = 0.20-0.26, p < .05). DISCUSSION AND IMPLICATIONS The AFE framework is useful for exploring the environmental factors of ACP, but further research is warranted to identify specific and immediate resources to support successful ACP among populations with socioeconomic disadvantage.
Collapse
Affiliation(s)
| | - Mary S Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Jana Lauderdale
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA
| | - Cathy A Maxwell
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
5
|
Piscitello G, Schell JO, Arnold RM, Schenker Y. Artificial intelligence for better goals of care documentation. BMJ Support Palliat Care 2024:spcare-2023-004657. [PMID: 38936969 DOI: 10.1136/spcare-2023-004657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 06/17/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVES Lower rates of goals of care (GOC) conversations have been observed in non-white hospitalised patients, which may contribute to racial disparities in end-of-life care. We aimed to assess how a targeted initiative to increase GOC documentation rates is associated with GOC documentation by race. METHODS We retrospectively assessed GOC documentation during a targeted GOC initiative for adult patients with an artificial intelligence predicted elevated risk of mortality. Patients were admitted to an urban academic medical centre in Pittsburgh, Pennsylvania between July 2021 and 31 December 2022. RESULTS The 3643 studied patients had a median age of 72 (SD 13.0) and were predominantly white (87%) with 42% admitted to an intensive care unit and 15% dying during admission. GOC documentation was completed for 28% (n=1019/3643). By race, GOC was documented for 30% black (n=105/351), 28% white (n=883/3161) and 24% other (n=31/131) patients (p=0.3933). There was no statistical difference in the rate of documented GOC among races over time (p=0.5142). CONCLUSIONS A targeted initiative to increase documented GOC conversations for hospitalised patients with an elevated risk of mortality is associated with similar documentation rates across racial groups. Further research is needed to assess whether this initiative may promote racial equity in GOC documentation in other settings.
Collapse
Affiliation(s)
- Gina Piscitello
- Section of Palliative Care and Medical Ethics, Division of Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Division of Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
6
|
Rahemi Z, Bacsu JDR, Shalhout SZ, Sabet M, Sirizi D, Smith ML, Adams SA. Past Disparities in Advance Care Planning Across Sociodemographic Characteristics and Cognition Levels in the United States. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.09.24307125. [PMID: 38766186 PMCID: PMC11100925 DOI: 10.1101/2024.05.09.24307125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
We aimed to examine past advance care planning (ACP) in U.S. older adults across different sociodemographic characteristics and cognition levels. We established the baseline trends from 10 years ago to assess if trends in 2024 have improved upon future data availability. We considered two legal documents in the Health and Retirement Study 2014 survey as measures for ACP: a living will and durable power of attorney for healthcare (DPOAH). Logistic regression models were fitted with outcome variables (living will, DPOAH, and both) stratified by cognition levels (dementia/impaired cognition versus normal cognition). Predictor variables included age, gender, ethnicity, race, education, marital status, rurality, everyday discrimination, social support, and loneliness. Age, ethnicity, race, education, and rurality were significant predictors of ACP (having a living will, DPOAH, and both the living will and DPOAH) across cognition levels. Participants who were younger, Hispanic, Black, had lower levels of education, or resided in rural areas were less likely to complete ACP. Examining ACP and its linkages to specific social determinants is essential to understanding disparities and educational strategies needed to facilitate ACP uptake among different population groups. Accordingly, this study aimed to examine past ACP disparities in relation to specific social determinants of health and different cognition levels. Future studies are required to evaluate whether existing disparities have improved over the last 10 years when 2024 data is released. Addressing ACP disparities among diverse populations, including racial and ethnic minorities with reduced cognition levels, is crucial for enhancing health equity and access to care.
Collapse
Affiliation(s)
- Zahra Rahemi
- School of Nursing, Clemson University Clemson, SC, 29634-0743
| | | | - Sophia Z. Shalhout
- Division of Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, Mike Toth Cancer Research Center, Mass Eye and Ear, Harvard Medical School Boston, Massachusetts, USA, 02114
| | - Morteza Sabet
- School of Mechanical and Automotive Engineering, College of Engineering, Computing and Applied Sciences, Clemson University 4 Research Dr, Greenville, SC 29607
| | - Delaram Sirizi
- Department of Health Sciences, College of Behavioral, Social, and Health Sciences, Clemson University, Clemson SC 29634
| | - Matthew Lee Smith
- Department of Health Behavior, School of Public Health, Center for Community Health and Aging Texas A&M University, College Station, TX 77843
| | - Swann Arp Adams
- College of Nursing and the Department of Epidemiology & Biostatistics, University of South Carolina Columbia, SC 29208
| |
Collapse
|
7
|
Rodriguez GM, Popat R, Rosas LG, Patel MI. Racial and Ethnic Disparities in Intensity of Care at the End of Life for Patients With Lung Cancer: A 13-Year Population-Based Study. J Clin Oncol 2024; 42:1646-1654. [PMID: 38478794 PMCID: PMC11095875 DOI: 10.1200/jco.23.01045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 05/09/2024] Open
Abstract
PURPOSE Lung cancer is the leading cause of cancer death in the United States. Disparities in lung cancer mortality among racial and ethnic minorities are well documented. Less is known as to whether racial and ethnic minority patients with lung cancer experience higher rates of intensity of care at the end of life (EOL) compared with non-Hispanic White (NHW) patients. METHODS We conducted a population-based analysis of patients 18 years and older with a lung cancer diagnosis who died between 2005 and 2018 using the California Cancer Registry linked to patient discharge data abstracts. Our primary outcome was intensity of care in the last 14 days before death (defined as any hospital admission or emergency department [ED] visit, intensive care unit [ICU] admission, intubation, cardiopulmonary resuscitation [CPR], hemodialysis, and death in an acute care setting). We used multivariable logistic regression models to evaluate associations between race and ethnicity and intensity of EOL care. RESULTS Among 207,429 patients with lung cancer who died from 2005 to 2018, the median age was 74 years (range, 18-107) and 106,821 (51%) were male, 146,872 (70.8%) were NHW, 1,045 (0.5%) were American Indian, 21,697 (10.5%) were Asian Pacific Islander (API), 15,490 (7.5%) were Black, and 22,325 (10.8%) were Hispanic. Compared with NHW patients, in the last 14 days before death, API, Black, and Hispanic patients had greater odds of a hospital admission, an ICU admission, intubation, CPR, and hemodialysis and greater odds of a hospital or ED death. CONCLUSION Compared with NHW patients, API, Black, and Hispanic patients who died with lung cancer experienced higher intensity of EOL care. Future studies should develop approaches to eliminate such racial and ethnic disparities in care delivery at the EOL.
Collapse
Affiliation(s)
- Gladys M. Rodriguez
- Department of Medicine, Northwestern University Feinberg School of Medicine and the Comprehensive Cancer Center, Chicago, IL
| | - Rita Popat
- Stanford University School of Medicine, Stanford, CA
- Department of Epidemiology and Population Health, Stanford, CA
| | - Lisa G. Rosas
- Stanford University School of Medicine, Stanford, CA
- Department of Epidemiology and Population Health, Stanford, CA
| | - Manali I. Patel
- Stanford University School of Medicine, Stanford, CA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| |
Collapse
|
8
|
Lin M, Williams D, Vitcov G, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. Parent Preferences and Experiences in Advance Care Planning in the Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:e1783-e1791. [PMID: 37201532 DOI: 10.1055/s-0043-1768960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Our objective was to evaluate the preferences and experiences of bereaved parents around advance care planning (ACP) in the neonatal intensive care unit (NICU). STUDY DESIGN Single-center cross-sectional survey of bereaved parents who experienced the death of a child in the Boston Children's Hospital NICU between 2010 and 2021 was carried out. Chi-square, Fisher's exact, Fisher Freeman Halton, and Wilcoxin rank sum tests were used to evaluate differences between parents who did and did not receive ACP. RESULTS Out of eligible parents, 40 out of 146 (27%) responded to our survey. Most parents (31 out of 33, 94%) rated ACP as being very important and 27 out of 33 (82%) reported having ACP discussions during their child's admission. Parents preferred initial ACP discussions to occur early in their child's illness trajectory with members of the primary NICU team, with most parents' experiences aligning with these preferences. CONCLUSION Parents value ACP discussions suggesting a further role for ACP in the NICU. KEY POINTS · NICU parents value and participate in advance care planning discussions. · Parents prefer advance care planning with members of the primary NICU, specialty, and palliative care teams. · Parents prefer advance care planning early in their child's illness trajectory.
Collapse
Affiliation(s)
- Matthew Lin
- Division of Hospital Medicine, Department of Pediatrics, Children's National Medical Center, Pediatric Palliative Care Program, Washington, District of Columbia
| | - David Williams
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Giselle Vitcov
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sadath Sayeed
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Christy Cummings
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| |
Collapse
|
9
|
Ashana DC, Welsh W, Preiss D, Sperling J, You H, Tu K, Carson SS, Hough C, White DB, Kerlin M, Docherty S, Johnson KS, Cox CE. Racial Differences in Shared Decision-Making About Critical Illness. JAMA Intern Med 2024; 184:424-432. [PMID: 38407845 PMCID: PMC10897823 DOI: 10.1001/jamainternmed.2023.8433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/18/2023] [Indexed: 02/27/2024]
Abstract
Importance Shared decision-making is the preferred method for evaluating complex tradeoffs in the care of patients with critical illness. However, it remains unknown whether critical care clinicians engage diverse patients and caregivers equitably in shared decision-making. Objective To compare critical care clinicians' approaches to shared decision-making in recorded conversations with Black and White caregivers of patients with critical illness. Design, Setting, and Participants This thematic analysis consisted of unstructured clinician-caregiver meetings audio-recorded during a randomized clinical trial of a decision aid about prolonged mechanical ventilation at 13 intensive care units in the US. Participants in meetings included critical care clinicians and Black or White caregivers of patients who underwent mechanical ventilation. The codebook included components of shared decision-making and known mechanisms of racial disparities in clinical communication. Analysts were blinded to caregiver race during coding. Patterns within and across racial groups were evaluated to identify themes. Data analysis was conducted between August 2021 and April 2023. Main Outcomes and Measures The main outcomes were themes describing clinician behaviors varying by self-reported race of the caregivers. Results The overall sample comprised 20 Black and 19 White caregivers for a total of 39 audio-recorded meetings with clinicians. The duration of meetings was similar for both Black and White caregivers (mean [SD], 23.9 [13.7] minutes vs 22.1 [11.2] minutes, respectively). Both Black and White caregivers were generally middle-aged (mean [SD] age, 47.6 [9.9] years vs 51.9 [8.8] years, respectively), female (15 [75.0%] vs 14 [73.7%], respectively), and possessed a high level of self-assessed health literacy, which was scored from 3 to 15 with lower scores indicating increasing health literacy (mean [SD], 5.8 [2.3] vs 5.3 [2.0], respectively). Clinicians conducting meetings with Black and White caregivers were generally young (mean [SD] age, 38.8 [6.6] years vs 37.9 [8.2] years, respectively), male (13 [72.2%] vs 12 [70.6%], respectively), and White (14 [77.8%] vs 17 [100%], respectively). Four variations in clinicians' shared decision-making behaviors by caregiver race were identified: (1) providing limited emotional support for Black caregivers, (2) failing to acknowledge trust and gratitude expressed by Black caregivers, (3) sharing limited medical information with Black caregivers, and (4) challenging Black caregivers' preferences for restorative care. These themes encompass both relational and informational aspects of shared decision-making. Conclusions and Relevance The results of this thematic analysis showed that critical care clinicians missed opportunities to acknowledge emotions and value the knowledge of Black caregivers compared with White caregivers. These findings may inform future clinician-level interventions aimed at promoting equitable shared decision-making.
Collapse
Affiliation(s)
- Deepshikha C. Ashana
- Department of Medicine, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Whitney Welsh
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - Doreet Preiss
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - Jessica Sperling
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - HyunBin You
- School of Nursing, Duke University, Durham, North Carolina
| | - Karissa Tu
- School of Medicine, University of Washington, Seattle
| | | | - Catherine Hough
- Department of Medicine, Oregon Health and Science University, Portland
| | - Douglas B. White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Meeta Kerlin
- Department of Medicine, University of Pennsylvania, Philadelphia
| | | | - Kimberly S. Johnson
- Department of Medicine, Duke University, Durham, North Carolina
- Geriatrics Research Education and Clinical Center (GRECC), Durham Veterans Affairs Healthcare System, Durham, North Carolina
| | | |
Collapse
|
10
|
Piracha NZ, Nickel LB, Quryshi A, Salah R, Padela AI. Muslims and End-of-Life Healthcare in Non-Muslim Majority Nations: A Systematic Literature Review. J Pain Symptom Manage 2024; 67:e299-e312. [PMID: 38218412 PMCID: PMC10939778 DOI: 10.1016/j.jpainsymman.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/08/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
CONTEXT As Muslim populations in non-Muslim majority nations grow and age, they will increasingly require culturally appropriate healthcare. Delivering such care requires understanding their experiences with, as well as preferences regarding, end-of-life healthcare. OBJECTIVES To examine the experiences, needs, and challenges of Muslim patients and caregivers with end-of-life, hospice, and palliative care. METHODS A systematic literature review using five databases (MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Library) and key terms related to Islam and end-of-life healthcare. Papers were limited to English-language empirical studies of adults in non-Muslim majority nations. After removing duplicates, titles, abstracts, and articles were screened for quality and reviewed by a multidisciplinary team. RESULTS From an initial list of 1867 articles, 29 articles met all inclusion criteria. Most studies focused on end-of-life healthcare not related to palliative or hospice services and examined Muslim patient and caregiver experiences rather than their needs or challenges. Content analysis revealed three themes: (1) the role of family in caregiving as a moral duty and as surrogate communicators; (2) gaps in knowledge among providers related to Muslim needs and gaps in patient/family knowledge about advance care planning; and (3) the influence of Islam on Muslim physicians' perspectives and practices. CONCLUSION There is scant research on Muslim patients' and caregivers' engagement with end-of-life healthcare in non-Muslim majority nations. Existing research documents knowledge gaps impeding both Muslim patient engagement with end-of-life care and the delivery of culturally appropriate healthcare.
Collapse
Affiliation(s)
- Natasha Z Piracha
- Division of Critical Care and Hospital Medicine, Department of Pediatrics (N.Z.P.), Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, New York, USA; Adult Palliative Care Service, Department of Medicine (N.Z.P.), Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, New York, USA
| | - Lauren B Nickel
- Department of Emergency Medicine (L.B.N., A.Q., A.I.P.), Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
| | - Afiya Quryshi
- Department of Emergency Medicine (L.B.N., A.Q., A.I.P.), Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Harvard University (A.Q.), Cambridge, Massachusetts, USA
| | - Ramy Salah
- Department of Palliative Medicine (R.S.), Palo Alto Medical Foundation, San Mateo, California, USA
| | - Aasim I Padela
- Department of Emergency Medicine (L.B.N., A.Q., A.I.P.), Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Initiative on Islam and Medicine (A.I.P.), Glendale Heights, Illinois, USA
| |
Collapse
|
11
|
Goetz ME, Ford CB, Greiner MA, Clark A, Johnson KG, Kaufman BG, Mantri S, Xian Y, O'Brien RJ, O'Brien EC, Lusk JB. Racial Disparities in Low-Value Care in the Last Year of Life for Medicare Beneficiaries With Neurodegenerative Disease. Neurol Clin Pract 2024; 14:e200273. [PMID: 38524836 PMCID: PMC10955333 DOI: 10.1212/cpj.0000000000200273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 03/26/2024]
Abstract
Background and Objectives There are racial disparities in health care services received by patients with neurodegenerative diseases, but little is known about disparities in the last year of life, specifically in high-value and low-value care utilization. This study evaluated racial disparities in the utilization of high-value and low-value care in the last year of life among Medicare beneficiaries with dementia or Parkinson disease. Methods This was a retrospective, population-based cohort analysis using data from North and South Carolina fee-for-service Medicare claims between 2013 and 2017. We created a decedent cohort of beneficiaries aged 50 years or older at diagnosis with dementia or Parkinson disease. Specific low-value utilization outcomes were selected from the Choosing Wisely initiative, including cancer screening, peripheral artery stenting, and feeding tube placement in the last year of life. Low-value outcomes included hospitalization, emergency department visits, neuroimaging services, and number of days receiving skilled nursing. High-value outcomes included receipt of occupational and physical therapy, hospice care, and medications indicated for dementia and/or Parkinson disease. Results Among 70,650 decedents, 13,753 were Black, 55,765 were White, 93.1% had dementia, and 7.7% had Parkinson disease. Adjusting for age, sex, Medicaid dual enrollment status, rural vs urban location, state (NC and SC), and comorbidities, Black decedents were more likely to receive low-value care including colorectal cancer screening (adjusted hazard ratio [aHR] 1.46 [1.32-1.61]), peripheral artery stenting (aHR 1.72 [1.43-2.08]), and feeding tube placement (aHR 2.96 [2.70-3.24]) and less likely to receive physical therapy (aHR 0.73 [0.64-0.85)], dementia medications (aHR 0.90 [0.86-0.95]), or Parkinson disease medications (aHR 0.88 [0.75-1.02]) within the last year of life. Black decedents were more likely to be hospitalized (aHR 1.28 [1.25-1.32]), more likely to be admitted to skilled nursing (aHR 1.09 [1.05-1.13]), and less likely to be admitted to hospice (aHR 0.82 [0.79-0.85]) than White decedents. Discussion We found racial disparities in care utilization among patients with neurodegenerative disease in the last year of life, such that Black decedents were more likely to receive specific low-value care services and less likely to receive high-value supportive care than White decedents, even after adjusting for health status and socioeconomic factors.
Collapse
Affiliation(s)
- Margarethe E Goetz
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Cassie B Ford
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Melissa A Greiner
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Amy Clark
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Kim G Johnson
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Brystana G Kaufman
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Sneha Mantri
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Ying Xian
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Richard J O'Brien
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Emily C O'Brien
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Jay B Lusk
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| |
Collapse
|
12
|
Gross J, Koffman J. Examining how goals of care communication are conducted between doctors and patients with severe acute illness in hospital settings: A realist systematic review. PLoS One 2024; 19:e0299933. [PMID: 38498549 PMCID: PMC10947705 DOI: 10.1371/journal.pone.0299933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/17/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Patient involvement in goals of care decision-making has shown to enhance satisfaction, affective-cognitive outcomes, allocative efficiency, and reduce unwarranted clinical variation. However, the involvement of patients in goals of care planning within hospitals remains limited, particularly where mismatches in shared understanding between doctors and patients are present. AIM To identify and critically examine factors influencing goals of care conversations between doctors and patients during acute hospital illness. DESIGN Realist systematic review following the RAMESES standards. A protocol has been published in PROSPERO (CRD42021297410). The review utilised realist synthesis methodology, including a scoping literature search to generate initial theories, theory refinement through stakeholder consultation, and a systematic literature search to support program theory. DATA SOURCES Data were collected from Medline, PubMed, Embase, CINAHL, PsychINFO, Scopus databases (1946 to 14 July 2023), citation tracking, and Google Scholar. Open-Grey was utilized to identify relevant grey literature. Studies were selected based on relevance and rigor to support theory development. RESULTS Our analysis included 52 papers, supporting seven context-mechanism-output (CMO) hypotheses. Findings suggest that shared doctor-patient understanding relies on doctors being confident, competent, and personable to foster trusting relationships with patients. Low doctor confidence often leads to avoidance of discussions. Moreover, information provided to patients is often inconsistent, biased, procedure-focused, and lacks personalisation. Acute illness, medical jargon, poor health literacy, and high emotional states further hinder patient understanding. CONCLUSIONS Goals of care conversations in hospitals are nuanced and often suboptimal. To improve patient experiences and outcome of care interventions should be personalised and tailored to individual needs, emphasizing effective communication and trusting relationships among patients, families, doctors, and healthcare teams. Inclusion of caregivers and acknowledgment at the service level are crucial for achieving desired outcomes. Implications for policy, research, and clinical practice, including further training and skills development for doctors, are discussed.
Collapse
Affiliation(s)
- Jamie Gross
- Northwick Park and Central Middlesex Hospitals, London North West University Healthcare NHS Trust, Harrow, United Kingdom
- King’s College London, Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, United Kingdom
| | - Jonathan Koffman
- Hull York Medical School, Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
| |
Collapse
|
13
|
Kirkpatrick H, Buccheri RK, Sharifi C. Advance Care Planning Engagement Strategies for Primary Care Providers Seeing Diverse Patient Populations: A Scoping Review. J Hosp Palliat Nurs 2024; 26:E20-E29. [PMID: 38096444 DOI: 10.1097/njh.0000000000001002] [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: 01/10/2024]
Abstract
Diverse patients are less likely than Whites to have advance care planning. The primary purpose of this scoping review was to summarize recent evidence about advance care planning engagement interventions for primary care providers working with diverse patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for Scoping Reviews (PRISMA-ScR) Checklist was followed. Peer-reviewed articles published in English since 2000 reporting the results of studies testing intervention programs in primary care to improve advance care planning with adult, racially diverse populations were included. Searches were conducted in 5 online databases and yielded 72 articles. Gray literature yielded 23 articles. Two authors independently reviewed the abstracts of 72 articles determining that 9 articles met the aim of this review. These studies were analyzed by communication tools and other resources, population, intervention, primary outcomes, instruments, and primary findings and organized into 3 categories: ( a ) provider-focused interventions, ( b ) patient-focused interventions, and ( c ) multilevel interventions. Improvement in advance care planning outcomes can be achieved for racially diverse populations by implementing targeted advance care planning engagement interventions for both providers and patients. These interventions can be used in primary care to increase advance care planning for diverse patients. More research is needed that evaluates best practices for integrating advance care planning into primary care workflows.
Collapse
|
14
|
Kruser JM, Ashana DC, Courtright KR, Kross EK, Neville TH, Rubin E, Schenker Y, Sullivan DR, Thornton JD, Viglianti EM, Costa DK, Creutzfeldt CJ, Detsky ME, Engel HJ, Grover N, Hope AA, Katz JN, Kohn R, Miller AG, Nabozny MJ, Nelson JE, Shanawani H, Stevens JP, Turnbull AE, Weiss CH, Wirpsa MJ, Cox CE. Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:187-199. [PMID: 38063572 PMCID: PMC10848901 DOI: 10.1513/annalsats.202310-925st] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.
Collapse
|
15
|
Lebovitz AL, Schwab SA, Richardson MM, Meyer KB, Sweigart B, Vesel T. Dialysis decision-making process by Chinese American patients at an urban, academic medical center: a retrospective chart review. BMC Palliat Care 2024; 23:25. [PMID: 38273297 PMCID: PMC10809624 DOI: 10.1186/s12904-024-01357-y] [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] [Received: 07/30/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Clinical practice guidelines emphasize shared decision-making for kidney replacement treatment, yet little is known about the influence of cultural differences on that process. We undertook a retrospective chart review to explore the process and timing of dialysis decision making and initiation in Chinese American patients to provide quality kidney care for this population. DESIGN Participants received outpatient care at Tufts Medical Center and dialysis at Dialysis Clinic, Inc. Boston or Somerville, MA from 2001-2021. Clinic chart review sourced demographic, clinical, and end-of-life care information from 180 participants (82 Chinese American, 98 other) from stage 4 chronic kidney disease (CKD) and dialysis initiation. RESULTS Chinese American participants were older (mean 70 vs. 59, p < 0.0001), less likely to speak English (12% vs. 87%, p < 0.0001), and used interpreter services more (80% vs. 11%, p < 0.0001). Chinese American participants had more visits (median 14 vs. 10, p = 0.005); were more often accompanied by family members (75% vs. 40%, p < 0.001); and had significantly lower rates of healthcare proxy documentation (35% vs. 55%, p = 0.006). There was no statistical difference in months between first CKD 4 visit and first dialysis. Both groups started dialysis at the same average eGFR and with similar rates of permanent dialysis access. Chinese American participants had significantly lower serum albumin at dialysis initiation (mean 3.3 g/dL vs 3.7 g/dL, p = 0.0003). Documentation reflected a low number of conversations about non-dialytic care, end-of-life planning, or palliative care in both groups across all visits. CONCLUSION The time between CKD 4 and dialysis initiation was the same in both groups, suggesting a similar overall outcome of care. Chart documentation suggests that Chinese American participants had a significantly higher number of visits with nephrologists where discussion about dialysis was noted and were more likely to have a family member present at the visit. Fewer Chinese American participants completed healthcare proxies. Among all study participants, healthcare proxy, code status, and palliative care discussions were reported less frequently than expected. These findings highlight opportunities for collaboration between palliative care clinicians and nephrologists.
Collapse
Affiliation(s)
| | | | - Michelle M Richardson
- Tufts Medical Center, Department of Medicine, William B. Schwartz Division of Nephrology, Tufts University School of Medicine, Dialysis Clinic, Inc., Boston, MA, USA
| | - Klemens B Meyer
- Tufts Medical Center, Department of Medicine, William B. Schwartz Division of Nephrology, Tufts University School of Medicine, Dialysis Clinic, Inc., Boston, MA, USA
| | | | - Tamara Vesel
- Tufts Medical Center, Department of Medicine, Division of Palliative Care, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA.
| |
Collapse
|
16
|
Okelo SO, Chesley CF, Riley I, Diaz AA, Collishaw K, Schnapp LM, Thakur N. Accelerating Action: Roadmap for the American Thoracic Society to Address Oppression and Health Inequity in Pulmonary and Critical Care Medicine. Ann Am Thorac Soc 2024; 21:17-26. [PMID: 37934586 DOI: 10.1513/annalsats.202305-412ps] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/07/2023] [Indexed: 11/08/2023] Open
Affiliation(s)
- Sande O Okelo
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, University of California, Los Angeles, Los Angeles, California
| | - Christopher F Chesley
- Division of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Isaretta Riley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Alejandro A Diaz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Lynn M Schnapp
- American Thoracic Society, New York, New York
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Neeta Thakur
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California; and
- Health Equity and Diversity Committee, American Thoracic Society, New York, New York
| |
Collapse
|
17
|
Dutta PA, Flynn SJ, Oreper S, Kantor MA, Mourad M. Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities. J Hosp Med 2024; 19:5-12. [PMID: 38041530 DOI: 10.1002/jhm.13248] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Racial and ethnic minority groups are less likely to have advance directives and living wills, despite the importance of advanced care planning (ACP) in end-of-life care. We aimed to understand the impact of an intervention to improve ACP documentation across race, ethnicity, and language on hospitalized patients at our institution. METHODS We launched an intervention to improve the rates of ACP documentation for hospitalized patients aged >75 or with advanced illness defined by the International Classification of Diseases 10th Revision codes. We analyzed ACP completion rates, preintervention, and intervention, and used interrupted time-series analyses to measure the differential impact of the intervention across race, ethnicity, and language. KEY RESULTS A total of 10,220 patients met the inclusion criteria. Overall rates of ACP documentation improved from 13.9% to 43.7% in the intervention period, with a 2.47% monthly increase in ACP documentation compared to baseline (p < .001). During the intervention period, the rate of ACP documentation increased by 2.72% per month for non-Hispanic White patients (p < .001), by 1.84% per month for Latinx patients (p < .001), and by 1.9% per month for Black patients (p < .001). Differences in the intervention trends between non-Hispanic White and Latinx patients (p = .04) and Black patients (p = .04) were significant. CONCLUSIONS An intervention designed to improve ACP documentation in hospitalized patients widened a disparity across race and ethnicity with Latinx and Black patients having lower rates of improvement. Our findings reinforce the need to measure the impact of quality improvement interventions on existing health disparities and to implement specific strategies to prevent worsening disparities.
Collapse
Affiliation(s)
- Priyanka A Dutta
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sarah J Flynn
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sandra Oreper
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Molly A Kantor
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Michelle Mourad
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
18
|
Vashisht A, Gutman G, Kaur T. ACP Conversations with Chinese and South Asian Patients: Physicians' Perspectives of Barriers and Facilitating Factors. Can Geriatr J 2023; 26:486-492. [PMID: 38045880 PMCID: PMC10684305 DOI: 10.5770/cgj.26.691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Introduction/Objective Advance Care Planning (ACP) discussions are infrequently conducted with physicians, even fewer among minorities. We explored physicians' experiences in engaging Chinese (CH) and South Asian (SA) patients in ACP conversations to understand initiation and participation patterns, topics covered, and barriers and facilitating factors. Method Twenty-two physicians with 15%+ SA patients aged 55+ and 19 with 15%+ CH patients aged 55+ were interviewed. Results SA- and CH-serving physicians described similar initiation patterns, cultural context, and need for standardized ACP routines. However, the SA-serving physicians described greater involvement of family members, while CH-serving physicians described more communication barriers and family members' desire to hide the diagnosis from patients. Conclusion Cultural taboos surrounding discussion around death and dying appear to influence CH older adults and families strongly. Lack of familiarity with ACP amongst the SA population accounts more for their limited engagement in ACP discussions.
Collapse
Affiliation(s)
- Avantika Vashisht
- Gerontology Research Center, Simon Fraser University, Vancouver, BC
- Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC
| | - Gloria Gutman
- Gerontology Research Center, Simon Fraser University, Vancouver, BC
| | - Taranjot Kaur
- Gerontology Research Center, Simon Fraser University, Vancouver, BC
- Biological Studies, Simon Fraser University, Burnaby, BC,
Canada
| |
Collapse
|
19
|
King JK, Kieu A, El-Deyarbi M, Aljneibi N, Al-Shamsi S, Hashim MJ, Östlundh L, King KE, King RH, AB Khan M, Govender RD. Towards a better understanding between non-Muslim primary care clinicians and Muslim patients: A literature review intended to reduce health care inequities in Muslim patients. HEALTH POLICY OPEN 2023; 4:100092. [PMID: 37383881 PMCID: PMC10297732 DOI: 10.1016/j.hpopen.2023.100092] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 03/14/2023] [Accepted: 03/19/2023] [Indexed: 04/03/2023] Open
Abstract
Although Muslims are a growing population within many non-Muslim countries, there are insufficient Muslim clinicians to care for them. Studies have shown that non-Muslim clinicians have limited knowledge and understanding of Islamic practices affecting health, which may lead to disparities in the quality of healthcare delivery and outcomes when caring for Muslim patients. Muslims come from many different cultures and ethnicities and have variations in their beliefs and practices. This literature review provides some insights which may strengthen therapeutic bonds between non-Muslim clinicians and their Muslim patients resulting in improved holistic, patient-centered care in the areas of cancer screening, mental health, nutrition, and pharmacotherapy. Additionally, this review informs clinicians about the Islamic perspective on childbirth, end of life issues, travel for Islamic pilgrimage, and fasting during the month of Ramadan. Literature was sourced by a comprehensive search in PubMed, Scopus, and CINAHL along with hand screening of citations. Title and abstract screening followed by full-text screening excluded studies including less than 30% Muslim participants, protocols, or reporting results deemed irrelevant to primary care. 115 papers were selected for inclusion in the literature review. These were grouped into the themes of general spirituality, which were discussed in the Introduction, and Islam and health, Social etiquette, Cancer screening, Diet, Medications and their alternatives, Ramadan, Hajj, Mental health, Organ donation and transplants, and End of life. Summarizing the findings of the review, we conclude that health inequities affecting Muslim patients can be addressed at least in part by improved cultural competency in non-Muslim clinicians, as well as further research into this area.
Collapse
Affiliation(s)
- Jeffrey K King
- Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
- Home Based Primary Care, Division of Extended Care and Geriatrics, Department of Veterans Affairs, Greater Los Angeles area, CA, USA
| | - Alexander Kieu
- Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
- Kanad Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Marwan El-Deyarbi
- Ambulatory Health Services, Abu Dhabi, United Arab Emirates
- Department of Pharmacology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Noof Aljneibi
- Emirates Center for Happiness Research, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Saif Al-Shamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Muhammad Jawad Hashim
- Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
| | | | | | - Renee Houjintang King
- Academic Family Medical Center, Ventura County Family Medicine Residency Program, 300 Hillmont Ave, Building 340, Suite 201, Ventura, CA, USA
| | - Moien AB Khan
- Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
- Health and Wellness Research Group, Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
- Primary Care, NHS North West London, London TW3 3EB, United Kingdom
| | - Romona Devi Govender
- Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
| |
Collapse
|
20
|
Kalita N, Corr PG, Ward MC, Xavier J, McDonald PL. Identifying facilitators and barriers to culturally responsive communication for racial, ethnic, sexual, and gender minoritized patients when screened for COVID-19 vaccinations: A scoping review protocol. PLoS One 2023; 18:e0290514. [PMID: 37796975 PMCID: PMC10553356 DOI: 10.1371/journal.pone.0290514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION Racial, ethnic, sexual, and gender minoritized groups are considered historically excluded groups and have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. The influence of social determinants of health (SDOH), including access to screening and treatment, and other systemic and structural factors are largely responsible for these disparities. Primary care practitioner (PCP) competence in culturally responsive screening practices will be critical to reducing the impact of systemic and structural factors serving as barriers to screening and treatment. Correspondingly, improving the capacity of PCPs to communicate with patients in a culturally responsive manner may influence improved screening and treatment outcomes for minoritized groups related to COVID-19. This scoping literature review aims to determine the current breadth of literature on culturally responsive communication (CRC) in regard to COVID-19 vaccination screening for historically excluded, or minoritized groups. Results from this review will inform the development of a training series and social marketing campaign to improve PCPs capacity in CRC. This manuscript provides details on our study protocol. OBJECTIVES This scoping literature review aims to analyze existing literature on culturally responsive COVID-19 vaccinations between PCPs and patients in the U.S., specifically for racial, ethnic, sexual, and gender minoritized groups. Results of this scoping review will inform the development of a training series and social marketing campaign to improve capacity of PCPs in this area. Additionally, the review will inform recommendations for future research. MATERIALS AND METHODS This scoping review will be performed following the framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Relevant studies between the years 2019-2022 were identified using a rigorous search strategy across four databases: MEDLINE (via PubMed), Scopus, Cochrane (CENTRAL; via Wiley), and CINAHL (via EBSCO), using Boolean and Medical Subject Headings (MeSH) search terms. Studies will be uploaded to the data extraction tool, Covidence, to remove duplicates and perform a title/abstract screening, followed by a full-text screening. RESULTS The data extraction and analysis phases of the scoping review are in progress. Data will be analyzed for themes related to culturally responsive COVID-19 screening practices in clinical encounters with the identified study populations. Results will be reported by theme and align to PRISMA-ScR guidelines. DISCUSSION To our knowledge, this is the first study to use scoping methods to investigate the barriers and facilitators to CRC of COVID-19 vaccine screening for historically excluded communities in the U.S. The work and results from this research will be directly utilized for the development of nationally-accessible, continuing medical education materials to teach PCPs about CRC, as well as other materials to influence relevant policy changes within the healthcare landscape.
Collapse
Affiliation(s)
- Nikhil Kalita
- Department of Epidemiology, The George Washington University Milken School of Public Health, Washington, D.C., United States of America
| | - Patrick G. Corr
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States of America
| | - Maranda C. Ward
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States of America
| | - Julia Xavier
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States of America
| | - Paige L. McDonald
- Department of Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States of America
| |
Collapse
|
21
|
Apramian T, Virag O, Gallagher E, Howard M. Fighting Fires and Battling the Clock: Advance Care Planning in Family Medicine Residency. Fam Med 2023; 55:574-581. [PMID: 37441757 PMCID: PMC10622132 DOI: 10.22454/fammed.2023.678786] [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: 07/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Few family physicians treating patients with life-limiting illness report regularly initiating advance care planning (ACP) conversations about illness understanding, values, or care preferences. To better understand how family medicine training contributes to this gap in clinical care, we asked how family medicine residents learn to engage in ACP in the workplace. METHODS We coded semistructured interviews with family medicine residents (n=9), reflective memos (n=9), and autoethnographic field notes (n=37) using a constructivist-grounded theory approach. We next used the constant comparative method of grounded theory to develop two composite narratives describing participants' experiences that we then member-checked with participants. RESULTS We identified six core categories of social process to describe how participants were taught to engage in advance care planning. These social processes included previously unidentified barriers to ACP that were specific to their role as learners. These barriers appeared to lead to cultural avoidance of prognosis, conflation of ACP and goals of care (GOC) conversations, and deferral of difficult conversations to nonprimary care settings. CONCLUSIONS Family medicine educators should consider developing interventions such as flexible clinic schedules, dedicated ACP time, deliberate observed practice, and structured teaching to address potential barriers identified in this exploratory research. Family medicine leaders may wish to consider directly teaching residents and preceptors about crucial differences between ACP and GOC discussions. Shifting curricular focus toward eliciting values and illness understanding during ACP could help resolve a cultural avoidance of prognosis that limits family medicine residents' attempts to engage in ACP.
Collapse
Affiliation(s)
- Tavis Apramian
- Division of Palliative Care, Department of Family & Community Medicine, University of TorontoToronto, ONCanada
| | - Olivia Virag
- Department of Family Medicine, McMaster UniversityHamilton, ONCanada
| | - Erin Gallagher
- Division of Palliative Care, Department of Family Medicine, McMaster UniversityHamilton, ONCanada
| | - Michelle Howard
- Division of Palliative Care, Department of Family Medicine, McMaster UniversityHamilton, ONCanada
| |
Collapse
|
22
|
Younan S, Cardona M, Sahay A, Willis E, Ni Chroinin D. Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned. FRONTIERS IN HEALTH SERVICES 2023; 3:1242413. [PMID: 37780404 PMCID: PMC10541151 DOI: 10.3389/frhs.2023.1242413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023]
Abstract
Background The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice. Methods We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus. Results From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems. Conclusion The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.
Collapse
Affiliation(s)
- Sarah Younan
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, NSW, Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Gold Coast, QLD, Australia
| | - Ashlyn Sahay
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Mackay, QLD, Australia
| | - Eileen Willis
- School of Nursing, Midwifery and Social Sciences, Central Queensland University, Mackay, QLD, Australia
| | - Danielle Ni Chroinin
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia
| |
Collapse
|
23
|
Siegal R, Nance A, Johnson A, Case A. "Just because I have a medical degree does not mean I have the answers": Using CBPR to enhance patient-centered care within a primary care setting. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2023; 72:217-229. [PMID: 37086213 DOI: 10.1002/ajcp.12677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 05/03/2023]
Abstract
Patient-centered care (PCC) is a health care delivery model that is considered a means to reduce inequities in the healthcare system, specifically through its prioritization of patient voice and preference in treatment planning. Yet, there are documented challenges to its implementation. Community-based participatory research (CBPR) is seemingly well-positioned to address such challenges, but there has been limited discussion of utilizing CBPR in this way. This article begins to address this gap. In it, we present three diverse stakeholders' perspectives on a CBPR project to enhance PCC within a primary care clinic serving low-income patients. These perspectives provide insights into benefits, challenges, and lessons learned in using CBPR to implement PCC. Key benefits of using CBPR to implement PCC include increasing the acceptability and feasibility of data collection tools and process, and the generating of high-quality actionable feedback. Important CBPR facilitators of PCC implementation include intentional power-sharing between patients and providers and having invested stakeholders who "champion" CBPR within an organization with empowering practices.
Collapse
Affiliation(s)
- Rachel Siegal
- Health Psychology Doctoral Program, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - Andrew Nance
- Atrium Health Primary Care Cabarrus Family Medicine, Kannapolis, North Carolina, USA
- Community Free Clinic, Concord, North Carolina, USA
| | | | - Andrew Case
- Health Psychology Doctoral Program, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
- Department of Psychological Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| |
Collapse
|
24
|
Rosa WE, McDarby M, Buller H, Ferrell BR. Palliative Care Clinician Perspectives on Person-Centered End-of-Life Communication for Racially and Culturally Minoritized Persons with Cancer. Cancers (Basel) 2023; 15:4076. [PMID: 37627105 PMCID: PMC10452546 DOI: 10.3390/cancers15164076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/28/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
The aim of this study was to examine interdisciplinary clinicians' perceptions of priorities in serious illness communication and shared decision-making with racially and culturally minoritized persons at end of life. Clinicians (N = 152) read a detailed case study about a patient self-identifying as Black and American Indian who describes mistrust of the healthcare system. Participants then responded to three open-ended questions about communication strategies and approaches they would employ in providing care. We conducted a thematic analysis of participants' responses to questions using an iterative, inductive approach. Interdisciplinary clinicians from nursing (48%), social work (36%), and chaplaincy (16%), responded to the study survey. A total of four themes emerged: (1) person-centered, authentic, and culturally-sensitive care; (2) pain control; (3) approaches to build trust and connection; and (4) understanding communication challenges related to racial differences. Significant efforts have been made to train clinicians in culturally inclusive communication, yet we know little about how clinicians approach "real world" scenarios during which patients from structurally minoritized groups describe care concerns. We outline implications for identifying unconscious bias, informing educational interventions to support culturally inclusive communication, and improving the quality of end-of-life care for patients with cancer from minoritized groups.
Collapse
Affiliation(s)
- William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA;
| | - Meghan McDarby
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA;
| | - Haley Buller
- City of Hope, Duarte, CA 91010, USA; (H.B.); (B.R.F.)
| | | |
Collapse
|
25
|
Kimpel CC, Lauderdale J, Schlundt D, Dietrich MS, Ratcliff AC, Maxwell CA. The impact of COVID on end-of-life planning views, social connection, and quality of life for low-income, older adults: A qualitative study. Palliat Support Care 2023:1-7. [PMID: 37539473 PMCID: PMC10838366 DOI: 10.1017/s1478951523000688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVES Low-income, older adults are less likely than those with high income to participate in advance care planning (ACP); however, the pandemic may have influenced their views. The aim of this report was to explore the perceptions of COVID-19 related to everyday life and ACP. METHODS We embedded ACP behavior inequities within the Social Ecological Model to highlight the importance of considering social inequities within an environmental context. Using a qualitative descriptive design, twenty individual interviews were conducted. Thematic analysis consisted of multiple rounds of independent and iterative coding by 2 coders that resulted in a hierarchically organized coding system. Final themes emerged through the inductive consideration of the transcript data and the deductive contribution of our theoretical framework. RESULTS Three major themes emerged: social connection, quality of life, and end-of-life planning views. COVID-19 had not changed ACP views, i.e., those with existing ACP maintained it and those without ACP still avoided planning. SIGNIFICANCE OF RESULTS Low-income, older adults experienced lower social connection and quality of life during COVID-19 but did not express changes to ACP views. Our findings of the loss of regular social practices and mental health struggles may have competed with participants' perception that this crisis had little, if any, effect on ACP. While clinicians should monitor low-income, older adults for ACP barriers during COVID-19, policymakers should prioritize ACP at the systems level. We plan to use participatory research methods to explore for the minimal ACP impact, focusing on barriers to ACP opportunities.
Collapse
Affiliation(s)
| | - Jana Lauderdale
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Mary S Dietrich
- Department of Biostatistics, Vanderbilt University Schools of Medicine and Nursing, Nashville, TN, USA
| | - Amy C Ratcliff
- Veteran Affairs Quality Scholars, Tennessee Valley Healthcare System VA, Nashville, TN, USA
| | - Cathy A Maxwell
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| |
Collapse
|
26
|
White DB, Andersen SK. Conversations on Goals of Care With Hospitalized, Seriously Ill Patients. JAMA 2023; 329:2021-2022. [PMID: 37210664 DOI: 10.1001/jama.2023.8970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- Douglas B White
- Program on Ethics and Decision Making in Critical Illness, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah K Andersen
- Program on Ethics and Decision Making in Critical Illness, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
27
|
Ma JE, Lowe J, Berkowitz C, Kim A, Togo I, Musser RC, Fischer J, Shah K, Ibrahim S, Bosworth HB, Totten AM, Dolor R. Provider Interaction With an Electronic Health Record Notification to Identify Eligible Patients for a Cluster Randomized Trial of Advance Care Planning in Primary Care: Secondary Analysis. J Med Internet Res 2023; 25:e41884. [PMID: 37171856 DOI: 10.2196/41884] [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: 08/13/2022] [Revised: 02/17/2023] [Accepted: 03/21/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) improves patient-provider communication and aligns care to patient values, preferences, and goals. Within a multisite Meta-network Learning and Research Center ACP study, one health system deployed an electronic health record (EHR) notification and algorithm to alert providers about patients potentially appropriate for ACP and the clinical study. OBJECTIVE The aim of the study is to describe the implementation and usage of an EHR notification for referring patients to an ACP study, evaluate the association of notifications with study referrals and engagement in ACP, and assess provider interactions with and perspectives on the notifications. METHODS A secondary analysis assessed provider usage and their response to the notification (eg, acknowledge, dismiss, or engage patient in ACP conversation and refer patient to the clinical study). We evaluated all patients identified by the EHR algorithm during the Meta-network Learning and Research Center ACP study. Descriptive statistics compared patients referred to the study to those who were not referred to the study. Health care utilization, hospice referrals, and mortality as well as documentation and billing for ACP and related legal documents are reported. We evaluated associations between notifications with provider actions (ie, referral to study, ACP not documentation, and ACP billing). Provider free-text comments in the notifications were summarized qualitatively. Providers were surveyed on their satisfaction with the notification. RESULTS Among the 2877 patients identified by the EHR algorithm over 20 months, 17,047 unique notifications were presented to 45 providers in 6 clinics, who then referred 290 (10%) patients. Providers had a median of 269 (IQR 65-552) total notifications, and patients had a median of 4 (IQR 2-8). Patients with more (over 5) notifications were less likely to be referred to the study than those with fewer notifications (57/1092, 5.2% vs 233/1785, 13.1%; P<.001). The most common free-text comment on the notification was lack of time. Providers who referred patients to the study were more likely to document ACP and submit ACP billing codes (P<.001). In the survey, 11 providers would recommend the notification (n=7, 64%); however, the notification impacted clinical workflow (n=9, 82%) and was difficult to navigate (n=6, 55%). CONCLUSIONS An EHR notification can be implemented to remind providers to both perform ACP conversations and refer patients to a clinical study. There were diminishing returns after the fifth EHR notification where additional notifications did not lead to more trial referrals, ACP documentation, or ACP billing. Creation and optimization of EHR notifications for study referrals and ACP should consider the provider user, their workflow, and alert fatigue to improve implementation and adoption. TRIAL REGISTRATION ClinicalTrials.gov NCT03577002; https://clinicaltrials.gov/ct2/show/NCT03577002.
Collapse
Affiliation(s)
- Jessica E Ma
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Jared Lowe
- Division of General Medicine & Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Callie Berkowitz
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Azalea Kim
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ira Togo
- Duke Office of Clinical Research, Durham, NC, United States
| | - R Clayton Musser
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Jonathan Fischer
- Department of Community & Family Medicine, Duke University School of Medicine, Durham, NC, United States
- Duke Population Health Management Office, Durham, NC, United States
| | - Kevin Shah
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Salam Ibrahim
- Duke Health Performance Services, Duke University Health System, Durham, NC, United States
| | - Hayden B Bosworth
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Community & Family Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Psychiatry and Behavioral Services, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Annette M Totten
- Oregon Rural Practice Based Research Network, Oregon Health & Science University School of Medicine, Portland, OR, United States
| | - Rowena Dolor
- Division of General Medicine & Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| |
Collapse
|
28
|
Wada RK, Wong L, Flohr A, Arndt RG, Ing DK, Loos JR, Kaneshige L, Teruya K, Peterman K, Albright CL, Masaki K. Simulation-Based Pediatric Interprofessional Team Training to Facilitate End-of-Life Discussions. Clin Simul Nurs 2023. [DOI: 10.1016/j.ecns.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
|
29
|
Chesley CF, Chowdhury M, Small DS, Schaubel D, Liu VX, Lane-Fall MB, Halpern SD, Anesi GL. Racial Disparities in Length of Stay Among Severely Ill Patients Presenting With Sepsis and Acute Respiratory Failure. JAMA Netw Open 2023; 6:e239739. [PMID: 37155170 PMCID: PMC10167564 DOI: 10.1001/jamanetworkopen.2023.9739] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/07/2023] [Indexed: 05/10/2023] Open
Abstract
Importance Although racial and ethnic minority patients with sepsis and acute respiratory failure (ARF) experience worse outcomes, how patient presentation characteristics, processes of care, and hospital resource delivery are associated with outcomes is not well understood. Objective To measure disparities in hospital length of stay (LOS) among patients at high risk of adverse outcomes who present with sepsis and/or ARF and do not immediately require life support and to quantify associations with patient- and hospital-level factors. Design, Setting, and Participants This matched retrospective cohort study used electronic health record data from 27 acute care teaching and community hospitals across the Philadelphia metropolitan and northern California areas between January 1, 2013, and December 31, 2018. Matching analyses were performed between June 1 and July 31, 2022. The study included 102 362 adult patients who met clinical criteria for sepsis (n = 84 685) or ARF (n = 42 008) with a high risk of death at the time of presentation to the emergency department but without an immediate requirement for invasive life support. Exposures Racial or ethnic minority self-identification. Main Outcomes and Measures Hospital LOS, defined as the time from hospital admission to the time of discharge or inpatient death. Matches were stratified by racial and ethnic minority patient identity, comparing Asian and Pacific Islander patients, Black patients, Hispanic patients, and multiracial patients with White patients in stratified analyses. Results Among 102 362 patients, the median (IQR) age was 76 (65-85) years; 51.5% were male. A total of 10.2% of patients self-identified as Asian American or Pacific Islander, 13.7% as Black, 9.7% as Hispanic, 60.7% as White, and 5.7% as multiracial. After matching racial and ethnic minority patients to White patients on clinical presentation characteristics, hospital capacity strain, initial intensive care unit admission, and the occurrence of inpatient death, Black patients experienced longer LOS relative to White patients in fully adjusted matches (sepsis: 1.26 [95% CI, 0.68-1.84] days; ARF: 0.97 [95% CI, 0.05-1.89] days). Length of stay was shorter among Asian American and Pacific Islander patients with ARF (-0.61 [95% CI, -0.88 to -0.34] days) and Hispanic patients with sepsis (-0.22 [95% CI, -0.39 to -0.05] days) or ARF (-0.47 [-0.73 to -0.20] days). Conclusions and Relevance In this cohort study, Black patients with severe illness who presented with sepsis and/or ARF experienced longer LOS than White patients. Hispanic patients with sepsis and Asian American and Pacific Islander and Hispanic patients with ARF both experienced shorter LOS. Because matched differences were independent of commonly implicated clinical presentation-related factors associated with disparities, identification of additional mechanisms that underlie these disparities is warranted.
Collapse
Affiliation(s)
- Christopher F. Chesley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Dylan S. Small
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Wharton Department of Statistics and Data Science, University of Pennsylvania, Philadelphia
| | - Douglas Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Meghan B. Lane-Fall
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| |
Collapse
|
30
|
Reich AJ, Reich JA, Mathew P. Advance Care Planning, Shared Decision Making, and Serious Illness Conversations in Onconephrology. Semin Nephrol 2023; 42:151349. [PMID: 37121171 DOI: 10.1016/j.semnephrol.2023.151349] [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: 05/02/2023]
Abstract
Advance care planning, shared decision making, and serious illness conversations are communication processes designed to promote patient-centered care. In onconephrology, patients face a series of complex medical decisions regarding their care at the intersection of oncology and nephrology. Clinicians who aim to ensure that patient preferences and values are integrated into treatment planning must work within a similarly complex care team comprising multiple disciplines. In this review, we describe key decision points in a patient's care trajectory, as well as guidance on how and when to engage in advance care planning, shared decision making, and serious illness discussions. Further research on these processes in the complex context of onconephrology is needed.
Collapse
Affiliation(s)
- Amanda Jane Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA.
| | - John Adam Reich
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Paul Mathew
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA
| |
Collapse
|
31
|
Crooks J, Trotter S, Clarke G. How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review. BMC Palliat Care 2023; 22:43. [PMID: 37062841 PMCID: PMC10106323 DOI: 10.1186/s12904-023-01168-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/04/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals' care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this. METHODS Mixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000-04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients' care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough's Weight of Evidence. RESULTS N=35 papers were included in total; all had Medium/High Weight of Evidence. Fifteen papers (comparing two or more ethnic groups) addressed the primary outcome measure. Twelve of the fifteen papers reported White patients had statistically higher rates of formally documented ACP in their care records than patients from other ethnic groups. There were no significant differences in the presence of informal ACP between ethnic groups. Nineteen papers addressed the secondary outcome measure; thirteen discussed patient-based factors impacting ACP presence with four key themes: poor awareness and understanding of ACP; financial constraints; faith and religion; and family involvement. Eight papers discussed clinician-based factors with three key themes: poor clinician confidence around cultural values and ideals; exacerbation of institutional constraints; and pre-conceived ideas of patients' wishes. CONCLUSIONS This review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences. TRIAL REGISTRATION PROSPERO-CRD42022315252.
Collapse
Affiliation(s)
| | - Sophie Trotter
- Academic Unit of Palliative Care, University of Leeds, Leeds, UK
| | - Gemma Clarke
- Academic Unit of Palliative Care, University of Leeds, Leeds, UK
| |
Collapse
|
32
|
Okah E, Cronholm PF, Crow B, Persaud A, Westby A, Bonham VL. Race-Based Care and Beliefs Regarding the Etiology of Racial Differences in Health Outcomes. Am J Prev Med 2023; 64:477-482. [PMID: 36935165 PMCID: PMC10031413 DOI: 10.1016/j.amepre.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/12/2022] [Accepted: 10/28/2022] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Physicians' perspectives regarding the etiology of racial health differences may be associated with their use of race in clinical practice (race-based practice). This study evaluates whether attributing racial differences in health to genetics, culture, or social conditions is associated with race-based practice. METHODS This is a cross-sectional analysis, conducted in 2022, of the Council of Academic Family Medicine Education Research Alliance 2021 general membership survey. Only actively practicing U.S. physicians were included. The survey included demographic questions; the Racial Attributes in Clinical Evaluation (RACE) scale (higher scores imply greater race-based practice); and 3 questions regarding beliefs that racial differences in genetics, culture (e.g., health beliefs), or social conditions (e.g., education) explained racial differences in health. Three multivariable linear regressions were used to evaluate the relationship between RACE scores and beliefs regarding the etiology of racial differences in health. RESULTS Of the 4,314 survey recipients, 949 (22%) responded, of whom 689 were actively practicing U.S. physicians. In multivariable regressions controlling for age, gender, race, ethnicity, and practice characteristics, a higher RACE score was associated with a greater belief that differences in genetics (β=3.57; 95% CI=3.19, 3.95) and culture (β=1.57; 95% CI=0.99, 2.16)-in but not social conditions-explained differences in health. CONCLUSIONS Physicians who believed that genetic or cultural differences between racial groups explained racial differences in health outcomes were more likely to use race in clinical care. Further research is needed to determine how race is differentially applied in clinical care on the basis of the belief in its genetic or cultural significance.
Collapse
Affiliation(s)
- Ebiere Okah
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Family Medicine and Community Health, School of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Peter F Cronholm
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania; The Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendan Crow
- Family Medicine Residency Program, Mountain Area Health Education Center (MAHEC), Asheville, North Carolina
| | - Anitra Persaud
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Andrea Westby
- Department of Family Medicine and Community Health, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Vence L Bonham
- National Human Genome Research Institute, NIH, Bethesda, Maryland
| |
Collapse
|
33
|
Andersen SK, Butler RA, Chang CCH, Arnold R, Angus DC, White DB. Prevalence of long-term decision regret and associated risk factors in a large cohort of ICU surrogate decision makers. Crit Care 2023; 27:61. [PMID: 36797793 PMCID: PMC9933411 DOI: 10.1186/s13054-023-04332-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Whether surrogate decision makers regret decisions about the use of life support for incapacitated, critically ill patients remain uncertain. We sought to determine the prevalence of decision regret among surrogates of adult ICU patients and identify factors that influence regret. METHODS We conducted a secondary analysis of data from the PARTNER 2 trial, which tested a family support intervention for surrogates of critically ill adults. At 6-month follow-up, surrogates rated their regret about life support decisions using the Decision Regret Scale (DRS), scored from 0 to 100, with higher scores indicating more regret. We used multiple linear regression to identify covariates associated with decision regret based on a psychological construct of regret. We constructed two models using the full cohort; model 1 included patient outcomes; model 2 focused on covariates known at the time of ICU decision-making. Subgroup analyses were also conducted based on patient survival status at hospital discharge and 6-month follow-up. RESULTS 748 of 848 surrogates had complete DRS data. The median (IQR) DRS score was 15 (0, 25). Overall, 54% reported mild regret (DRS 5-25), 19% moderate-strong regret (DRS 30-100), and 27% no regret (DRS 0). Poor patient outcome at 6 months (death or severe functional dependence) was associated with more regret in model 1 (β 10.1; 95% C.I. 3.2, 17.0). In model 2, palliative care consultation (3.0; 0.1, 5.9), limitations in life support (LS) prior to death (6.3; 3.1, 9.4) and surrogate black race (6.3; 0.3, 12.3) were associated with more regret. Other modulators of regret in subgroup analyses included surrogate age and education level, surrogate-patient relationship, death in hospital (compared to the post-discharge period), and code status at time of ICU admission. CONCLUSIONS One in five ICU surrogate decision makers experience moderate to strong regret about life support decisions in ICU. Poor patient outcomes are linked to more regret. Decisions to limit life support prior to patient death may also increase regret. Future studies are needed to understand how regret relates to decision quality and how to lessen lasting regret.
Collapse
Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St. Scaife Hall, Room 608, HPU010604, Pittsburgh, 15261, PA, USA.
| | - Rachel A Butler
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St. Scaife Hall, Room 608, HPU010604, Pittsburgh, 15261, PA, USA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA, USA
| | - Chung-Chou H Chang
- The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Derek C Angus
- The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St. Scaife Hall, Room 608, HPU010604, Pittsburgh, 15261, PA, USA
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
34
|
Lenko R, Voepel-Lewis T, Robinson-Lane SG, Silveira MJ, Hoffman GJ. Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults. J Aging Health 2022; 34:1281-1290. [PMID: 35621163 PMCID: PMC9633341 DOI: 10.1177/08982643221104926] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine advance care planning (ACP) trends among an increasingly diverse aging population, we compared informal and formal ACP use by race/ethnicity among U.S. older adults (≤65 years). METHODS We used Health and Retirement Study data (2012-2018) to assess relationships between race/ethnicity and ACP type (i.e., no ACP, informal ACP only, formal ACP only, or both ACP types). We reported adjusted risk ratios with 95% confidence intervals. RESULTS Non-Hispanic Black and Hispanic respondents were 1.77 (1.60, 1.96) and 1.76 (1.55, 1.99) times as likely, respectively, to report no ACP compared to non-Hispanic White respondents. Non-Hispanic Black and Hispanic respondents were 0.74 (0.71, 0.78) and 0.74 (0.69, 0.80) times as likely, respectively, to report using both ACP types as non-Hispanic White respondents. DISCUSSION Racial/ethnic differences in ACP persist after controlling for a variety of barriers to and facilitators of ACP which may contribute to disparities in end-of-life care.
Collapse
Affiliation(s)
- Rachel Lenko
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing
| | - Terri Voepel-Lewis
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing
| | - Sheria G. Robinson-Lane
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing
| | - Maria J. Silveira
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan
| | - Geoffrey J. Hoffman
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing
| |
Collapse
|
35
|
Lin M, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. The Case for Advance Care Planning in the NICU. Pediatrics 2022; 150:189893. [PMID: 36321383 DOI: 10.1542/peds.2022-057824] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
Many NICUs have reached an inflection point where infant deaths following limitation of life-sustaining treatments outnumber those following unsuccessful resuscitations, and many infants who survive continue to require intensive supports. Families of such infants with serious illness may benefit from a standardized, process-oriented approach in decisional-support. Advance care planning (ACP), or communication that supports patients, or their surrogate decision-makers, in sharing values, goals, and preferences for future medical care, is recognized as a valuable strategy in supporting adults with serious and chronic illness. Although the role of ACP in older children and adolescents is evolving, its utility has not been systematically explored in the perinatal context. This article builds a case for formalizing a role for ACP in the NICU by defining ACP and appraising recent outcomes research, reviewing the current state of parental needs for decisional support and serious illness in the NICU, and describing how ACP may address current limitations in primary and specialty pediatric palliative care and challenges for decision-making in the newborn period.
Collapse
Affiliation(s)
- Matthew Lin
- Pediatric Palliative Care Program, Children's National Medical Center, Washington, District of Columbia
| | | | | | - Joanne Wolfe
- Departments of Psychosocial Oncology and Palliative Care and Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | | |
Collapse
|
36
|
Luth EA, Manful A, Weissman JS, Reich A, Ladin K, Semco R, Ganguli I. Practice Billing for Medicare Advance Care Planning Across the USA. J Gen Intern Med 2022; 37:3869-3876. [PMID: 35083654 PMCID: PMC9640523 DOI: 10.1007/s11606-022-07404-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/05/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Medicare introduced billing codes in 2016 to encourage clinicians to engage in advance care planning (ACP) and promote goal-concordantend-of-life care, but uptake has been modest. While prior research examined individual-level factors in ACP billing, organization-level factors associated with physician practices billing for ACP remain unknown. OBJECTIVE Examine the role of practices in ACP billing. DESIGN Retrospective cohort study analyzing 2016-2018 national Medicare data. PARTICIPANTS A total of 53,926 practices with at least 10 attributed Medicare beneficiaries. MAIN MEASURES Outcomes were practice-level ACP billing (any use by the practice) and ACP use rate by practice-attributed beneficiaries. Practice characteristics were number of beneficiaries attributed to the practice; percentage of beneficiaries by race, Medicare-Medicaid dual enrollment, sex, and age; practice size; and specialty mix. KEY RESULTS Fifteen percent of practices billed for ACP. In adjusted models, we found higher odds of ACP billing and higher ACP use rates among practices with more primary care physicians (billing AOR: 10.01, 95%CI: 8.81-11.38 for practices with 75-100% (vs 0) primary care physicians), and those serving more Medicare beneficiaries (billing AOR: 4.55, 95%CI 4.08-5.08 for practices with highest (vs lowest) quintile of beneficiaries), and larger shares of female beneficiaries (billing AOR: 3.06, 95% CI 2.01-4.67 for 75-100% (vs <25%) female ). CONCLUSIONS Several years after Medicare introduced ACP reimbursements for physicians, relatively few practices bill for ACP. ACP billing was more likely in large practices with a greater percentage of primary care physicians. To increase ACP billing uptake, policymakers and health system leaders might target interventions to larger practices where a small number of physicians already bill for ACP and to specialty practices that serve as the primary source of care for seriously ill patients.
Collapse
Affiliation(s)
| | - Adoma Manful
- Vanderbilt University, Nashville, TN, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Amanda Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, MA, USA
| | | | - Ishani Ganguli
- Harvard Medical School and Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
37
|
Naik AD, Walling AM. Getting patients ready for "in the moment" decisions. J Am Geriatr Soc 2022; 70:2474-2477. [PMID: 35781226 DOI: 10.1111/jgs.17935] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Aanand D Naik
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, USA.,UTHealth Consortium on Aging, University of Texas Health Science Center, Houston, Texas, USA.,VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Texas, USA.,VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| |
Collapse
|
38
|
Greenberg AL, Lin JA, Colley A, Finlayson E, Bongiovanni T, Wick EC. Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California. JAMA Netw Open 2022; 5:e2220379. [PMID: 35793086 PMCID: PMC9260472 DOI: 10.1001/jamanetworkopen.2022.20379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Hospice care is associated with improved quality of life and goal-concordant care. Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery. OBJECTIVE To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients discharged to hospice after a surgical hospitalization for a digestive disorder in California-licensed hospitals between January 1, 2015, and December 31, 2019. Data were analyzed from August 1 to November 30, 2021. EXPOSURES Patient age, race and ethnicity, principal language, payer, and Distressed Community Index (DCI). MAIN OUTCOMES AND MEASURES Admission type and most common diagnoses and procedures for surgical hospitalizations that resulted in discharge to hospice, annual hospitalization trend for 3 years preceding hospice enrollment, and most common diagnoses for patients who were readmitted after hospice enrollment were summarized. Age, race and ethnicity, principal language, payer, and DCI were compared between patients who were readmitted after hospice enrollment and those who were not. RESULTS Of 2688 patients with surgical hospitalizations resulting in discharge to hospice (mean [SD] age, 73.2 [14.7] years; 1459 women [54.3%]), 2389 (88.9%) had urgent or emergent discharges. The most common diagnoses were cancer (primary and metastatic; 1541 [57.3%]) and bowel obstruction (563 [20.9%]). The most common procedures were bowel resection, fecal diversion, inferior vena cava filter, gastric bypass, and paracentesis. In the 3 years preceding hospice enrollment, this cohort had a mean (SD) of 2.21 (2.77) hospitalizations per patient (1537 of 5953 surgical [25.8%]). Of these, 3594 of 5953 total (60.4%) and 840 of 1537 surgical (54.7%) hospitalizations were within 1 year of hospice enrollment. Three hundred and sixty-eight patients (13.7%) were readmitted after hospice enrollment, with infection being the most common readmission diagnosis. Readmitted patients were more likely to be younger (mean [SD] age, 69.7 [16.4] vs 73.8 [14.3] years; P < .001), to speak a principal language other than English (62 of 368 [16.8%] vs 292 of 2320 [12.6%]; P = .02), to be insured through Medicaid (70 of 368 [19.0%] vs 223 of 2320 [9.6%]; P < .001), and to be from a community with higher DCI (198 of 360 [55.0%] vs 1117 of 2269 [49.2%]; P = .04) and were less likely to be White (195 of 368 [53.0%] vs 1479 of 2320 [63.8%]; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest multiple opportunities for advance care planning in this surgical cohort, with a particular focus on emergent care. Further study is needed to understand the reasons for rehospitalization after hospice discharge and identify ways to improve communication and decision-making support for patients who choose to enroll in hospice care. Given the frequent antecedent interactions with the health care system among this population, longitudinal and tailored approaches may be beneficial to promote equitable end-of-life care; however, further research is needed to clarify barriers and understand differing patient needs.
Collapse
Affiliation(s)
| | - Joseph A. Lin
- Department of Surgery, University of California, San Francisco
| | - Alexis Colley
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
| | | | | |
Collapse
|
39
|
Murakami N, Baggett ND, Schwarze ML, Ladin K, Courtwright AM, Goldberg HJ, Nolley EP, Jain N, Landzberg M, Wentlandt K, Lai JC, Shinall MC, Ufere NN, Jones CA, Lakin JR. Top Ten Tips Palliative Care Clinicians Should Know About Solid Organ Transplantation. J Palliat Med 2022; 25:1136-1142. [PMID: 35275707 PMCID: PMC9467633 DOI: 10.1089/jpm.2022.0013] [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: 11/12/2022] Open
Abstract
Solid organ transplantation (SOT) is a life-saving procedure for people with end-stage organ failure. However, patients experience significant symptom burden, complex decision making, morbidity, and mortality during both pre- and post-transplant periods. Palliative care (PC) is well suited and historically underdelivered for the transplant population. This article, written by a team of transplant specialists (surgeons, cardiologists, nephrologists, hepatologists, and pulmonologists), PC clinicians, and an ethics specialist, shares 10 high-yield tips for PC clinicians to consider when caring for SOT patients.
Collapse
Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nathan D Baggett
- Division of Emergency Medicine, Health Partners Institute/Regions Hospital, St. Paul, Minnesota, USA
| | | | - Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, Massachusetts, USA.,Department of Community Health, Tufts University, Medford, Massachusetts, USA
| | - Andrew M Courtwright
- Department of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eric P Nolley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nelia Jain
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael Landzberg
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kirsten Wentlandt
- Division of Palliative Care, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, California, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Section of Palliative Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| |
Collapse
|
40
|
Ladin K, Bronzi OC, Gazarian PK, Perugini JM, Porteny T, Reich AJ, Rodgers PE, Perez S, Weissman JS. Understanding The Use Of Medicare Procedure Codes For Advance Care Planning: A National Qualitative Study. Health Aff (Millwood) 2022; 41:112-119. [PMID: 34982632 PMCID: PMC9683633 DOI: 10.1377/hlthaff.2021.00848] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In 2016 Medicare introduced advance care planning Current Procedural Terminology (CPT) codes to reimburse clinicians for time spent providing the service. Despite recent increases, use of these codes remains low for reasons incompletely captured by quantitative research. To further identify barriers and facilitators to code use for Medicare fee-for-service enrollees, we conducted case studies at eleven health systems, including 272 interviews with clinicians, administrators, and key leadership. Five themes related to use of the new codes emerged: code-based constraints to billing, burdening patients with unexpected charges, ethical concerns with billing for discussion of advance care plans, incentives to signal the importance of their use in billing, and increasing both workflow burden and the need for institutional supports and training. Respondents also observed that use was facilitated by health systems' investment in clinician training and in processes to audit the codes' use. Our findings suggest that increased reimbursement, strong institutional commitment and support, and streamlined workflow could improve the use of the new CPT codes to document receipt of and ensure access to Medicare advance care planning.
Collapse
Affiliation(s)
| | | | | | | | | | - Amanda J. Reich
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | |
Collapse
|