Facilitating Timely Advance Care Planning: Discussions in the Ambulatory Setting With a Heart Failure Population

Shared Decision-Making Tools Implemented in the Electronic Health Record: Scoping Review

BACKGROUND

Patient-centered care promotes the involvement of patients in decision-making related to their health care. The adoption and implementation of shared decision-making (SDM) into routine care are constrained by several obstacles, including technical and time constraints, clinician and patient attitudes and perceptions, and processes that exist outside the standardized clinical workflow.

OBJECTIVE

We aimed to understand the integration and implementation characteristics of reported SDM interventions integrated into an electronic health record (EHR) system.

METHODS

We conducted a scoping review using the methodological framework by Arksey and O'Malley with guidance from the Joanna Briggs Institute. Eligibility criteria included original research and reviews focusing on SDM situations in a real-world clinical setting and EHR integration of SDM tools and processes. We excluded retrospective studies, conference abstracts, simulation studies, user design studies, opinion pieces, and editorials. To identify eligible studies, we searched the following databases on January 11, 2021: MEDLINE, Embase, CINAHL Complete, Cochrane Library including CENTRAL, PsycINFO, Scopus, and Web of Science Core Collection. We systematically categorized descriptive data and key findings in a tabular format using predetermined data charting forms. Results were summarized using tables and associated narratives related to the review questions.

RESULTS

Of the 2153 studies, 18 (0.84%) were included in the final review. There was a high degree of variation across studies, including SDM definitions, standardized measures, technical integration, and implementation strategies. SDM tools that targeted established health care processes promoted their use. Integrating SDM templates and tools into an EHR appeared to improve the targeted outcomes of most (17/18, 94%) studies. Most SDM interventions were designed for clinicians. Patient-specific goals and values were included in 56% (10/18) of studies. The 2 most common study outcome measures were SDM-related measures and SDM tool use.

CONCLUSIONS

Understanding how to integrate SDM tools directly into a clinician's workflow within the EHR is a logical approach to promoting SDM into routine clinical practice. This review contributes to the literature by illuminating features of SDM tools that have been integrated into an EHR system. Standardization of SDM tools and processes, including the use of patient decision aids, is needed for consistency across SDM studies. The implementation approaches for SDM applications showed varying levels of planning and effort to promote SDM intervention awareness. Targeting accepted and established clinical processes may enhance the adoption and use of SDM tools. Future studies designed as randomized controlled trials are needed to expand the quality of the evidence base. This includes the study of integration methods into EHR systems as well as implementation methods and strategies deployed to operationalize the uptake of the SDM-integrated tools. Emphasizing patients' goals and values is another key area for future studies.

Heart failure outpatient clinics resources in Italy: a viewpoint of Italian Society of Cardiology organization

The current paper reports the model organization, level of health care, and type of medical and research activities related to the existing heart failure centers of the Italian Society of Cardiology. Of note, we conduced an internal survey among the members of heart failure working group and related hospital and territorial sites about the quality of care and assistance levels according to the local hospital resources and type of diagnostic therapeutic and management resources. Thirty-two hospital ambulatorial structures have been identified, the centers were equally distributed within the national ground, with similar concentration between north and south regions of the Italian country. We distinguished three different levels of organization: (1) basal territorial clinics in which patients with suspected or already diagnosed heart failure (HF) are initially identified and screened; (2) intermediate clinics in which HF patients can be routinary followed by HF specialists supported by a dedicated staff including imaging and arrythmologist experts, and interventional cardiologist; (3) advanced clinics composed by all the technical and staff resources capable of guarantying repetitive invasive assessment, continuous invasive monitoring, dedicated telemedicine structures focused on more advanced HF management integrated by heart transplantation or mechanical assistance programs. Different type of assistance is supported by a relevant number of research activity primarily conducted by the Italian Society of Cardiology or spontaneous studies arranged by HF specialist members. The number of HF centers has increased over the past few decades in proportion to the progressive rise in HF diagnoses and associated hospitalization. The expansion of ambulatory structures has been facilitated by an increasing socioeconomic and research influence. The quality of HF services in Italy could be raised by improving the network and connections between HF specialists, general practitioners (GPs), caregivers, and other specialists frequently working in this field.

Crucial Conversations for High-Risk Populations before Surgery: Advance Care Planning in a Preoperative Setting

Background: High-risk patients undergoing elective surgery are at risk for perioperative complications, including readmissions and death. Advance care planning (ACP) may allow for preparation for such events. Objectives: (1) To assess the completion rate of advance directives (ADs) and their association with one year readmissions and mortality (2) to examine clinical events for decedents. Design: This is an observational cohort study conducted through chart review. Setting/Subjects: Subjects were 400 patients undergoing preoperative evaluation for elective surgery at two hospitals in the United States. Measurements: The prevalence of ADs at the time of surgery and at one year, readmissions, and mortality at one year were determined. Results: Three-hundred ninety patients were included. In total, 102 (26.4%) patients were readmitted, yet did not complete an AD. Seventeen (4.4%) patients filed an AD during follow-up. Nineteen patients died and mortality rate was 4.9%. There was a significant association between completing an AD before death. Of the decedents, seven (37%) underwent resuscitation, but only four had ADs. Conclusions: Many high-risk surgical patients would benefit from ADs before clinical decline. Preoperative clinics present a missed opportunity to ensure ACP occurs before complications arise.