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Bose Brill S, Riley SR, Prater L, Schnell PM, Schuster ALR, Smith SA, Foreman B, Xu WY, Gustin J, Li Y, Zhao C, Barrett T, Hyer JM. Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure. J Gen Intern Med 2024:10.1007/s11606-024-08604-1. [PMID: 38769259 DOI: 10.1007/s11606-024-08604-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 01/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice. OBJECTIVE Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life. DESIGN This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020. PARTICIPANTS A total of 48,466 deceased patients diagnosed with heart failure on Medicare. MAIN MEASURES Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services. KEY RESULTS In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter. CONCLUSIONS Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.
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Affiliation(s)
- Seuli Bose Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH, 43215, USA.
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Sean R Riley
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH, 43215, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Laura Prater
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Patrick M Schnell
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Biostatistics, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Anne L R Schuster
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sakima A Smith
- Division of Cardiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Beth Foreman
- Division of Cardiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Wendy Yi Xu
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Jillian Gustin
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Yiting Li
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Chen Zhao
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Todd Barrett
- Ohio State University Ross Heart Hospital, Columbus, OH, USA
| | - J Madison Hyer
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Lasmarías C, Aradilla-Herrero A, Silva Fontana Rosa N, Trelis J. Perceptions and experiences of onco-haematology professionals in relation to advance care planning: a qualitative study. Support Care Cancer 2024; 32:180. [PMID: 38386075 DOI: 10.1007/s00520-024-08371-z] [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: 07/21/2023] [Accepted: 02/11/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE The objective of this study is to identify the beliefs, values, perceptions, and experiences of medical oncology, radiation oncology, and clinical haematology professionals about the advance care planning process. METHODS Qualitative exploratory study. There were four focus groups with 14 nurses and 12 physicians (eight medical oncology, one radiation oncology, three haematology). A reflexive thematic analysis of the data obtained was performed. RESULTS We identified 20 thematic categories, which we grouped into four themes: lack of knowledge about advance care planning; perception of the advance care planning process: knowledge acquired from practice; barriers and facilitators for the implementation of advance care planning; and communication as a key aspect of advance care planning. CONCLUSIONS The participants valued advance care planning as an early intervention tool that promotes autonomy. They perceived difficulties in approaching planning due to lack of knowledge, training, and time. They identified the therapeutic relationship with the person, the participation of the person's loved ones, teamwork, and communication skills as essential to ensuring the quality of the process. Finally, they recognised that palliative care professionals provide added value in supporting planning processes.
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Affiliation(s)
- Cristina Lasmarías
- Nursing Research Unit, Catalan Institute of Oncology, Barcelona, Spain.
- GRIN IDIBELL Research Group, IDIBELL / Universitat de Barcelona, Barcelona, Spain.
| | - Amor Aradilla-Herrero
- Escuelas Universitarias Gimbernat (EUG), adscrita a la Universitat Autònoma de Barcelona, Sant Cugat del Vallès, 08174, Barcelona, Spain
| | | | - Jordi Trelis
- Hospital de Martorell, Barcelona, Martorell, Spain
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Golmohammadi M, Ebadi A, Ashrafizadeh H, Rassouli M, Barasteh S. Factors related to advance directives completion among cancer patients: a systematic review. BMC Palliat Care 2024; 23:3. [PMID: 38166983 PMCID: PMC10762918 DOI: 10.1186/s12904-023-01327-w] [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: 02/12/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. METHODS A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. RESULTS Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". CONCLUSION The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.
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Affiliation(s)
- Mobina Golmohammadi
- Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hadis Ashrafizadeh
- Student Research Committee, Faculty of Nursing, Dezful University of Medical Sciences, Dezful, Iran
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Salman Barasteh
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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Levoy K, Sullivan SS, Chittams J, Myers RL, Hickman SE, Meghani SH. Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care. J Pain Symptom Manage 2023; 65:e715-e743. [PMID: 36764411 PMCID: PMC10192153 DOI: 10.1016/j.jpainsymman.2023.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
CONTEXT There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer. OBJECTIVE To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer. METHODS Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990-2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting. RESULTS Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes-cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use-were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use. CONCLUSION This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana.
| | - Suzanne S Sullivan
- School of Nursing (S.S.S.), University at Buffalo, State University of New York, Buffalo, New York
| | - Jesse Chittams
- BECCA (Biostatistics, Evaluation, Collaboration, Consultation & Analysis) Lab, Office of Nursing Research (J.C.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Ruth L Myers
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana
| | - Susan E Hickman
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences (S.H.M.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics (S.H.M.), University of Pennsylvania, Philadelphia, Pennsylvania
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Bar-Sela G, Tur-Sinai A, Givon-Schaham N, Bentur N. Advance Care Planning and Attainment of Cancer Patients' End-of-Life Preferences: Relatives' Perspective. Am J Hosp Palliat Care 2023; 40:322-328. [PMID: 35587799 PMCID: PMC9941650 DOI: 10.1177/10499091221099921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The purpose of this study is to determine which element of advance care planning (ACP) - an advance directives (AD) document or an end-of-life discussion between patient and family (DwF), if any-improves the likelihood of cancer patients' attaining their preferences regarding treatments in the last month of life and dying in the place they prefer. METHODS First-degree relatives of deceased cancer patients, interviewed by telephone, were asked if the treatments the patients received in their last month of life and their place of death corresponded to the patients' preferences. Nominal logistic regression analyses were conducted in search of significant association between having an AD document and/or conducting a DwF and patients' treatment and place of death in accordance with their preferences. RESULTS 491 deceased patients were included in the study. Their average age was 68; 52% were women. According to 32% of the relatives, the patients' treatment in the last month of life was aligned with their preferences and 55% said the patients had died in their preferred place. Only 16.5% had an AD document, 58.5% only discussed their treatment preferences with relatives, and 25% did neither. DwF and ability to speak until last week of life were significantly related to receiving treatment consistent with patients' preferences. Dying where the patient prefers is significantly associated with having an AD and a DwF, with an AD yielding higher odds. CONCLUSION A multifaceted interconnection exists between the two elements of ACP in attaining cancer patients' wishes and abetting better end of life care.
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Affiliation(s)
- Gil Bar-Sela
- Oncology and Hematology Division, Emek Medical Center, Israel
| | - Aviad Tur-Sinai
- Department of Health Systems Management, The Max Stern Yezreel Valley College, Jezreel Valley, Israel,School of Nursing, University of Rochester Medical Center, New York
| | - Noa Givon-Schaham
- The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Netta Bentur
- The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Israel,Netta Bentur, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Utilisation of goals of care discussions and palliative care prior to image-guided procedures near the end of life. Clin Radiol 2022; 77:345-351. [PMID: 35177227 DOI: 10.1016/j.crad.2022.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/19/2022] [Indexed: 11/03/2022]
Abstract
AIM To characterise image-guided procedures performed near the end of life and the use of goals of care discussions (GOC) and palliative care consultation (PCC) prior to these procedures. MATERIALS AND METHODS Retrospective chart review of 3,714 consecutive inpatient procedures performed for 2,351 patients and 8,206 outpatient procedures performed for 5,225 patients within a suburban medical system. Data were collected on demographics, procedures performed, mortality, and use of GOC or PCC prior to the procedures. Procedures near the end of life were classified as emergent, elective, or palliative. Logistic regression was used to assess for demographic disparities in care. RESULTS Nine percent of inpatients died within 30 days of their procedure, 57% of which were within the same hospitalisation. Of these patients, 59% had a documented GOC and 35% had a PCC. Similarly, 7% of outpatients died within 6 months of their procedure. A minority of these patients had a documented GOC (37%) or PCC (13%). There were few statistically significant demographic disparities in this care and the associated odds ratios were small. CONCLUSION A wide array of image-guided procedures is performed near the end of life. GOC and PCC are underutilised prior to these procedures. Few demographic disparities exist in this care.
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Fleuren N, Depla MFIA, Pasman HRW, Janssen DJA, Onwuteaka-Philipsen BD, Hertogh CMPM, Huisman M. Association Between Subjective Remaining Life Expectancy and Advance Care Planning in Older Adults: A Cross-Sectional Study. J Pain Symptom Manage 2021; 62:757-767. [PMID: 33631323 DOI: 10.1016/j.jpainsymman.2021.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 01/06/2023]
Abstract
CONTEXT Advance care planning (ACP) becomes more relevant with deteriorating health or increasing age. People might be more inclined to engage in ACP as they feel that they are approaching end of life. The perception of approaching end of life could be quantified as subjective remaining life expectancy (SRLE). OBJECTIVES First, to describe the prevalence of ACP with health care providers or written directives ("formal engagement in ACP") and ACP with loved-ones ("informal engagement in ACP") among older persons in the general population in The Netherlands. Second, to assess the association between SRLE and engagement in ACP. METHODS Cross-sectional study using data from the Longitudinal Aging Study Amsterdam (LASA) measurement wave of 2015-2016. Participants (n = 1585) were aged ≥ 57 years. RESULTS Median age was 69.4 years (IQR: 64.1-76.7), and median SRLE 25.9 years (17.7-36.0). Formal engagement in ACP was present in 32.6%, informal without formal engagement in 45.8%, and 21.6% was not engaged in ACP. For respondents with SRLE < 25 years, there was a nonstatistically significant association between SRLE and engagement in ACP (aOR: 0.97; 95% CI: 0.93-1.01; P= .088), and a statistically significant, small association with formal vs. informal engagement in ACP (aOR: 0.96; 0.93-0.99; P= .009). For respondents with SRLE ≥ 25 years there was no association between SRLE and engagement in ACP. CONCLUSION The perception of approaching end of life is associated with higher prevalence of formal engagement in ACP, but only for those with SRLE < 25 years. For clinicians, asking patients after their SRLE might serve as a starting point to explore readiness for ACP.
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Affiliation(s)
- Nienke Fleuren
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Marja F I A Depla
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - H Roeline W Pasman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Daisy J A Janssen
- Maastricht University, Care and Public Health Research Institute, Health Services Research, Maastricht, The Netherlands; CIRO, Research and Development, Horn, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Amsterdam UMC, Vrije Universiteit Amsterdam, Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Martijn Huisman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Vrije Universiteit Amsterdam, Faculty of Sociology, Amsterdam, The Netherlands
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Yeun YR. The Effects of Advance Care Planning on Decision Conflict and Psychological Distress: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2021; 24:144-153. [PMID: 37674564 PMCID: PMC10180057 DOI: 10.14475/jhpc.2021.24.3.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 09/08/2023]
Abstract
Purpose Advance care planning (ACP) is widely understood to improve end-of-life care. This systematic review and meta-analysis aimed to examine the effects of ACP interventions on decision conflict and psychological distress. Methods A search of PubMed, CINAHL, CENTRAL, EMBASE, KISS, KoreaMed, and RISS was conducted in November 2020. The study included randomized controlled trials. Data were pooled using fixed- and random-effects models. Results Fourteen studies were identified that cumulatively included 1,548 participants. ACP interventions were effective in alleviating decision conflict (d=-0.53; 95% CI -0.83 to -0.23), depression (d=-1.22; 95% CI -1.71 to -0.74) and anxiety (d=-0.76; 95% CI -1.12 to -0.39). Conclusion ACP interventions have significant positive effects on reducing decision conflict and psychological distress. A high level of bias was shown related to allocation concealment and blinding. The results of this study are expected to be useful for end-of-life care providers to improve the effectiveness of ACP interventions.
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Affiliation(s)
- Young-Ran Yeun
- Department of Nursing, Kangwon National University, Samcheok, Korea
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Prater LC, O'Rourke B, Schnell P, Xu W, Li Y, Gustin J, Lockwood B, Lustberg M, White S, Happ MB, Retchin SM, Wickizer TM, Bose-Brill S. Examining the Association of Billed Advance Care Planning With End-of-Life Hospital Admissions Among Advanced Cancer Patients in Hospice. Am J Hosp Palliat Care 2021; 39:504-510. [PMID: 34427154 DOI: 10.1177/10499091211039449] [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: 11/17/2022] Open
Abstract
BACKGROUND Advance care planning (ACP), or the consideration and communication of care preferences for the end-of-life (EOL), is a critical process for improving quality of care for patients with advanced cancer. The incorporation of billed service codes for ACP allows for new inquiries on the association between systematic ACP and improved EOL outcomes. OBJECTIVE Using the IBM MarketScan® Database, we conducted a retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice between January 2016 and December 2017. We evaluated the association between billed ACP services and EOL hospital admissions in the final 30 days of life. DESIGN This is a cross-sectional retrospective cohort study. PARTICIPANTS A total of 3,705 patients met the study criteria. MAIN MEASURES ACP was measured via the presence of a billed ACP encounter (codes 99497 and 99498) prior to the last 30 days of life; hospital admissions included a dichotomous indicator for inpatient admission in the final 30 days of life. KEY RESULTS Controlling for key covariates, patients who received billed ACP were less likely to experience inpatient hospital admissions in the final 30 days of life compared to those not receiving billed ACP (OR: 0.34; p < 0.001). CONCLUSION The receipt of a billed ACP encounter is associated with reduced EOL hospital admissions in a population of patients with advanced cancer on hospice care. Strategies for consistent, anticipatory delivery of billable ACP services prior to hospice referral may prevent potentially undesired late-life hospital admissions.
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Affiliation(s)
- Laura C Prater
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.,Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Brian O'Rourke
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Patrick Schnell
- Division of Biostatistics, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Wendy Xu
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Yiting Li
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Jillian Gustin
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Bethany Lockwood
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Maryam Lustberg
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus OH, USA.,James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Susan White
- James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Beth Happ
- The Ohio State University College of Nursing, Columbus, OH, USA
| | - Sheldon M Retchin
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Thomas M Wickizer
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Garg T, Shnayder-Adams MM, Keller EJ, Makary MS. Ethical Issuing Arising Around Biliary Interventions. Semin Intervent Radiol 2021; 38:388-392. [PMID: 34393351 DOI: 10.1055/s-0041-1731407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tushar Garg
- Division of Vascular and Interventional Radiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Eric J Keller
- Division of Vascular and Interventional Radiology, Stanford University, Stanford, California
| | - Mina S Makary
- Division of Vascular and Interventional Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Lim MJR, Foo QXJ, Chan NGC, Miny S. PROTOCOL: Community-based interventions for initiating early end-of-life conversations in nonterminally Ill adults: a systematic review. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1168. [PMID: 37051181 PMCID: PMC8356288 DOI: 10.1002/cl2.1168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
This systematic review aims to answer the following research questions: (1) What are the existing community-based interventions for initiating advance care planning (ACP) conversations and quality end-of-life (EoL) planning behaviours in nonterminally ill adults internationally? (2) What are the effects of community-based interventions on the initiation of ACP conversations and EoL planning behaviours of nonterminally ill adults in the community?
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Affiliation(s)
| | - Qi Xuan Joel Foo
- Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
| | | | - Samuel Miny
- Research Support UnitNUS Yong Loo Lin School of MedicineSingaporeSingapore
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Vukkadala N, Fardeen T, Ramchandran K, Divi V. End-of-Life Practice Patterns in Head and Neck Cancer. Laryngoscope 2021; 131:1769-1773. [PMID: 33491219 DOI: 10.1002/lary.29423] [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: 04/24/2020] [Revised: 12/16/2020] [Accepted: 01/04/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE/HYPOTHESIS Despite the importance of symptom management and end-of-life (EOL) care in head and neck cancers (HNC), there is little literature on care practices in this population. This study examines EOL care practice patterns using nationally established metrics. STUDY DESIGN Retrospective chart review. METHODS Review of HNC patients who were actively followed and treated (defined as one clinic note within 90 days, two within preceding 9 months, and having received treatment at our institution) and died between January 1, 2017 and December 31, 2018. The cohort was reviewed for performance on Quality Oncology Practice Initiative (QOPI®) and other metrics. RESULTS Of 133 patients identified, 52 met inclusion criteria. The average age at death was 69.8 years. About 59% had distant metastases, 30% had locoregional disease, 11% were undergoing primary treatment. Twenty-three percentage received chemotherapy within the last 14 days of life. Fifty percentage of patients were admitted in the last 30 days of life, and 33% died in the hospital. Fifty-four percentage of patients had either Physician Orders for Life-Sustaining Treatment or Advanced Directive on file. Eighty-one percentage of patients had any type of goals of care discussion documented. Sixty-five percentage of all patients received referrals to palliative care and 46% of all patients enrolled in hospice. The median days in hospice was 12. Having a goals of care discussion was significantly associated with utilization of palliative and hospice care. CONCLUSIONS Provider-documented goals of care discussions were strongly correlated to referrals and enrollment in palliative and hospice care. Areas for improvement include better documentation of treatment directives and reducing low-utility treatments. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1769-1773, 2021.
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Affiliation(s)
- Neelaysh Vukkadala
- Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Touran Fardeen
- Department of Medicine, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Kavitha Ramchandran
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Vasu Divi
- Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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Living with Metastatic Cancer: A Roadmap for Future Research. Cancers (Basel) 2020; 12:cancers12123684. [PMID: 33302472 PMCID: PMC7763639 DOI: 10.3390/cancers12123684] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Although people with metastatic cancer are living longer with their disease, they are faced with challenges that can interfere with their quality of life. These challenges include worsening disease, survival time, symptoms, distress, and financial problems. The aim of this review paper is to describe a framework to guide future efforts to address these challenges. The framework includes the risk factors (predisposing factors), triggers (precipitating factors), and responses (perpetuating factors) that contribute to the onset and maintenance of problems in living with metastatic cancer. We conclude by suggesting areas for future work to prevent problems, manage triggers, and reduce unhelpful responses. Abstract Living with metastatic cancer, or metavivorship, differs from cancer survivorship and has changed as novel treatments have increased survival time. The purpose of this narrative review is to describe factors that impact challenges in metavivorship within a conceptual framework to guide future research. This review focuses on the specific metavivorship outcomes of progressive disease, survival time, symptoms, distress, financial toxicity, and quality of life. We describe the predisposing, precipitating, and perpetuating (3P) model of metavivorship. Understanding the biological, psychological, and social 3P factors that contribute to the development and maintenance of challenges in metavivorship provides a roadmap for future research. Implications of this model include prevention by targeting predisposing factors, management of precipitating factors after onset of metastatic disease, and treatment of perpetuating factors to reduce symptoms and improve quality of life during the chronic phase of metavivorship. This can be accomplished through biopsychosocial screening efforts, monitoring of patient-reported outcomes, education and communication interventions, interdisciplinary symptom management, advance care planning, and behavioral interventions to cultivate psychological resilience.
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The Impact of Organizational Factors on Nurses' Knowledge, Perceptions, and Behaviors Around Advance Care Planning. J Hosp Palliat Nurs 2020; 22:283-291. [PMID: 32568936 DOI: 10.1097/njh.0000000000000656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to understand the organizational context of nurses' use of advance care plans (ACPs). We use a modified version of Bandera's social cognitive theory model to understand relationships between organizational constructs such as experience with ACPs and satisfaction with organizational support and oncology nurses' knowledge, behaviors, and perceptions around ACPs. The sample included practicing registered nurses with a major focus in oncology who were members of the Oncology Nursing Society in the United States, and nurses at medical hospital or community care settings were included. Institutional review board approval was obtained, and permission was granted from the oncology nursing organization for online surveys. A validated ACP survey was used to measure nurses' experiences and perceptions of working with ACP. Perceptions of ACP by patients, vicarious experience with ACP, direct experience of ACP, having received training, and perceptions of organizational support for ACP were all predictive of total ACP behaviors in the workplace. The final regression model had 3 independent variables and accounted for 33% of the variance in total ACP behaviors. Both vicarious and direct experience with ACP was associated with ACP behaviors in workplaces. This implies the need for more vicarious and direct training experiences, as well as organization support, to build self-efficacy to perform ACP.
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15
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Dalhammar K, Malmström M, Schelin M, Falkenback D, Kristensson J. The impact of initial treatment strategy and survival time on quality of end-of-life care among patients with oesophageal and gastric cancer: A population-based cohort study. PLoS One 2020; 15:e0235045. [PMID: 32569329 PMCID: PMC7307755 DOI: 10.1371/journal.pone.0235045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/10/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Oesophageal and gastric cancer are highly lethal malignancies with a 5-year survival rate of 15-29%. More knowledge is needed about the quality of end-of-life care in order to understand the burden of the illness and the ability of the current health care system to deliver timely and appropriate end-of-life care. The aim of this study was to describe the impact of initial treatment strategy and survival time on the quality of end-of-life care among patients with oesophageal and gastric cancer. METHODS This register-based cohort study included patients who died from oesophageal and gastric cancer in Sweden during 2014-2016. Through linking data from the National Register for Esophageal and Gastric Cancer, the National Cause of Death Register, and the Swedish Register of Palliative Care, 2156 individuals were included. Associations between initial treatment strategy and survival time and end-of-life care quality indicators were investigated. Adjusted risk ratios (RRs) with 95% confidence intervals were calculated using modified Poisson regression. RESULTS Patients with a survival of ≤3 months and 4-7 months had higher RRs for hospital death compared to patients with a survival ≥17 months. Patients with a survival of ≤3 months also had a lower RR for end-of-life information and bereavement support compared to patients with a survival ≥17 months, while the risks of pain assessment and oral assessment were not associated with survival time. Compared to patients with curative treatment, patients with no tumour-directed treatment had a lower RR for pain assessment. No significant differences were shown between the treatment groups regarding hospital death, end-of-life information, oral health assessment, and bereavement support. CONCLUSIONS Short survival time is associated with several indicators of low quality end-of-life care among patients with oesophageal and gastric cancer, suggesting that a proactive palliative care approach is imperative to ensure quality end-of-life care.
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Affiliation(s)
- Karin Dalhammar
- Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Marlene Malmström
- Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Maria Schelin
- Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Dan Falkenback
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Jimmie Kristensson
- Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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16
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Fernandes R, Fess EG, Sullivan S, Brack M, DeMarco T, Li D. Supportive Care for Superutilizers of a Managed Care Organization. J Palliat Med 2020; 23:1444-1451. [PMID: 32456602 PMCID: PMC7583336 DOI: 10.1089/jpm.2019.0288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Ohana Health Plan, Inc., (OHP) is one of the first managed care organizations offering supportive care services targeted to superutilizers. Bristol Hospice Hawaii, LLC, partnered with OHP to provide interdisciplinary supportive care services to home-bound OHP members. Objectives: The purpose of this study was to measure symptom relief, satisfaction, resource utilization, and cost savings associated with supportive care. Design: Prospective study. Setting: Over 12 months, 27 superutilizer members residing in the community were referred by OHP, 21 members were enrolled into supportive care. Measurements: Data were collected upon admission and repeatedly thereafter using the Edmonton Symptom Assessment Scale (ESAS) and the Missoula-Vitas Quality of Life Index (MVQOLI). The Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale was administered at discharge. Emergency department (ED) visits and hospital utilization were tracked. Results: Median age was 63 years; more than half had cardiac diagnoses. Majority of members were Hawaiian and other Pacific Islander. Median length of stay in supportive care was 90 days. Five (23%) members enrolled in hospice following supportive care. Symptom improvement occurred in pain (p < 0.0001), anxiety (p = 0.0052), and shortness of breath (p = 0.0447). This model has shown a 79.5% reduction of ED visits per thousand members and a 75% reduction of hospitalizations per thousand. Overall net savings was 36%. Discussions and documentation of end-of-life wishes increased from 23% to 85%. Conclusion: Supportive care is highly effective in reducing costs associated with superutilizers. Our experience demonstrates the effectiveness of supportive care approaches in this population through improved care and lower health care costs overall.
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Affiliation(s)
- Ritabelle Fernandes
- Division of Palliative Medicine, Department of Geriatric Medicine, John A Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.,Bristol Hospice Hawaii, LLC, Honolulu, Hawaii, USA
| | - Ed G Fess
- Ohana Health Plan, Inc., Honolulu, Hawaii, USA
| | | | - Mona Brack
- Ohana Health Plan, Inc., Honolulu, Hawaii, USA
| | - Tara DeMarco
- Bristol Hospice Hawaii, LLC, Honolulu, Hawaii, USA
| | - Dongmei Li
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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McDermott CL, Engelberg RA, Sibley J, Sorror ML, Curtis JR. The Association between Chronic Conditions, End-of-Life Health Care Use, and Documentation of Advance Care Planning among Patients with Cancer. J Palliat Med 2020; 23:1335-1341. [PMID: 32181689 DOI: 10.1089/jpm.2019.0530] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Multiple chronic conditions (MCCs) are associated with increased intensity of end-of-life (EOL) care, but their effect is not well explored in patients with cancer. Objective: We examined EOL health care intensity and advance care planning (ACP) documentation to better understand the association between MCCs and these outcomes. Design: Retrospective cohort study. Setting/Subjects: Patients aged 18+ years at UW Medicine who died during 2010-2017 with poor prognosis cancer, with or without chronic liver disease, chronic pulmonary disease, coronary artery disease, dementia, diabetes with end-stage organ damage, end-stage renal disease, heart failure, or peripheral vascular disease. Measurements: ACP documentation 30+ days before death, in-hospital death, and inpatient or intensive care unit (ICU) admission in the last 30 days. We performed logistic regression for outcomes. Results: Of 15,092 patients with cancer, 10,596 (70%) had 1+ MCCs (range 1-8). Patients with cancer and heart failure had highest odds of hospitalization (odds ratio [OR] 1.67, 95% confidence interval [CI] 1.46-1.91), ICU admission (OR 2.06, 95% CI 1.76-2.41), or in-hospital death (OR 1.62, 95% CI 1.43-1.84) versus patients with cancer and other conditions. Patients with ACP 30+ days before death had lower odds of in-hospital death (OR 0.65, 95% CI 0.60-0.71), hospitalization (OR 0.67, 95% CI 0.61-0.74), or ICU admission (OR 0.71, 95% CI 0.64-0.80). Conclusions: Patients with ACP 30+ days before death had lower odds of high-intensity EOL care. Further research needs to explore how to best use ACP to ensure patients receive care aligned with patient and family goals for care.
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Affiliation(s)
- Cara L McDermott
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - James Sibley
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Mohamed L Sorror
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutch, Seattle, Washington, USA
| | - J Randall Curtis
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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