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Leao DLL, Pavlova M, Groot W. Risk selection reduces efficiency of value-based healthcare. Int J Health Plann Manage 2023; 38:1088-1096. [PMID: 37665086 DOI: 10.1002/hpm.3648] [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: 03/29/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 09/05/2023] Open
Abstract
Value-based healthcare aims to improve efficiency and value for patients. Value-based payment models are a form of provider reimbursement to achieve this. Studies on these models have found positive results, but may be biased by unintended consequences, such as risk selection. Risk selection is a multi-dimensional phenomenon that occurs at the patient, hospital, and system level, and is a source of inefficiency and inequality in healthcare. Risk selection may occur because of selection bias in the outcomes that are evaluated and rewarded, or due to the selection of lower cost patients. Risk selection may also stem from professional reputation. The motivation to engage in risk selection may also arise from differences in the meaning of value. To mitigate these unintended consequences, several strategies can be adopted. These include making value-based payment models attractive, but not mandatory, as well as incentivising transparent reporting of best practices, using adequate risk adjustment, expanding performance metrics, and including patient-reported experience measures. Other mitigation strategies could include adopting a mixture of performance measures, using mixed methods of paying physicians, and implementing monitoring and evaluation mechanisms. However, such approaches are not flawless, and the problem may never be fully solved. This perspective serves as a warning for the constant presence of risk selection, as well as informing policy makers, politicians, and organisations implementing VBP models on ways to minimise the possibility of risk selection.
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Affiliation(s)
- Diogo L L Leao
- Department of Health Services Research, CAHPRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAHPRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Wim Groot
- Department of Health Services Research, CAHPRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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2
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Walling AM, Ast K, Harrison JM, Dy SM, Ersek M, Hanson LC, Kamal AH, Ritchie CS, Teno JM, Rotella JD, Periyakoil VS, Ahluwalia SC. Patient-Reported Quality Measures for Palliative Care: The Time is now. J Pain Symptom Manage 2023; 65:87-100. [PMID: 36395918 DOI: 10.1016/j.jpainsymman.2022.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT While progress has been made in the ability to measure the quality of hospice and specialty palliative care, there are notable gaps. A recent analysis conducted by Center for Medicare and Medicaid Services (CMS) revealed a paucity of patient-reported measures, particularly in palliative care domains such as symptom management and communication. OBJECTIVES The research team, consisting of quality measure and survey developers, psychometricians, and palliative care clinicians, used established state-of-the art methods for developing and testing patient-reported measures. METHODS We applied a patient-centered, patient-engaged approach throughout the development and testing process. This sequential process included 1) an information gathering phase; 2) a pre-testing phase; 3) a testing phase; and 4) an endorsement phase. RESULTS To fill quality measure gaps identified during the information gathering phase, we selected two draft measures ("Feeling Heard and Understood" and "Receiving Desired Help for Pain") for testing with patients receiving palliative care in clinic-based settings. In the pre-testing phase, we used an iterative process of cognitive interviews to refine draft items and corresponding response options for the proposed measures. The alpha pilot test supported establishment of protocols for the national beta field test. Measures met conventional criteria for reliability, had strong face and construct validity, and there was diversity in program level scores. The measures received National Quality Forum (NQF) endorsement. CONCLUSION These measures highlight the key role of patient voices in palliative care and fill a much-needed gap for patient-reported experience measures in our field.
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Affiliation(s)
- Anne M Walling
- Department of Medicine (A.W.), University of California, Los Angeles, California; VA Greater Los Angeles Health System (A.W.), Los Angeles, California; RAND Health Care (A.W., J.H., S.A.), Santa Monica, California.
| | - Katherine Ast
- American Academy of Hospice and Palliative Medicine (K.A.,J.R.), Chicago, Illinois
| | | | - Sydney M Dy
- Department of Health Policy and Management (S.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mary Ersek
- Department of Veterans Affairs (M.E.), Philadelphia, Pennsylvania; University of Pennsylvania Schools of Nursing and Medicine (M.E.), Philadelphia, Pennsylvania
| | - Laura C Hanson
- Division of Geriatric Medicine and Palliative Care Program (L.H.), University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Arif H Kamal
- Duke University School of Medicine (A.K.), Durham, North Carolina
| | - Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine ( C.R.), Massachusetts General Hospital, Boston, Massachusetts
| | - Joan M Teno
- Oregon Health and Science University School of Medicine (J.T.), Portland, Oregon
| | - Joseph D Rotella
- American Academy of Hospice and Palliative Medicine (K.A.,J.R.), Chicago, Illinois
| | - Vyjeyanthi S Periyakoil
- Stanford University School of Medicine (V.P.),Stanford, California; VA Palo Alto Health Care System (V.P.), Livemore, California, USA
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Cao S, Huang H, Bo S, Feng M, Liang Y, Liu Y, Zhao Q. What influences informal caregivers' risk perceptions and responses to home care safety of older adults with disabilities: A qualitative study. Front Public Health 2022; 10:901457. [PMID: 36091500 PMCID: PMC9449117 DOI: 10.3389/fpubh.2022.901457] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/09/2022] [Indexed: 01/22/2023] Open
Abstract
Objective This study aimed to explore the factors that influence risk perceptions and responses by informal caregivers of older adults with disabilities. Methods A descriptive qualitative study was performed, and the socio-ecological framework was applied to interpret the complex influences on individual risk perceptions and responses. Semistructured interviews were conducted with 16 informal caregivers of older adults with disabilities. The interviews were transcribed verbatim and analyzed using content analysis. Results The four levels of the socio-ecological framework successfully allowed for the analysis of influences on the risk perceptions and responses of informal caregivers as follows: at the individual level: previous experiences, personality characteristics, health literacy, and care burden; at the familial level: economic status, emotional connection, informational and decisional support; at the community level: health service accessibility and neighbor communication; and at the social level: responsibility-driven culture, media advocacy, and aging policies. Conclusions The establishment of risk perceptions and coping behaviors by informal caregivers was affected by many factors. Using the framework to interpret our findings provided insight into the influence of these varying factors. Comprehensive, realistic, and achievable strategies are needed for improving the risk perceptions of informal caregivers in home care by addressing personal, familial, and social environmental factors.
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Affiliation(s)
- Songmei Cao
- School of Nursing, Chongqing Medical University, Chongqing, China,Department of Nursing, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huanhuan Huang
- School of Nursing, Chongqing Medical University, Chongqing, China,Department of Nursing, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Suping Bo
- Department of Nursing, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Man Feng
- Department of Nursing, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Yiqing Liang
- Department of Nursing, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Yuqing Liu
- Global Health Research Center, Duke Kunshan University, Kunshan, China
| | - Qinghua Zhao
- Department of Nursing, First Affiliated Hospital of Chongqing Medical University, Chongqing, China,*Correspondence: Qinghua Zhao
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Teno JM. Seriously Ill Individuals—A Canary in the Coal Mine for Medicare’s Transition to Accountable Health Care? JAMA HEALTH FORUM 2022; 3:e222306. [DOI: 10.1001/jamahealthforum.2022.2306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joan M. Teno
- School of Medicine, Oregon Health & Science University, Portland
- School of Public Health, Brown University, Providence, Rhode Island
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Anhang Price R, Bradley MA, Ye F, Schlang D, DeYoreo M, Cleary PD, Elliott MN, Montemayor CK, Timmer M, Tolpadi A, Teno JM. Reliable and Valid Survey-Based Measures to Assess Quality of Care in Home-Based Serious Illness Programs. J Palliat Med 2022; 25:864-872. [PMID: 34936490 PMCID: PMC9145570 DOI: 10.1089/jpm.2021.0424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: There is a pressing need for standardized measures to assess the quality of home-based serious illness care. Currently, there are no validated quality measures that are specific to home-based serious illness programs (SIPs) and the unique needs of their patients. Objective: To develop and evaluate standardized survey-based measures of serious illness care experiences for assessing and comparing quality of home-based serious illness care programs. Methods: From October 2019 through January 2020, we administered a survey to patients who received care from 32 home-based SIPs across the United States. Using the 2263 survey responses, we assessed item performance and constructed composite measures via factor analysis, evaluated item-scale correlations, estimated reliability, and examined validity by regressing overall ratings and willingness to recommend care on each composite. Results: The overall survey response rate was 36%. Confirmatory factor analyses supported five composite quality measures: Communication, Care Coordination, Help for Symptoms, Planning for Care, and Support for Family and Friends. Cronbach's alpha estimates for the composite measures ranged from 0.69 to 0.85, indicating adequate internal consistency in assessing their underlying constructs. Interprogram reliability ranged from 0.67 to 0.80 at 100 completed surveys per measure, meeting common standards for distinguishing between programs' performance. Together, the composites explained 45% of the variance in patients' overall care ratings. Communication, Care Coordination, and Planning for Care were the strongest predictors of overall ratings. Conclusion: Our analyses provide evidence of the feasibility, reliability, and validity of proposed survey-based measures to assess the quality of home-based serious illness care from the perspective of patients and their families.
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Affiliation(s)
- Rebecca Anhang Price
- RAND Corporation, Arlington, Virginia, USA
- Address correspondence to: Rebecca Anhang Price, PhD, RAND Corporation, 1200 S Hayes Street, Arlington, VA 22202, USA
| | | | - Feifei Ye
- RAND Corporation, Pittsburgh, Pennsylvania, USA
| | | | | | - Paul D. Cleary
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | - Joan M. Teno
- Oregon Health and Science University, Portland, Oregon, USA
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Feldman DB, O'Rourke MA, Corn BW, Hudson MF, Patel N, Agarwal R, Fraser VL, Deininger H, Fowler LA, Bakitas MA, Krouse RA, Subbiah IM. Development of a measure of clinicians' self-efficacy for medical communication (SEMC). BMJ Support Palliat Care 2022:bmjspcare-2022-003593. [PMID: 35534186 DOI: 10.1136/bmjspcare-2022-003593] [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: 03/06/2022] [Accepted: 04/21/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Studies of clinician-patient communication have used varied, ad hoc measures for communication efficacy. We developed and validated the Self-Efficacy for Medical Communication (SEMC) scale as a standard, quantitative measure of clinician-reported skills in communicating difficult news. METHODS Using evidence-based scale development guidelines, we created two 16-item forms of the SEMC, one assessing communication with patients and one assessing communication with families. Clinicians providing oncological care in four organisations were invited to participate and provided consent. Participant demographics, responses to the SEMC items and responses to convergent and discriminant measures (those expected to relate strongly and weakly to the SEMC) were collected online. We performed analyses to determine the convergent and discriminant validity of the SEMC as well as its reliability and factor structure. RESULTS Overall, 221 oncology clinicians (including physicians, residents, fellows, medical students, nurses, nurse practitioners and physician assistants) participated. The patient and family forms both demonstrated high internal consistency reliability (alpha=0.94 and 0.96, respectively) and were strongly correlated with one another (r=0.95, p<0.001). Exploratory factor analysis demonstrated that the SEMC measures a unitary construct (eigenvalue=9.0), and its higher mean correlation with convergent (r=0.46) than discriminant (r=0.22) measures further supported its validity. CONCLUSIONS Our findings support the SEMC's validity and reliability as a measure of clinician-rated communication skills regarding conducting difficult conversations with patients and families. It provides a useful standard tool for future research in oncology provider-patient serious illness communication.
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Affiliation(s)
| | - Mark A O'Rourke
- Prisma Health Upstate Cancer Institute, Greenville, South Carolina, USA
| | | | - Matthew F Hudson
- Prisma Health Upstate Cancer Institute, Greenville, South Carolina, USA
| | - Naimik Patel
- Prisma Health Upstate Cancer Institute, Greenville, South Carolina, USA
| | - Rajiv Agarwal
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Heidi Deininger
- University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, USA
| | - Lauren A Fowler
- University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Marie A Bakitas
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Robert A Krouse
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Zaytseva A, Verger P, Ventelou B. United, can we be stronger? Did French general practitioners in multi-professional groups provide more chronic care follow-up during lockdown? BMC Health Serv Res 2022; 22:519. [PMID: 35440039 PMCID: PMC9016683 DOI: 10.1186/s12913-022-07937-z] [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] [Received: 02/07/2022] [Accepted: 04/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background Given the importance of the continuous follow-up of chronic patients, we evaluated the performance of French private practice general practitioners (GPs) practicing in multi-professional group practices (MGP) regarding chronic care management during the first Covid-19 lockdown in Spring 2020 compared to GPs not in MGP. We consider two outcomes: continuity of care provision for chronic patients and proactivity in contacting these patients. Methods The cross-sectional web questionnaire of 1191 GPs took place in April 2020. We exploit self-reported data on: 1) the frequency of consultations for chronic patients during lockdown compared to their “typical” week before the pandemic, along with 2) GPs’ proactive behaviour when contacting their chronic patients. We use probit and bivariate probit models (adjusted for endogeneity of choice of engagement in MGP) to test whether GPs in MGP had significantly different responses to the Covid-19 crisis compared to those practicing outside MGP. Results Out of 1191 participants (response rate: 43.1%), around 40% of GPs were female and 34% were younger than 50 years old. Regression results indicate that GPs in MGP were less likely to experience a drop in consultations related to complications of chronic diseases (− 45.3%). They were also more proactive (+ 13.4%) in contacting their chronic patients compared to their peers practicing outside MGP. Conclusion We demonstrate that the MGP organisational formula was beneficial to the follow-up of patients with chronic conditions during the lockdown; therefore, it appears beneficial to expand integrated practices, since they perform better when facing a major shock. Further research is needed to confirm the efficiency of these integrated practices outside the particular pandemic setup. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07937-z.
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Affiliation(s)
- Anna Zaytseva
- Aix-Marseille University, CNRS, EHESS, Centrale Marseille, AMSE, 5-9 Boulevard Maurice Bourdet, CS 50498, 13205, Marseille Cedex 1, France. .,Southeastern Regional Health Observatory, ORS Paca, Provence-Alpes-Côte d'Azur, Marseille, France, 27 Boulevard Jean Moulin, 13385, Marseille Cedex 5, France.
| | - Pierre Verger
- Southeastern Regional Health Observatory, ORS Paca, Provence-Alpes-Côte d'Azur, Marseille, France, 27 Boulevard Jean Moulin, 13385, Marseille Cedex 5, France.,Aix-Marseille University, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005, Marseille, France
| | - Bruno Ventelou
- Aix-Marseille University, CNRS, EHESS, Centrale Marseille, AMSE, 5-9 Boulevard Maurice Bourdet, CS 50498, 13205, Marseille Cedex 1, France
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8
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Rollison J, Bandini JI, Gilbert M, Phillips J, Ahluwalia SC. Incorporating the Patient and Caregiver Voice in Palliative Care Quality Measure Development. J Pain Symptom Manage 2022; 63:293-300. [PMID: 34389415 DOI: 10.1016/j.jpainsymman.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/03/2021] [Indexed: 11/22/2022]
Abstract
CONTEXT Despite rapid growth in outpatient palliative care, we lack an understanding of patient and caregiver experiences of care received in this context. OBJECTIVES As part of a national effort to develop palliative care quality metrics for use in accountability programs, we sought to develop survey items assessing patients' experiences of outpatient palliative care, incorporating the patient's voice. METHODS We conducted 25 one-hour telephone cognitive interviews using a convenience sample of outpatient palliative care patients and caregivers to cognitively test survey items. Guided by a semi-structured protocol, we assessed the comprehensibility, ambiguity, and adaptability of survey instructions and specific items/response options. RESULTS Participants generally understood the intended meaning of the question content. Some participants struggled with the stated time period of three months as a reference period for reporting their experiences. While some expressed preferences for question wording, no clear patterns emerged across participants. CONCLUSION In general, question wording and response options did not present challenges to understanding content. Respondents ascribed a variety of meanings to the concepts, validating that the measures capture a range of experiences. However, the referenced timeframe of three months was more difficult to answer for some questions than others. Implications for research, policy or practice: Based on the findings from the cognitive testing, the survey items are being tested as part of a national study to understand the quality of care for patients. These measures may be used in the future by Medicare to help outpatient palliative care programs improve their care.
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Affiliation(s)
| | | | | | | | - Sangeeta C Ahluwalia
- RAND Corporation, Santa Monica, California, USA; UCLA Fielding School of Public Health, Los Angeles, California, USA.
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9
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Yorganci E, Sampson EL, Gillam J, Aworinde J, Leniz J, Williamson LE, Cripps RL, Stewart R, Sleeman KE. Quality indicators for dementia and older people nearing the end of life: A systematic review. J Am Geriatr Soc 2021; 69:3650-3660. [PMID: 34331704 DOI: 10.1111/jgs.17387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Robust quality indicators (QIs) are essential for monitoring and improving the quality of care and learning from good practice. We aimed to identify and assess QIs for the care of older people and people with dementia who are nearing the end of life and recommend QIs for use with routinely collected electronic data across care settings. METHODS A systematic review was conducted, including five databases and reference chaining. Studies describing the development of QIs for care of older people and those with dementia nearing the end of life were included. QIs were categorized as relating to processes or outcomes, and mapped against six care domains. The psychometric properties (acceptability, evidence base, definition, feasibility, reliability, and validity) of each QI were assessed; QIs were categorized as robust, moderate, or poor. RESULTS From 12,980 titles and abstracts screened, 37 papers and 976 QIs were included. Process and outcome QIs accounted for 780 (79.7%) and 196 (20.3%) of all QIs, respectively. Many of the QIs concerned physical aspects of care (n = 492, 50.4%), and very few concerned spiritual and cultural aspects of care (n = 19, 1.9%). Three hundred and fifteen (32.3%) QIs were robust and of those 220 were measurable using routinely collected electronic data. The final shortlist of 71 QIs came from seven studies. CONCLUSIONS Of the numerous QIs developed for care of older adults and those with dementia nearing the end of life, most had poor or moderate psychometric properties or were not designed for use with routinely collected electronic datasets. Infrastructure for data availability, combined with use of robust QIs, is important for enhancing understanding of care provided to this population, identifying unmet needs, and improving service provision.
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Affiliation(s)
- Emel Yorganci
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Juliet Gillam
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Jesutofunmi Aworinde
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Javiera Leniz
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Lesley E Williamson
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Rachel L Cripps
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Katherine E Sleeman
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
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García-Navarro EB, Araujo-Hernández M, Rigabert A, Rojas-Ocaña MJ. Attitudes of nursing degree students towards end of life processes. A cultural approach (Spain-Senegal). PLoS One 2021; 16:e0254870. [PMID: 34415902 PMCID: PMC8378746 DOI: 10.1371/journal.pone.0254870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/05/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction The concept of death is abstract, complex and has a number of meanings. Thus, its understanding and the approach taken to it depend, to a large extent, on aspects such as age, culture, training and religion. Nursing students have regular contact with the process of death and so it is of great interest to understand the attitudes they have towards it. As we live in a plural society it is even more interesting to not only understand the attitudes of Spanish students but, also, those of students coming from other countries. In the present article, we seek to identify and compare the attitudes held by nursing degree students at Hekima-Santé University (Senegal) and the University of Huelva (Spain) about end of life processes. The study identifies elements that condition attitudes and coping with death, whilst considering curricular differences with regards to specific end of life training. Method A descriptive, cross-sectional and multi-center study was conducted. The overall sample (N = 142) was divided into groups: Hekima-Santé University (Dakar, Senegal) and the University of Huelva (Huelva, Spain). The measurement instruments used were an ad-hoc questionnaire and Bugen´s Coping with Death Scale. Results Statistically significant differences (p = 0.005, 95%CI) were found in relation to overall Bugen Scale scores. We can confirm that specialized end of life training (University of Huelva, Spain) did not lead to better coping when compared with a population whose academic curriculum did not provide specific training and who engaged in more religious practices (Hekima-Santé University, Senegal). Conclusions In cultures where religion not only influences the spiritual dimension of the individual, but acts in the ethical and moral system and consequently in the economic, educational and family sphere, the accompaniment at the end of life transcends the formative plane. Considering the plural society in which we live, the training that integrates the Degree in Nursing with regard to the care of the final process, must be multidimensional in which spirituality and faith are integrated, working emotional and attentional skills, as well as cultural competence strategies in this process.
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Affiliation(s)
- E. Begoña García-Navarro
- Department of Nursing and Health Sciences, University of Huelva, Huelva, Spain
- Research Group ESEIS, Social Studies and Social Intervention, Center for Research in Contemporary Thought and Innovation for Development (COIDESO), University of Huelva, Huelva, Spain
| | | | - Alina Rigabert
- Methodology and Data Analysis Department, Andalusia Beturia Foundation for Health Research (FABIS), Huelva, Spain
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11
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Bandini JI, Schlang D, Kim H, Bradley M, Price RA, Bunker JN, Teno JM. "If We Turned Our Backs, They Would Ignore Our Wishes": Bereaved Family Perceptions of Concordance of Care at the End of Life. J Palliat Med 2021; 24:1667-1672. [PMID: 33826426 DOI: 10.1089/jpm.2020.0714] [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
Background: The key to high-quality care at the end of life is goal-concordant care, defined as care that is consistent with patient wishes. Objectives: To characterize decedent wishes for care at the end of life and to examine next of kin narratives of their loved ones' perceptions of whether wishes were honored. Design: Mortality follow-back survey and in-depth interviews. Setting/Subjects: Survey responses (n = 601) were from next of kin of decedents who died in the San Francisco Bay area of the United States. Interviews were conducted with 51 next of kin, of whom 14 indicated that the decedent received care that was inconsistent with their wishes. Measurements: The survey asked if the decedent had wishes or plans for care and if care provided ever went against those wishes. In-depth interviews focused on aspects of care at the end of life that were not consistent with the decedent's wishes. Results: Approximately 10% of next of kin who reported on the survey that the decedent had specific wishes for medical care at the end of life also reported that the decedent received care that went against their wishes in the last month of life. The main theme of the in-depth interviews with next of kin who reported care that went against wishes was that discordant care was inconsistent with wishes for comfort-focused care and a lack of symptom palliation. Conclusions: Despite decades of work to improve quality of end-of-life care, poor pain and symptom management that result in lack of comfort remain the main reason that next of kin state wishes were not honored.
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Affiliation(s)
| | | | - Hyosin Kim
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | | | | | - Jennifer N Bunker
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Yank V, Gale RC, Nevedal A, Okwara L, Koenig CJ, Trivedi RB, Dupke NJ, Kabat M, Asch SM. Improving Uptake of a National Web-Based Psychoeducational Workshop for Informal Caregivers of Veterans: Mixed Methods Implementation Evaluation. J Med Internet Res 2021; 23:e16495. [PMID: 33410759 PMCID: PMC7819783 DOI: 10.2196/16495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 07/13/2020] [Accepted: 11/18/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although web-based psychoeducational programs may be an efficient, accessible, and scalable option for improving participant well-being, they seldom are sustained beyond trial publication. Implementation evaluations may help optimize program uptake, but few are performed. When the US Department of Veterans Affairs (VA) launched the web-based psychoeducational workshop Building Better Caregivers (BBC) for informal caregivers of veterans nationwide in 2013, the workshop did not enroll as many caregivers as anticipated. OBJECTIVE This study aims to identify the strengths and weaknesses of initial implementation, strategies likely to improve workshop uptake, whether the VA adopted these strategies, and whether workshop enrollment changed. METHODS We used mixed methods and the Promoting Action on Research Implementation in Health Services (PARIHS) implementation evaluation framework. In stage 1, we conducted semistructured interviews with caregivers, local staff, and regional and national VA leaders and surveys with caregivers and staff. We collected and analyzed survey and interview data concurrently and integrated the results to identify implementation strengths and weaknesses, and strategies likely to improve workshop uptake. In stage 2, we reinterviewed national leaders to determine whether the VA adopted recommended strategies and used national data to determine whether workshop enrollment changed over time. RESULTS A total of 54 caregivers (n=32, 59%), staff (n=13, 24%), and regional (n=5, 9%) and national (n=4, 7%) leaders were interviewed. We received survey responses from 72% (23/32) of caregivers and 77% (10/13) of local staff. In stage 1, survey and interview results were consistent across multiple PARIHS constructs. Although participants from low-enrollment centers reported fewer implementation strengths and more weaknesses, qualitative themes were consistent across high- and low-enrollment centers, and across caregiver, staff, and leadership respondent groups. Identified strengths included belief in a positive workshop impact and the use of some successful outreach approaches. Implementation weaknesses included missed opportunities to improve outreach and to better support local staff. From these, we identified and recommended new and enhanced implementation strategies-increased investment in outreach and marketing capabilities; tailoring outreach strategies to multiple stakeholder groups; use of campaigns that are personal, repeated, and detailed, and have diverse delivery options; recurrent training and mentoring for new staff; and comprehensive data management and reporting capabilities. In stage 2, we determined that the VA had adopted several of these strategies in 2016. In the 3 years before and after adoption, cumulative BBC enrollment increased from 2139 (2013-2015) to 4030 (2016-2018) caregivers. CONCLUSIONS This study expands the limited implementation science literature on best practices to use when implementing web-based psychoeducational programs. We found that robust outreach and marketing strategies and support for local staff were critical to the implementation success of the BBC workshop. Other health systems may want to deploy these strategies when implementing their web-based programs.
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Affiliation(s)
- Veronica Yank
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Randall C Gale
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Andrea Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Leonore Okwara
- Department of Behavioral and Community Health, University of Maryland, Baltimore, MD, United States
| | - Christopher J Koenig
- Department of Communication Studies, San Francisco State University, San Francisco, CA, United States
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, United States
| | - Nancy J Dupke
- VA Caregivers Support Program, Department of Veterans Affairs, Washington, DC, United States
| | - Margaret Kabat
- VA Caregivers Support Program, Department of Veterans Affairs, Washington, DC, United States
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, United States
- Division of Primary Care and Population Health, Stanford University, Palo Alto, CA, United States
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Kolesnichenko O, Mazelis L, Sotnik A, Yakovleva D, Amelkin S, Grigorevsky I, Kolesnichenko Y. Sociological modeling of smart city with the implementation of UN sustainable development goals. SUSTAINABILITY SCIENCE 2021; 16:581-599. [PMID: 33425036 PMCID: PMC7779083 DOI: 10.1007/s11625-020-00889-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/24/2020] [Indexed: 06/12/2023]
Abstract
UNLABELLED The COVID-19 pandemic before mass vaccination can be restrained only by the limitation of contacts between people, which makes the digital economy a key condition for survival. More than half of the world's population lives in urban areas, and many cities have already transformed into "smart" digital/virtual hubs. Digital services ensure city life safe without an economy lockout and unemployment. Urban society strives to be safe, sustainable, well-being, and healthy. We set the task to construct a hybrid sociological and technological concept of a smart city with matched solutions, complementary to each other. Our modeling with the elaborated digital architectures and with the bionic solution for ensuring sufficient data governance showed that a smart city in comparison with the traditional city is tightly interconnected inside like a social "organism". Society has entered a decisive decade during which the world will change by moving closer towards SDGs targets 2030 as well as by the transformation of cities and their digital infrastructures. It is important to recognize the large vector of sociological transformation as smart cities are just a transition phase to human-centered personal space or smart home. The "atomization" of the world urban population raises the gap problem in achieving SDGs because of different approaches to constructing digital architectures for smart cities or smart homes in countries. The strategy of creating smart cities should bring each citizen closer to SDGs at the individual level, laying in the personal space the principles of sustainable development and wellness of personality. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s11625-020-00889-5.
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Affiliation(s)
- Olga Kolesnichenko
- I. M. Sechenov First Moscow State Medical University, 11/2 Rossolimo Street, 119021 Moscow, Russia
| | - Lev Mazelis
- Department of Mathematics and Modeling, Vladivostok State University of Economics and Service, 41 Gogolya Street, 690014 Vladivostok, Russia
| | - Alexander Sotnik
- ZAO (CJSC) Firm CV PROTEK, 2 Chermyanskaya Street, 2, 127282 Moscow, Russia
| | - Dariya Yakovleva
- Department of Mathematics and Modeling, Vladivostok State University of Economics and Service, 41 Gogolya Street, 690014 Vladivostok, Russia
| | - Sergey Amelkin
- Moscow State Linguistic University, 38 Ostozhenka Street, 119034 Moscow, Russia
| | - Ivan Grigorevsky
- A.K. Aylamazyan Program Systems Institute of RAS, 4A Peter I Street, 152024 Pereslavl-Zalessky, Russia
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Myers JD. The Role of the Physician Assistant in Hospice and Palliative Medicine. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Henson LA, Edmonds P, Johnston A, Johnson HE, Ng Yin Ling C, Sklavounos A, Ellis-Smith C, Gao W. Population-Based Quality Indicators for End-of-Life Cancer Care: A Systematic Review. JAMA Oncol 2020; 6:142-150. [PMID: 31647512 DOI: 10.1001/jamaoncol.2019.3388] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Improving the quality of cancer care is an international priority. Population-based quality indicators (QIs) are key to this process yet remain almost exclusively used for evaluating care during the early, often curative, stages of disease. Objectives To identify all existing QIs for the care of patients with cancer who have advanced disease and/or are at the end of life and to evaluate each indicator's measurement properties and appropriateness for use. Evidence Review For this systematic review, 5 electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, and the Cochrane Library) were searched from inception through February 4, 2019, for studies describing the development, review, and/or testing of QIs for the care of patients with cancer who have advanced disease and/or are at the end of life. For each QI identified, descriptive information was extracted and 6 measurement properties (acceptability, evidence base, definition, feasibility, reliability, and validity) were assessed using previously established criteria, with 4 possible ratings: positive, intermediate, negative, and unknown. Ratings were collated and each QI classified as appropriate for use, inappropriate for use, or of limited testing. Among the QIs determined as appropriate for use, a recommended shortlist was generated by excluding those that were specific to patient subgroups and/or care settings; related QIs were identified, and the indicator with the highest rating was retained. Findings The search yielded 7231 references, 35 of which (from 28 individual studies) met the eligibility criteria. Of 288 QIs extracted (260 unique), 103 (35.8%) evaluated physical aspects of care and 109 (37.8%) evaluated processes of care. Quality indicators relevant to psychosocial (18 [6.3%]) or spiritual and cultural (3 [1.0%]) care domains were limited. Eighty QIs (27.8%) were determined to be appropriate for use, 116 (40.3%) inappropriate for use, and 92 (31.9%) of limited testing. The measurement properties with the fewest positive assessments were acceptability (38 [13.2%]) and validity (63 [21.9%]). Benchmarking data were reported for only 16 QIs (5.6%). The final 15 recommended QIs came from 6 studies. Conclusions and Relevance The findings suggest that only a small proportion of QIs developed for the care of patients with cancer who have advanced disease and/or are at the end of life have received adequate testing and/or are appropriate for use. Further testing may be needed, as is research to establish benchmarking data and to expand QIs relevant to psychosocial, cultural, and spiritual care domains.
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Affiliation(s)
- Lesley Anne Henson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Polly Edmonds
- King's College Hospital National Health Service Foundation Trust, Denmark Hill, London, United Kingdom
| | - Anna Johnston
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Halle Elizabeth Johnson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Clarissa Ng Yin Ling
- Medical Student, King's College London GKT School of Medical Education, King's College London, London, United Kingdom
| | - Alexandros Sklavounos
- Medical Student, King's College London GKT School of Medical Education, King's College London, London, United Kingdom
| | - Clare Ellis-Smith
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
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Sanders JJ, Paladino J, Reaves E, Luetke-Stahlman H, Anhang Price R, Lorenz K, Hanson LC, Curtis JR, Meier DE, Fromme EK, Block SD. Quality Measurement of Serious Illness Communication: Recommendations for Health Systems Based on Findings from a Symposium of National Experts. J Palliat Med 2019; 23:13-21. [PMID: 31721629 DOI: 10.1089/jpm.2019.0335] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Communication between clinicians and patients fundamentally shapes the experience of serious illness. There is increasing recognition that health systems should routinely implement structures and processes to assure high-quality serious illness communication (SIC) and measure the effectiveness of their efforts on key outcomes. The absence, underdevelopment, or limited applicability of quality measures related specifically to SIC, and their limited application only to those seen by specialist palliative and hospice care teams, hinder efforts to improve care planning, service delivery, and health outcomes for all seriously ill patients. Objective: We convened an expert stakeholder symposium and subsequently surveyed participants to consider challenges, opportunities, priorities, and strategies to improve quality measurement specific to SIC. Results: We identified several barriers and opportunities to improving quality measurement of SIC. These include issues related to the definition of SIC, methodological challenges related to measuring SIC and related outcomes, underutilization of technologies that can facilitate measurement, and measurement development, and dissemination. Conclusions: Patients, clinicians, and health systems increasingly align around the importance of high-quality communication in serious illness. We offer recommendations for various stakeholder groups to advance SIC quality measurement. Enthusiasm and a sense of urgency among health systems to drive and measure communication improvements inform our proposal for a set of example measures for implementation now.
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Affiliation(s)
- Justin J Sanders
- Harvard Medical School, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joanna Paladino
- Harvard Medical School, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Erica Reaves
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Karl Lorenz
- Division of Palliative Care, Palo Alto VA Health Care System, Stanford University School of Medicine, Palo Alto, California
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
- Division of Geriatric Medicine and Palliative Care Program, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
| | - Diane E Meier
- Center to Advance Palliative Care, New York, New York
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik K Fromme
- Harvard Medical School, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan D Block
- Harvard Medical School, Boston, Massachusetts
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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Richards CA, Liu CF, Hebert PL, Ersek M, Wachterman MW, Reinke LF, Taylor LL, O’Hare AM. Family Perceptions of Quality of End-of-Life Care for Veterans with Advanced CKD. Clin J Am Soc Nephrol 2019; 14:1324-1335. [PMID: 31466952 PMCID: PMC6730503 DOI: 10.2215/cjn.01560219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/24/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the quality of end-of-life care for patients with advanced CKD. We describe the relationship between patterns of end-of-life care and dialysis treatment with family-reported quality of end-of-life care in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We designed a retrospective observational study among a national cohort of 9993 veterans with advanced CKD who died in Department of Veterans Affairs facilities between 2009 and 2015. We used logistic regression to evaluate associations between patterns of end-of-life care and receipt of dialysis (no dialysis, acute dialysis, maintenance dialysis) with family-reported quality of end-of-life care. RESULTS Overall, 52% of cohort members spent ≥2 weeks in the hospital in the last 90 days of life, 34% received an intensive procedure, and 47% were admitted to the intensive care unit, in the last 30 days, 31% died in the intensive care unit, 38% received a palliative care consultation in the last 90 days, and 36% were receiving hospice services at the time of death. Most (55%) did not receive dialysis, 12% received acute dialysis, and 34% received maintenance dialysis. Patients treated with acute or maintenance dialysis had more intensive patterns of end-of-life care than those not treated with dialysis. After adjustment for patient and facility characteristics, receipt of maintenance (but not acute) dialysis and more intensive patterns of end-of-life care were associated with lower overall family ratings of end-of-life care, whereas receipt of palliative care and hospice services were associated with higher overall ratings. The association between maintenance dialysis and overall quality of care was attenuated after additional adjustment for end-of-life treatment patterns. CONCLUSIONS Among patients with advanced CKD, care focused on life extension rather than comfort was associated with lower family ratings of end-of-life care regardless of whether patients had received dialysis.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Chuan-Fen Liu
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Paul L. Hebert
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa W. Wachterman
- Section of General Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lynn F. Reinke
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, and
| | - Leslie L. Taylor
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Ann M. O’Hare
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- School of Medicine, University of Washington, Seattle, Washington
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Mather HL, Bollens-Lund E, Husain M, Kelley AS. Candidate Claims-Based Indicators of Functional Impairment: An Exploration in a Sample of Medicare Beneficiaries. J Pain Symptom Manage 2019; 58:e8-e11. [PMID: 31170446 PMCID: PMC11208069 DOI: 10.1016/j.jpainsymman.2019.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Harriet L Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Mohammed Husain
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
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Kelley AS, Ferreira KB, Bollens-Lund E, Mather H, Hanson LC, Ritchie CS. Identifying Older Adults With Serious Illness: Transitioning From ICD-9 to ICD-10. J Pain Symptom Manage 2019; 57:1137-1142. [PMID: 30876955 PMCID: PMC11200201 DOI: 10.1016/j.jpainsymman.2019.03.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 01/02/2023]
Abstract
CONTEXT Identifying the seriously ill population is integral to improving the value of health care. Efforts to identify this population using existing data are anchored to a list of severe medical conditions (SMCs) using diagnostic codes. Published approaches have used International Classification of Diseases, Ninth Revision (ICD-9) codes, which has since been replaced by ICD-10. OBJECTIVES We translated SMCs from ICD-9 to ICD-10 using a refined code list. We aimed to test the hypothesis that people identified by ICD-9 or ICD-10 codes would have similar Medicare costs, health care utilization, and mortality. METHODS Using data from the National Health and Aging Trends Study linked to Medicare claims, we compared samples from periods using ICD-9 (2014) and ICD-10 (2016). We included participants with six-month fee-for-service Medicare data before their interview date who had an SMC identified within that period. We compared the groups' demographic, functional, and medical characteristics and followed up them for six months to compare outcomes. RESULTS Among subjects in the 2016 (ICD-10) sample, 19.9% were hospitalized, 24.6% used the emergency department, 7.2% died, and average Medicare spending totaled $9902.04 over six months of follow-up. We observed no significant differences between the 2014 and 2016 samples (P > 0.05); both samples represent 18% of Medicare fee-for-service beneficiaries. CONCLUSION Identifying the seriously ill population using currently available data requires using ICD-10 to define SMCs. Routine measurement of function, quality of life, and caregiver strain will further enhance the identification process and efficiently target palliative care services and appropriate quality measures.
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Affiliation(s)
- Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center, Bronx, New York, USA.
| | - Katelyn B Ferreira
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura C Hanson
- Division of Geriatric Medicine Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine University of California, San Francisco, San Francisco, California, USA
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20
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Turnbull AE, Chessare CM, Coffin RK, Needham DM. More than one in three proxies do not know their loved one's current code status: An observational study in a Maryland ICU. PLoS One 2019; 14:e0211531. [PMID: 30699212 PMCID: PMC6353188 DOI: 10.1371/journal.pone.0211531] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/16/2019] [Indexed: 12/21/2022] Open
Abstract
Rationale The majority of ICU patients lack decision-making capacity at some point during their ICU stay. However the extent to which proxy decision-makers are engaged in decisions about their patient’s care is challenging to quantify. Objectives To assess 1)whether proxies know their patient’s actual code status as recorded in the electronic medical record (EMR), and 2)whether code status orders reflect ICU patient preferences as reported by proxy decision-makers. Methods We enrolled proxy decision-makers for 96 days starting January 4, 2016. Proxies were asked about the patient’s goals of care, preferred code status, and actual code status. Responses were compared to code status orders in the EMR at the time of interview. Characteristics of patients and proxies who correctly vs incorrectly identified actual code status were compared, as were characteristics of proxies who reported a preferred code status that did vs did not match actual code status. Measurements and main results Among 111 proxies, 42 (38%) were incorrect or unsure about the patient’s actual code status and those who were correct vs. incorrect or unsure were similar in age, race, and years of education (P>0.20 for all comparisons). Twenty-nine percent reported a preferred code status that did not match the patient’s code status in the EMR. Matching preferred and actual code status was not associated with a patient’s age, gender, income, admission diagnosis, or subsequent in-hospital mortality or with proxy age, gender, race, education level, or relation to the patient (P>0.20 for all comparisons). Conclusions More than 1 in 3 proxies is incorrect or unsure about their patient’s actual code status and more than 1 in 4 proxies reported that a preferred code status that did not match orders in the EMR. Proxy age, race, gender and education level were not associated with correctly identifying code status or code status concordance.
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Affiliation(s)
- Alison E. Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Caroline M. Chessare
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Rachel K. Coffin
- Medical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
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Waller A, Turon H, Bryant J, Zucca A, Evans TJ, Sanson-Fisher R. Medical oncology outpatients' preferences and experiences with advanced care planning: a cross-sectional study. BMC Cancer 2019; 19:63. [PMID: 30642289 PMCID: PMC6332530 DOI: 10.1186/s12885-019-5272-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 01/02/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Medical oncology outpatients are a group for whom advance care planning (ACP) activities are particularly relevant. Patient views can help prioritise areas for improving end of life communication. The study aimed to determine in a sample of medical oncology outpatients: (1) the perceived importance of participating in ACP activities; (2) the proportion of patients who have ever participated in ACP activities; and (3) the proportion of patients who had not yet participated in ACP activities who were willing to do so in next month. METHODS Adult medical oncology outpatients in two Australian cancer treatment centres were consecutively approached to complete a pen-and-paper survey. Items explored perceived importance, previous participation, and willingness to participate across key ACP activities including: discussing wishes with their family or doctor; recording wishes in a written document; appointing a substitute decision maker (SDM); and discussing life-expectancy. RESULTS 185 participants completed the survey (51% consent rate). Most patients agreed it was important to: discuss end of life wishes with family (85%) and doctors (70%) and formally record wishes (73%). Few had discussed end of life wishes with a doctor (11%), recorded their wishes (15%); chosen a SDM (28%); discussed life expectancy (30%); or discussed end of life wishes with family (30%). Among those who had not participated in ACP, most were willing to discuss life expectancy (66%); discuss end of life wishes with family (57%) and a doctor (55%); and formally record wishes (56%) in the next month. Fewer wanted to appoint a SDM (40%). CONCLUSION Although medical oncology outpatients perceive ACP activities are important, rates of uptake are relatively low. The willingness of many patients to engage in ACP activities suggests a gap in current ACP practice. Efforts should focus on ensuring patients and families have clarity about the legal and other ramifications of ACP activities, and better education and training of health care providers in initiating conversations about end of life issues.
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Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Heidi Turon
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Alison Zucca
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Tiffany-Jane Evans
- Clinical Research Design and Statistics Support Unit, Hunter Medical Research Institute, New Lambton Heights, NSW Australia
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW Australia
- Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW Australia
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22
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Stevenson D, Sinclair N, Krone E, Bramson J. Trends in Hospice Quality Oversight and Key Challenges to Making it More Effective, 2006-2015. J Palliat Med 2019; 22:670-676. [PMID: 30625006 DOI: 10.1089/jpm.2018.0445] [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: 11/13/2022] Open
Abstract
Background: Given the limited ability of hospice patients to assess, monitor, and respond to substandard care, quality oversight has an important role to play in the hospice sector. The IMPACT Act of 2014 required that agencies be recertified at least every three years, but it did not otherwise alter hospice quality oversight. Objectives: To illuminate the current hospice quality oversight process and discuss its role alongside other government monitoring and public reporting efforts. Methods: Retrospective analysis (2006-2015) concerning hospice accreditation status, deficiency trends, survey frequency and deficiency outcomes, and termination from the Medicare program. Results: The proportion of privately accredited hospice agencies increased from 15% to 39%, a trend driven largely by its increased use among for-profit agencies. The combined rate of deficiencies per agency increased 35% over the past decade, with issues around care planning, aide and homemaker services, and clinical assessment featured most prominently. Nearly half (45%) of all surveys resulted in deficiency citations; however, less than one-in-four hospice agencies were surveyed in a given year. Over the past decade, 28 agencies were terminated from the Medicare program; most of these agencies were unaccredited and operated on a for-profit basis. Conclusions: The IMPACT Act addressed one of the biggest shortcomings in hospice oversight. Our findings highlight additional reforms that could be considered. First, reporting inspection results from private and public recertification surveys could promote greater transparency and accountability. Second, making a wider range of intermediate sanctions available to oversight agencies could enhance enforcement efforts and, ideally, incentivize agencies to improve quality of care.
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Affiliation(s)
- David Stevenson
- 1 Department of Health Policy, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Nicholas Sinclair
- 1 Department of Health Policy, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Emily Krone
- 1 Department of Health Policy, Vanderbilt School of Medicine, Nashville, Tennessee
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23
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Flieger SP, Spatz E, Cherlin EJ, Curry LA. Quality Improvement Initiatives to Reduce Mortality: An Opportunity to Engage Palliative Care and Improve Advance Care Planning. Am J Hosp Palliat Care 2018; 36:97-104. [PMID: 30122054 DOI: 10.1177/1049909118794149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND: Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning. OBJECTIVE: In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning. METHODS: We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning. RESULTS: Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes. CONCLUSIONS: Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.
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Affiliation(s)
- Signe Peterson Flieger
- 1 Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Erica Spatz
- 2 Yale School of Medicine, New Haven, CT, USA
| | - Emily J Cherlin
- 3 Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, CT, USA
| | - Leslie A Curry
- 3 Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, CT, USA
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24
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Abstract
BACKGROUND Payment models for palliative care vary across nations, with few adopting contemporary payments designs that apply to other parts of the health system. AIM To propose optimal payment arrangements for palliative care. APPROACH Review of relevant literature on funding mechanisms in health care generally and palliative care in particular. RESULTS Payment models for palliative care should move toward activity-based funding using an agreed classification, be uncapped funding with performance monitoring, and make explicit use of performance metrics and reporting. CONCLUSIONS If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted.
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Affiliation(s)
- Stephen Duckett
- Health Program, Grattan Institute, 8 Malvina Place, Carlton, VIC, 3053, Australia.
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25
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Teno JM, Montgomery R, Valuck T, Corrigan J, Meier DE, Kelley A, Curtis JR, Engelberg R. Accountability for Community-Based Programs for the Seriously Ill. J Palliat Med 2017; 21:S81-S87. [PMID: 29195052 DOI: 10.1089/jpm.2017.0583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Innovation is needed to improve care of the seriously ill, and there are important opportunities as we transition from a volume- to value-based payment system. Not all seriously ill are dying; some recover, while others are persistently functionally impaired. While we innovate in service delivery and payment models for the seriously ill, it is important that we concurrently develop accountability that ensures a focus on high-quality care rather than narrowly focusing on cost containment. The Gordon and Betty Moore Foundation convened a meeting of 45 experts to arrive at guiding principles for measurement, create a starter measurement set, specify a proposed definition of the denominator and its refinement, and identify research priorities for future implementation of the accountability system. A series of articles written by experts provided the basis for debate and guidance in formulating a path forward to develop an accountability system for community-based programs for the seriously ill, outlined in this article. As we innovate in existing population-based payment programs such as Medicare Advantage and develop new alternative payment models, it is important and urgent that we develop the foundation for accountability along with actionable measures so that the healthcare system ensures high-quality person- and family-centered care for persons who are seriously ill.
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Affiliation(s)
- Joan M Teno
- 1 Department of Gerontology and Geriatrics, University of Washington , Seattle, Washington
| | | | | | - Janet Corrigan
- 4 Gordon and Betty Moore Foundation , Palo Alto, California
| | - Diane E Meier
- 5 Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics, Mount Sinai School of Medicine , New York, New York
| | - Amy Kelley
- 6 Brookdale Department of Geriatrics, Icahn School of Medicine at Mount Sinai , New York, New York; James J. Peters VA, Bronx, New York
| | - J Randall Curtis
- 2 Pulmonary and Critical Care Medicine, University of Washington , Seattle, Washington
| | - Ruth Engelberg
- 2 Pulmonary and Critical Care Medicine, University of Washington , Seattle, Washington
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26
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Curtis JR, Sathitratanacheewin S, Starks H, Lee RY, Kross EK, Downey L, Sibley J, Lober W, Loggers ET, Fausto JA, Lindvall C, Engelberg RA. Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges. J Palliat Med 2017; 21:S52-S60. [PMID: 29182487 DOI: 10.1089/jpm.2017.0542] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As our population ages and the burden of chronic illness rises, there is increasing need to implement quality metrics that measure and benchmark care of the seriously ill, including the delivery of both primary care and specialty palliative care. Such metrics can be used to drive quality improvement, value-based payment, and accountability for population-based outcomes. METHODS In this article, we examine use of the electronic health record (EHR) as a tool to assess quality of serious illness care through narrative review and description of a palliative care quality metrics program in a large healthcare system. RESULTS In the search for feasible, reliable, and valid palliative care quality metrics, the EHR is an attractive option for collecting quality data on large numbers of seriously ill patients. However, important challenges to using EHR data for quality improvement and accountability exist, including understanding the validity, reliability, and completeness of the data, as well as acknowledging the difference between care documented and care delivered. Challenges also include developing achievable metrics that are clearly linked to patient and family outcomes and addressing data interoperability across sites as well as EHR platforms and vendors. This article summarizes the strengths and weakness of the EHR as a data source for accountability of community- and population-based programs for serious illness, describes the implementation of EHR data in the palliative care quality metrics program at the University of Washington, and, based on that experience, discusses opportunities and challenges. Our palliative care metrics program was designed to serve as a resource for other healthcare systems. DISCUSSION Although the EHR offers great promise for enhancing quality of care provided for the seriously ill, significant challenges remain to operationalizing this promise on a national scale and using EHR data for population-based quality and accountability.
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Affiliation(s)
- J Randall Curtis
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington.,3 Department of Bioethics and Humanities, University of Washington , Seattle, Washington
| | - Seelwan Sathitratanacheewin
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Helene Starks
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Department of Bioethics and Humanities, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Robert Y Lee
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Erin K Kross
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Lois Downey
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - James Sibley
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - William Lober
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - Elizabeth T Loggers
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Seattle Cancer Care Alliance , Seattle, Washington.,7 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - James A Fausto
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Charlotta Lindvall
- 8 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Ruth A Engelberg
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
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27
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Higginson IJ, Daveson BA, Morrison RS, Yi D, Meier D, Smith M, Ryan K, McQuillan R, Johnston BM, Normand C. Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries. BMC Geriatr 2017; 17:271. [PMID: 29169346 PMCID: PMC5701500 DOI: 10.1186/s12877-017-0648-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 10/19/2017] [Indexed: 11/10/2022] Open
Abstract
Background Achieving choice is proposed as a quality marker. But little is known about what influences preferences especially among older adults. We aimed to determine and compare, across three countries, factors associated with preferences for place of death and treatment, and actual site of death. Methods We recruited adults aged ≥65-years from hospital-based multiprofessional palliative care services in London, Dublin, New York, and followed them for >17 months. All services offered consultation on hospital wards, support for existing clinical teams, outpatient services and received funding from their National Health Service and/or relevant Insurance reimbursements. The New York service additionally had 10 inpatient beds. All worked with and referred patients to local hospices. Face-to-face interviews recorded most and least preferred place of death, treatment goal priorities, demographic and clinical information using validated questionnaires. Multivariable and multilevel analyses assessed associated factors. Results One hundred and thirty eight older adults (64 London, 59 Dublin, 15 New York) were recruited, 110 died during follow-up. Home was the most preferred place of death (77/138, 56%) followed by inpatient palliative care/hospice units (22%). Hospital was least preferred (35/138, 25%), followed by nursing home (20%) and home (16%); hospice/palliative care unit was rarely least preferred (4%). Most respondents prioritised improving quality of life, either alone (54%), or equal with life extension (39%); few (3%) chose only life extension. There were no significant differences between countries. Main associates with home preference were: cancer diagnosis (OR 3.72, 95% CI 1.40–9.90) and living with someone (OR 2.19, 1.33–3.62). Adults with non-cancer diagnoses were more likely to prefer palliative care units (OR 2.39, 1.14–5.03). Conversely, functional independence (OR 1.05, 1.04–1.06) and valuing quality of life (OR 3.11, 2.89–3.36) were associated with dying at home. There was a mismatch between preferences and achievements – of 85 people who preferred home or a palliative care unit, 19 (25%) achieved their first preference. Conclusion Although home is the most common first preference, it is polarising and for 16% it is the least preferred. Inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there. Factors affecting stated preferences and met preferences differ. Available services, notably community support and palliative care units, require expansion. Contrasting actual place of death with capacity for meeting patient and family needs may be a better quality indicator than simply ‘achieved preferences’. Electronic supplementary material The online version of this article (10.1186/s12877-017-0648-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Irene J Higginson
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK.
| | - Barbara A Daveson
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029-6574, USA
| | - Deokhee Yi
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK.
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029-6574, USA
| | - Melinda Smith
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK
| | - Karen Ryan
- Mater Misericordiae Hospital, Eccles Street, Dublin 7, Ireland
| | | | - Bridget M Johnston
- The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
| | - Charles Normand
- The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
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28
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Ryan AM, Rodgers PE. Linking Quality and Spending to Measure Value for People with Serious Illness. J Palliat Med 2017; 21:S74-S80. [PMID: 29091529 DOI: 10.1089/jpm.2017.0496] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Healthcare payment is rapidly evolving to reward value by measuring and paying for quality and spending performance. Rewarding value for the care of seriously ill patients presents unique challenges. OBJECTIVE To evaluate the state of current efforts to measure and reward value for the care of seriously ill patients. DESIGN We performed a PubMed search of articles related to (1) measures of spending for people with serious illness and (2) linking spending and quality measures and rewarding performance for the care of people with serious illness. We limited our search to U.S.-based studies published in English between January 1, 1960, and March 31, 2017. We supplemented this search by identifying public programs and other known initiatives that linked quality and spending for the seriously ill and extracted key program elements. RESULTS Our search related to linking spending and quality measures and rewarding performance for the care of people with serious illness yielded 277 articles. We identified three current public programs that currently link measures of quality and spending-or are likely to within the next few years-the Oncology Care Model; the Comprehensive End-Stage Renal Disease Model; and Home Health Value-Based Purchasing. Models that link quality and spending consist of four core components: (1) measuring quality, (2) measuring spending, (3) the payment adjustment model, and (4) the linking/incentive model. We found that current efforts to reward value for seriously ill patients are targeted for specific patient populations, do not broadly encourage the use of palliative care, and have not closely aligned quality and spending measures related to palliative care. CONCLUSIONS We develop recommendations for policymakers and stakeholders about how measures of spending and quality can be balanced in value-based payment programs.
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Affiliation(s)
- Andrew M Ryan
- 1 Department of Health Management and Policy, University of Michigan School of Public Health , Ann Arbor, Michigan.,2 Institute for Healthcare Policy and Innovation, University of Michigan , Ann Arbor, Michigan
| | - Phillip E Rodgers
- 2 Institute for Healthcare Policy and Innovation, University of Michigan , Ann Arbor, Michigan.,3 Department of Family Medicine, and Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School , Ann Arbor, Michigan
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29
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Schulz R, Beach SR, Friedman EM, Martsolf GR, Rodakowski J, James AE. Changing Structures and Processes to Support Family Caregivers of Seriously Ill Patients. J Palliat Med 2017; 21:S36-S42. [PMID: 29091533 DOI: 10.1089/jpm.2017.0437] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although family caregivers provide a significant portion of health and support services to adults with serious illness, they are often marginalized by existing healthcare systems and procedures. OBJECTIVE We examine the role of caregivers in existing systems of care, identify needed changes in structures and processes, and describe how these changes might be monitored and assessed and who should be accountable for implementing them. DESIGN Based on a broad assessment of the caregiving literature, the recent National Academy of Sciences Report on family caregiving, and descriptive data from two national surveys, we describe structural and process barriers that limit caregivers' ability to provide effective care. SUBJECTS To describe the unique challenges and impacts of caring for seriously ill patients, we report data from a nationally representative sample of older adults and their caregivers (National Health and Aging Trends Study [NHATS]; National Study of Caregiving [NSOC]) to identify the prevalence and impact on family caregivers of seriously ill patients who have high needs for support and are high cost to the healthcare system. MEASUREMENTS Standardized measures of patient status and caregiver roles and impacts are used. RESULTS Multiple structural and process barriers limit the ability of caregivers to provide effective care. These issues are exacerbated for the more than 13 million caregivers who provide care and support to 9 million seriously ill older adults. CONCLUSIONS Fundamental changes are needed in the way we identify, assess, and support caregivers. Educational and workforce development reforms are needed to enhance the competencies of healthcare and long-term service providers to effectively engage caregivers.
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Affiliation(s)
- Richard Schulz
- 1 Department of Psychiatry, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Scott R Beach
- 2 University Center for Social and Urban Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Esther M Friedman
- 3 Pardee RAND Graduate School, RAND Corporation , Santa Monica, California
| | - Grant R Martsolf
- 4 Pardee RAND Graduate School, RAND Corporation , Pittsburgh, Pennsylvania
| | - Juleen Rodakowski
- 5 Department of Occupational Therapy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - A Everette James
- 6 Health Policy Institute, University of Pittsburgh , Pittsburgh, Pennsylvania
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