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Bose Brill S, Riley SR, Prater L, Schnell PM, Schuster ALR, Smith SA, Foreman B, Xu WY, Gustin J, Li Y, Zhao C, Barrett T, Hyer JM. Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure. J Gen Intern Med 2024; 39:2487-2495. [PMID: 38769259 PMCID: PMC11436682 DOI: 10.1007/s11606-024-08604-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 01/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice. OBJECTIVE Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life. DESIGN This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020. PARTICIPANTS A total of 48,466 deceased patients diagnosed with heart failure on Medicare. MAIN MEASURES Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services. KEY RESULTS In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter. CONCLUSIONS Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.
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Affiliation(s)
- Seuli Bose Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH, 43215, USA.
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Sean R Riley
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH, 43215, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Laura Prater
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Patrick M Schnell
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Biostatistics, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Anne L R Schuster
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sakima A Smith
- Division of Cardiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Beth Foreman
- Division of Cardiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Wendy Yi Xu
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Jillian Gustin
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Yiting Li
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Chen Zhao
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Todd Barrett
- Ohio State University Ross Heart Hospital, Columbus, OH, USA
| | - J Madison Hyer
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Liu X, Wang T, Cheung DST, Chau PH, Ho MH, Han Y, Lin CC. Dyadic advance care planning: systematic review of patient-caregiver interventions and effects. BMJ Support Palliat Care 2024; 14:245-255. [PMID: 37857471 DOI: 10.1136/spcare-2023-004430] [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: 06/14/2023] [Accepted: 09/29/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Family caregiver's involvement in advance care planning (ACP) is essential to provide high-quality end-of-life (EOL) care and to ease the surrogate decision-making burden. However, no systematic review has focused on existing ACP interventions involving patients and their families. AIM To systematically summarise current ACP interventions involving patients and their families. METHODS Five English and two Chinese databases were searched from inception to September 2022. The eligible studies were experimental studies describing original data. The Joanna Briggs Institute critical appraisal tools assessed the methodological quality. Narrative synthesis was conducted for data analysis. RESULTS In total, twenty-eight articles were included. Fifteen studies were randomised controlled trials, and the rest 13 studies were quasi-experimental studies. The data synthesis identified: (1) Key intervention components: strategies to promote ACP, ACP discussion and follow-up, as well as the role of family caregivers; (2) Effects on intended outcomes: interventions have shown benefit on completion of ACP actions, while inconsistent findings were found on the process outcomes and quality of EOL care. In addition, a logic model for patient-caregiver dyadic ACP was created, and the underlying mechanisms of action included well-preparation, open discussion and adequate support for plan/action. CONCLUSIONS This review provides comprehensive evidence about patient-caregiver dyadic ACP, a promising intervention to better prepare for EOL communication and decision-making. A logic model has been mapped to give a preliminary indication for future implementation. More empirical studies are needed to improve this model and culturally adapt it in a real-world setting.
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Affiliation(s)
- Xiaohang Liu
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Tongyao Wang
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Denise Shuk Ting Cheung
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Pui Hing Chau
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Mu-Hsing Ho
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Yuanxia Han
- Department of Pancreatic Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chia-Chin Lin
- School of Nuring, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
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Matthieu MM, Oliver CM, Hernandez GI, McCullough JA, Adkins DA, Mallory MJ, Taylor LD, Jensen JL, Garner KK. Application of motivational interviewing to group: Teaching advance care planning via group visits for clinical professionals. PATIENT EDUCATION AND COUNSELING 2024; 120:108116. [PMID: 38150951 DOI: 10.1016/j.pec.2023.108116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/01/2023] [Accepted: 12/12/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE Advance Care Planning (ACP) via Group Visits (ACP-GV) is an innovative patient-centered intervention used in the United States Department of Veterans Affairs (VA) healthcare system. The goal of ACP-GV is to spread ACP to veterans and caregivers in medically underserved rural areas. Veterans, caregivers and those they trust participate in a group led by clinicians in Veterans Health Administration healthcare and/or community-based settings. To learn how to facilitate ACP-GV, clinicians attend ACP-GV training. The training teaches the ACP-GV group model and the theoretical components of Motivational Interviewing (MI) (Rollnick & Miller, 1995), which are used to empower participants to have conversations about their healthcare values and preferences. Therefore, the aim is to describe the specific MI techniques utilized by group facilitators in the innovative ACP-GV intervention. DISCUSSION We provide exemplars for how group facilitators apply the MI techniques to the group discussion with participants. Lastly, we provide a scripted case example of a coded MI-concordant session of ACP-GV delivered with veterans in a healthcare setting that can be used in future training and education for clinicians interested in facilitating ACP using a group modality. CONCLUSION MI is a key aspect of delivering ACP-GV, a high-quality, patient-centered intervention for veterans, caregivers and those they trust.
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Affiliation(s)
- Monica M Matthieu
- US Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, USA; Saint Louis University, School of Social Work, Saint Louis, MO, USA.
| | - Ciara M Oliver
- US Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, USA
| | - Gissa I Hernandez
- US Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, USA
| | - Jane Ann McCullough
- US Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, USA
| | - David A Adkins
- US Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, HSR&D Center of Innovation: Center for Mental Healthcare & Outcomes Research, Little Rock, AR, USA
| | - Mary J Mallory
- US Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, USA
| | - Laura D Taylor
- US Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, USA
| | - Jamie L Jensen
- US Department of Veterans Affairs Medical Center, San Francisco Veterans Healthcare System, San Francisco, CA, USA
| | - Kimberly K Garner
- US Department of Veterans Affairs Medical Center, Central Arkansas Veterans Healthcare System, Geriatric Research, Education and Clinical Center, Little Rock, AR, USA; University of Arkansas for Medical Sciences, College of Medicine, Department of Psychiatry, Little Rock, AR, USA
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McMahan RD, Hickman SE, Sudore RL. What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning: a Narrative Review. J Gen Intern Med 2024; 39:652-660. [PMID: 38169025 PMCID: PMC10973287 DOI: 10.1007/s11606-023-08579-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
Advance care planning (ACP) has been recognized as crucial by patients, families, and clinicians; however, different definitions and measurements have led to inconsistencies in practice and mixed evidence in the literature. This narrative review explores ACP's evolution, innovations, and outcomes using thematic analysis to synthesize data from randomized controlled trials, reviews, and editorials. Key findings include (1) ACP has evolved over the past several decades from a sole focus on code status and advance directive (AD) forms to a continuum of care planning over the life course focused on tailored preparation for patients and surrogate decision-makers and (2) ACP measurement has evolved from traditional outcome metrics, such as AD completion, to a comprehensive outcomes framework that includes behavior change theory, systems, implementation science, and a focus on surrogate outcomes. Since the recent development of an ACP consensus definition and outcomes framework, high-quality trials have reported mainly positive outcomes for interventions, especially for surrogates, which aligns with the patient desire to relieve decision-making burden for loved ones. Additionally, measurement of "clinically meaningful" ACP information, including documented goals of care discussions, is increasingly being integrated into electronic health records (EHR), and emerging, real-time assessments and natural language processing are enhancing ACP evaluation. To make things easier for patients, families, and care teams, clinicians and researchers can use and disseminate these evolved definitions; provide patients validated, easy-to-use tools that prime patients for conversations and decrease health disparities; use easy-to-access clinician training and simple scripts for interdisciplinary team members; and document patients' values and preferences in the medical record to capture clinically meaningful ACP so this information is available at the point of care. Future efforts should focus on efficient implementation, expanded reimbursement options, and seamless integration of EHR documentation to ensure ACP's continued evolution to better serve patients and their care partners.
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Affiliation(s)
- Ryan D McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Veterans Administration Medical Center, San Francisco, CA, USA.
| | - Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc, Indianapolis, IN, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Veterans Administration Medical Center, San Francisco, CA, USA
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Ahluwalia SC, Bandini JI, Kogan AC, Bekelman DB, Olsen B, Phillips J, Sudore RL. Impact of group visits for older patients with heart failure on advance care planning outcomes: Preliminary data. J Am Geriatr Soc 2021; 69:2908-2915. [PMID: 34077563 PMCID: PMC8497395 DOI: 10.1111/jgs.17283] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Advance care planning (ACP) is critically important for heart failure patients, yet important challenges exist. Group visits can be a helpful way to engage patients and caregivers in identifying values and preferences for future care in a resource-efficient way. We sought to evaluate the impact of group visits for ACP among older adults with heart failure and their caregivers on ACP-related outcomes. METHODS We conducted a mixed-methods pilot study evaluating the impact of an ACP group visit for older adults with heart failure and their caregivers on ACP-related outcomes including readiness and self-efficacy. The evidence-based PREPARE for Your Care video-based intervention was used to guide the group visits. Twenty patients and 10 caregivers attended one of the five 90-min group visits led by a trained facilitator. Group visit participants completed pre-, post-, and 1-month follow-up surveys using validated 5-point ACP readiness and self-efficacy scales. Qualitative feedback obtained within 3 days of a group visit was analyzed using a directed content analysis. RESULTS Patient participants had a median age of 78 years. Approximately half were female while caregiver participants were mostly female. Participants were predominantly white. Patient readiness scores improved significantly pre-to-post (+0.53; p = 0.002) but was not sustained at 1-month follow-up. Patient and caregiver self-efficacy showed some improvement pre-to-post but was also not sustained at follow-up. Interviews revealed positive impacts of group visits across the three themes: encouraging reviewing or revisiting prior ACP activities, motivating patients to take direct steps towards ACP, and serving as a "wake-up" call to action. CONCLUSIONS Disease-focused group visits may have a short-term effect on ACP outcomes but ongoing touchpoints are likely necessary to sustain ACP over time. The results highlight a need for follow-up ACP conversations after a single group visit. Timing for follow-ups and the ideal person to follow-up ACP conversations needs to be explored.
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Affiliation(s)
- Sangeeta C. Ahluwalia
- RAND Corporation, Santa Monica, CA
- UCLA Fielding School of Public Health, Los Angeles, CA
| | | | - Alexis Coulourides Kogan
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
| | - David B. Bekelman
- Department of Medicine, Eastern Colorado VA HCS and Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus
| | - Bonnie Olsen
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
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