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Umberfield EE, Fields MC, Lenko R, Morgan TP, Adair ES, Fromme EK, Lum HD, Moss AH, Wenger NS, Sudore RL, Hickman SE. An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go? J Am Med Dir Assoc 2024; 25:557-564.e8. [PMID: 38395413 PMCID: PMC10996838 DOI: 10.1016/j.jamda.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research. DESIGN Integrative review. SETTING AND PARTICIPANTS Not applicable. METHODS We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization. RESULTS Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified. CONCLUSIONS AND IMPLICATIONS Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.
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Affiliation(s)
- Elizabeth E Umberfield
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA.
| | - Matthew C Fields
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Rachel Lenko
- Department of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA
| | - Teryn P Morgan
- Center for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA
| | | | - Erik K Fromme
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA; Divisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
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Cole CS, Lum HD, Hickman SE. Factors influencing clinician decision-making about POLST use with nursing facility residents: A qualitative study. J Am Geriatr Soc 2024; 72:1199-1206. [PMID: 38126923 PMCID: PMC11018460 DOI: 10.1111/jgs.18717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/17/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND National POLST guidance indicates POLST is intended for individuals at risk of life-threatening clinical events due to serious illness. Even though this patient population includes many, but not all, nursing facility residents, there is evidence that POLST is used broadly in this setting. This study aimed to identify clinician perspectives regarding factors that influence their decision-making about whether to use POLST with nursing facility residents and to distinguish between inappropriate and appropriate use. METHODS We conducted a descriptive qualitative study to explore the experience of nursing facility clinicians using POLST with residents and deciding who is appropriate and inappropriate for POLST. Participants were purposively sampled from multiple states using POLST. Interviews were audio-recorded and professionally transcribed. We used rapid qualitative analysis to code data and identify themes. RESULTS We interviewed 28 clinicians from 14 states about how they decided whether to use POLST with nursing facility residents and to distinguish between inappropriate and appropriate use. Four themes emerged as factors driving clinician-decision-making POLST use: (1) belief that "everyone is appropriate"; (2) resident and family preferences; (3) resident health status; and (4) policies requiring POLST [Correction added after first online publication on 07 Feb 2024. The word "For" has been changed to "Four" in the previous sentence.]. In most cases, participants cited resident and family preferences for treatment limitations as well as prognosis and clinical assessments in determining when POLST use was appropriate. Factors influencing potentially inappropriate POLST use included nursing facility policies requiring POLST completion that preempted clinical judgments of appropriateness. CONCLUSIONS Findings highlight the disconnect between National POLST guidance and current use of POLST in nursing facilities. Policies requiring POLST use in nursing facilities and the belief that "everyone is appropriate" may impede clinician autonomy and lead to potentially inappropriate POLST use. Given varying approaches to POLST use in nursing facilities, there is a need to refocus attention on the intended population for POLST.
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Affiliation(s)
- Connie S. Cole
- Indiana University School of Nursing, Indianapolis, Indiana
- University of Colorado School of Medicine, Aurora, Colorado
- RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Hillary D. Lum
- University of Colorado School of Medicine, Aurora, Colorado
| | - Susan E. Hickman
- Indiana University School of Nursing, Indianapolis, Indiana
- RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
- IU Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana
- Indiana University School of Medicine, Indianapolis, Indiana
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hickman SE, Fromme EK. Realizing the Promise of Advance Care Planning Will Require Health System Accountability to Quality Standards. Jt Comm J Qual Patient Saf 2024; 50:93-94. [PMID: 38171950 DOI: 10.1016/j.jcjq.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 11/20/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
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Arnold RM, Levoy K, Hickman SE, Jawahri AE, Jackson V, Tulsky JA. JPSM Controversies in Palliative Care: "What is the Most Important, Measurable Goal of Serious Illness Conversations in the Ambulatory Setting?". J Pain Symptom Manage 2024; 67:e105-e110. [PMID: 37591321 DOI: 10.1016/j.jpainsymman.2023.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
There is widespread agreement that clinicians should talk to seriously ill patients and their families about their illnesses. However, advance directives as a quality metric have been called into question because of the lack of data that these conversations lead to goal-concordant care. The controversy has led many to reexamine the purpose of conversations with seriously ill patients and what should be discussed in ambulatory visits. In this Controversies in Palliative care, experts in palliative care review the literature and suggest both how it influences their clinical practice and what research needs to be done to clarify the controversy. While there is not a single outcome that the experts agree on, they posit a variety of different ways to assess these conversations.
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Affiliation(s)
- Robert M Arnold
- Department of Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (R.M.A.), UPMC Health System, Palliative and Supportive Care Institute, Pittsburgh, PA, USA.
| | - Kristin Levoy
- Department of Community and Health Systems (K.L., S.E.H.), Indiana University School of Nursing, Indianapolis, IN, USA; Indiana University Center for Aging Research (K.L., S.E.H.), Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L.), Indianapolis, IN, USA
| | - Susan E Hickman
- Department of Community and Health Systems (K.L., S.E.H.), Indiana University School of Nursing, Indianapolis, IN, USA; Indiana University Center for Aging Research (K.L., S.E.H.), Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Areej El Jawahri
- Cancer Center (A.E.J.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Department of Medicine (V.J.), Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (J.A.T.), Dana-Farber Cancer Institute, Boston, MA; Division of Palliative Medicine, Department of Medicine (J.A.T.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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van Nijnatten TJA, Payne NR, Hickman SE, Ashrafian H, Gilbert FJ. Corrigendum to "Overview of trials on artificial intelligence algorithms in breast cancer screening - A roadmap for international evaluation and implementation" [Eur. J. Radiol. 167 (2023) 111087]. Eur J Radiol 2024; 170:111202. [PMID: 37988959 DOI: 10.1016/j.ejrad.2023.111202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- T J A van Nijnatten
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - N R Payne
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
| | - S E Hickman
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom; Department of Radiology, Barts Health NHS Trust, The Royal London Hospital, 80 Newark Street, London E1 2ES, United Kingdom
| | - H Ashrafian
- Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, United Kingdom
| | - F J Gilbert
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom; Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom.
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van Nijnatten TJA, Payne NR, Hickman SE, Ashrafian H, Gilbert FJ. Overview of trials on artificial intelligence algorithms in breast cancer screening - A roadmap for international evaluation and implementation. Eur J Radiol 2023; 167:111087. [PMID: 37690352 DOI: 10.1016/j.ejrad.2023.111087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
Accumulating evidence from retrospective studies demonstrate at least non-inferior performance when using AI algorithms with different strategies versus double-reading in mammography screening. In addition, AI algorithms for mammography screening can reduce work load by moving to single human reading. Prospective trials are essential to avoid unintended adverse consequences before incorporation of AI algorithms into UK's National Health Service (NHS) Breast Screening Programme (BSP). A stakeholders' meeting was organized in Newnham College, Cambridge, UK to undertake a review of the current evidence to enable consensus discussion on next steps required before implementation into a screening programme. It was concluded that a multicentre multivendor testing platform study with opt-out consent is preferred. AI thresholds from different vendors should be determined while maintaining non-inferior screening performance results, particularly ensuring recall rates are not increased. Automatic recall of cases using an agreed high sensitivity AI score versus automatic rule out with a low AI score set at a high sensitivity could be used. A human reader should still be involved in decision making with AI-only recalls requiring human arbitration. Standalone AI algorithms used without prompting maintain unbiased screening reading performance, but reading with prompts should be tested prospectively and ideally provided for arbitration.
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Affiliation(s)
- T J A van Nijnatten
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - N R Payne
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
| | - S E Hickman
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom; Department of Radiology, Barts Health NHS Trust, The Royal London Hospital, 80 Newark Street, London E1 2ES, United Kingdom
| | - H Ashrafian
- Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, United Kingdom
| | - F J Gilbert
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom; Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, United Kingdom.
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Smith NLH, Sudore RL, Myers AL, Hammes BJ, Hickman SE. Reasons for Discordance Between Life-Sustaining Treatment Preferences and Medical Orders in Nursing Facilities Without POLST. Am J Hosp Palliat Care 2023; 40:837-843. [PMID: 36154692 PMCID: PMC10321076 DOI: 10.1177/10499091221127996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Life-sustaining treatment (LST) orders are important communication tools used to ensure preference-concordant care at the end of life. Recent studies reveal concerning rates of discordance between current preferences and documented LST orders, especially in nursing facilities without POLST. Reasons for discordance in facilities using POLST have been explored, however the majority of nursing facilities in the United States do not yet use the POLST form. DESIGN Qualitative descriptive study using constant comparative analysis. SETTING Nursing facilities in Indiana (n = 6) not using POLST. PARTICIPANTS Residents (n = 15) and surrogate decision-makers of residents without decisional capacity (n = 15) with discordance between current preferences and documented LST orders. MEASUREMENTS Do not resuscitate, do not hospitalize (DNH), and do not intubate (DNI) orders were extracted from medical charts. Current preferences were elicited using the Respecting Choices Advanced Steps model. A semi-structured interview guide was used to explore reasons for discordance between current preferences and LST orders. RESULTS Reasons for discordance included: (1) inadequate information about the range of available LST options, what each involves, and how to formally communicate preferences; (2) no previous discussion with facility staff; (3) no documentation of previously expressed preferences; and (4) family involvement. CONCLUSION Reasons for discordance between expressed preferences and LST orders suggest that in facilities without a uniform and systematic LST order documentation strategy like POLST, these conversations may not occur and/or be documented. Staff should be aware that residents and surrogates may have preferences about LSTs that require strategic solicitation and documentation.
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Affiliation(s)
- Nicholette L. Heim Smith
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Anne L. Myers
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
| | - Bernard J. Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, WI, USA
| | - Susan E. Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, IN, USA
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
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Cole CS, Blackburn J, Carpenter JS, Chen CX, Hickman SE. Pain and Associated Factors in Nursing Home Residents. Pain Manag Nurs 2023; 24:384-392. [PMID: 37003932 PMCID: PMC10440293 DOI: 10.1016/j.pmn.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Understanding factors associated with risk of pain allows residents and clinicians to plan care and set priorities, however, factors associated with pain in nursing home residents has not been conclusively studied. AIM To evaluate the association between pain and nursing home (NH) resident demographic and clinical characteristics. DESIGN Retrospective analysis of Minimum Data Set 3.0 records of nursing home residents residing in 44 Indiana NHs between September 27, 2011 and December 27, 2019 (N = 9,060). RESULTS Pain prevalence in this sample of NH residents was 23.7%. Of those with pain, 28.0% experienced moderate to severe/frequent pain and 54.6% experienced persistent pain. Risk factors for moderate to severe/frequent pain include female sex; living in a rural setting; intact, mildly, or moderately impaired cognition; arthritis; contracture; anxiety; and depression. In contrast, stroke and Alzheimer's disease and Alzheimer's-disease related dementias (AD/ADRD) were associated with decreased risk of reporting moderate to severe/frequent pain, likely representing both the under-assessment and under-reporting of pain among cognitively impaired NH residents. Risk factors for persistent pain included age <70, Black race, living in a rural location, intact cognition, contracture, and depression. CONCLUSIONS Pain remains a pressing problem for NH residents. In this study, we identified demographic and clinical factors associated with moderate to severe frequent pain and persistent pain. Residents with a diagnosis of AD/ADRD were less likely to report pain, likely representing the difficulty of evaluating pain in these residents. It is important to note that those with cognitive impairment may not experience any less pain, but assessment and reporting difficulties may make them appear to have less pain. Knowledge of factors associated with pain for NH residents has the potential for improving the ability to predict, prevent, and provide better pain care in NH residents.
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Affiliation(s)
- Connie S Cole
- School of Nursing, Indiana University, Indianapolis, Indiana; School of Medicine, University of Colorado, Aurora, Colorado; RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University, Indianapolis, Indiana.
| | - Justin Blackburn
- Richard Fairbanks School of Public Health, Indiana University Purdue University, Indianapolis, Indiana
| | | | - Chen X Chen
- School of Nursing, Indiana University, Indianapolis, Indiana
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, Indiana; RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana
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Hickman SE, Lum HD, Walling AM, Savoy A, Sudore RL. The care planning umbrella: The evolution of advance care planning. J Am Geriatr Soc 2023; 71:2350-2356. [PMID: 36840690 PMCID: PMC10958534 DOI: 10.1111/jgs.18287] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Susan E. Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Hillary D. Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Center, Colorado, Aurora, USA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, School of Medicine, University of California Los Angeles, California, Los Angeles, USA
- VA Greater Los Angeles Health System, Los Angeles, California, USA
| | - April Savoy
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
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Holtz LR, Kroenke K, Gao S, Hickman SE, Torke AM, Johnson NM, Pemberton A, Vrobel A, Pan M, Sachs GA. Indiana Palliative Excellence in Alzheimer's Care Efforts (IN-PEACE): Protocol for a randomized controlled trial in persons with advanced dementia. Contemp Clin Trials 2023; 130:107217. [PMID: 37149000 DOI: 10.1016/j.cct.2023.107217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/29/2023] [Accepted: 05/03/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Dementia affects 6.5 million persons in the U.S., a number which is expected to double by 2060. More than half of persons with dementia die at home, creating an enormous burden for both patients and caregivers. However, there is a paucity of research on community-based palliative care interventions for advanced dementia. OBJECTIVES The Indiana Palliative Excellence in Alzheimer's Care Efforts (IN-PEACE) study is a randomized trial to test the effectiveness of a collaborative predominantly telehealth home-based intervention for persons with advanced dementia residing in the community and their primary, informal caregivers. The primary aim is to determine if this palliative care focused supportive intervention is superior to usual care in reducing neuropsychiatric symptoms of dementia. Secondarily, intervention effects on other patient symptoms (e.g., pain), caregiver distress and depression, and emergency department (ED)/hospitalization events are examined. METHODS The study population consists of participant pairs comprising a person with dementia and their primary, informal caregiver. The person with dementia must be ≥65 years old, with a clinical diagnosis of moderate to severe dementia. A total of 201 demographically and socioeconomically diverse participant pairs have been randomized to the IN-PEACE care coordination intervention (n = 99) or usual care (n = 102). Outcome assessments are conducted at baseline, and quarterly for up to 2 years (3, 6, 9, 12, 15, 18, 21, and 24 months). DISCUSSION IN-PEACE results will inform care for the large number of individuals with advanced dementia residing in the community and enable informal caregivers to provide effective home-based care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT03773757.
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Affiliation(s)
- Laura R Holtz
- Indiana University Center for Aging Research, Regenstrief Institute, Inc
| | - Kurt Kroenke
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine; Center for Health Services Research, Regenstrief Institute, Inc.
| | - Sujuan Gao
- Department of Biostatistics and Health Data Sciences, , Indiana University School of Medicine
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Inc; Community and Health Systems, Indiana University School of Nursing
| | - Alexia M Torke
- Indiana University Center for Aging Research, Regenstrief Institute, Inc; Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine; Eskenazi Health, Indianapolis, IN, USA; Indiana University Health Physicians
| | - Nina M Johnson
- Indiana University Center for Aging Research, Regenstrief Institute, Inc
| | | | | | - Minmin Pan
- Department of Biostatistics and Health Data Sciences, , Indiana University School of Medicine
| | - Greg A Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Inc; Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine; Eskenazi Health, Indianapolis, IN, USA
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Cole CS, Carpenter JS, Blackburn J, Chen CX, Jones BL, Hickman SE. Pain trajectories of nursing home residents. J Am Geriatr Soc 2023; 71:1188-1197. [PMID: 36508731 PMCID: PMC10089959 DOI: 10.1111/jgs.18182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/16/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Understanding changes in nursing home (NH) resident pain over time would provide a more informed perspective, allowing opportunities to alter the course of illness, plan care, and set priorities. Therefore, the purpose of this analysis was to identify and characterize clinically meaningful, dynamic pain trajectories in NH residents. METHODS Retrospective longitudinal analysis of NH resident pain scores with a length of stay >100 days (N = 4864). Group-based trajectory modeling was applied to Minimum Data Set 3.0 assessments to identify pain trajectories. Trajectories were then characterized using unadjusted and adjusted cross-sectional associations between residents' demographic and clinical characteristics and their pain trajectory. RESULTS We identified four distinct trajectories: (1) consistent pain absence (48.9%), (2) decreasing-increasing pain presence (21.8%), (3) increasing-decreasing pain presence (15.3%), and (4) persistent pain presence (14.0%). Demographics of younger age and living in a rural area were associated with the persistent pain presence trajectory. Clinical variables of obesity and intact cognition were associated with being in the persistent pain presence trajectory. A smaller proportion of residents with moderately or severely impaired cognition were in any of the trajectory groups with pain. CONCLUSIONS We identified and characterized four pain trajectories among NH residents, including persistent pain presence which was associated with demographic characteristics (younger, female, rural) and clinical factors (obese, fracture, contracture). Moreover, residents with a diagnosis of Alzheimer's disease or dementia were less likely to be in any of the three trajectories with pain, likely representing the difficulty in evaluating pain in these residents. It is important that NH staff understand, recognize, and respond to the factors associated with the identified pain trajectories to improve mitigation of potentially persistent pain (e.g., hip fracture, contracture) or improve proxy pain assessment skills for residents at risk for under reporting of pain (e.g., Alzheimer's Disease).
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Affiliation(s)
- Connie S. Cole
- School of Nursing, Indiana University, Indianapolis, Indiana
- School of Medicine, University of Colorado Anschutz, Aurora, Colorado
- RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University, Indianapolis, Indiana
| | | | - Justin Blackburn
- Richard Fairbanks School of Public Health, Indiana University Purdue University, Indianapolis, Indiana
| | - Chen X. Chen
- School of Nursing, Indiana University, Indianapolis, Indiana
| | - Bobby L. Jones
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Susan E. Hickman
- School of Nursing, Indiana University, Indianapolis, Indiana
- RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University, Indianapolis, Indiana
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana
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13
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Hickman SE, Sudore RL, Torke AM, Tang Q, Bakoyannis G, Heim Smith N, Myers AL, Hammes BJ. POLST recall, concordance, and decision quality outcomes among nursing home residents and surrogate decision-makers. J Am Geriatr Soc 2023. [PMID: 36929327 DOI: 10.1111/jgs.18330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND POLST orders are actionable in an emergency, so it is important that the decisions be of high quality and concordant with current preferences. The goal of this study is to determine the relationship between concordance and decision quality outcomes, including decision satisfaction and decisional conflict, among nursing facility residents and surrogates who recall POLST. METHODS We completed structured interviews in 29 nursing facilities with 275 participants who had previously signed a POLST form. This included residents who were still making their own medical decisions (n = 123) and surrogate decision-makers for residents without decisional capacity (n = 152). POLST recall was defined as remembering talking about and/or completing the POLST form previously signed by the participant. Concordance was determined by comparing preferences elicited during a standardized interview with the POLST form on file. Decisional conflict, decision satisfaction, and conversation quality were assessed with standardized tools. RESULTS Half of participants (50%) remembered talking about or completing the POLST form, but recall was not associated with the length of time since POLST completion or concordance with existing preferences. In multivariable analyses, there was no association between POLST recall, concordance, and decision quality outcomes, though satisfaction was associated with conversation quality. CONCLUSIONS Half of the residents and surrogates in this study recalled the POLST they previously signed. Neither the age of the form nor the ability to recall the POLST conversation should be considered indicators of whether existing POLST orders match current preferences. Findings confirm a relationship between POLST conversation quality and satisfaction, underscoring the importance of POLST completion as a communication process.
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Affiliation(s)
- Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA.,Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexia M Torke
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Giorgos Bakoyannis
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Nicholette Heim Smith
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Anne L Myers
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, Wisconsin, USA
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14
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Levoy K, Sullivan SS, Chittams J, Myers RL, Hickman SE, Meghani SH. Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care. J Pain Symptom Manage 2023; 65:e715-e743. [PMID: 36764411 DOI: 10.1016/j.jpainsymman.2023.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
CONTEXT There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer. OBJECTIVE To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer. METHODS Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990-2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting. RESULTS Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes-cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use-were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use. CONCLUSION This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana.
| | - Suzanne S Sullivan
- School of Nursing (S.S.S.), University at Buffalo, State University of New York, Buffalo, New York
| | - Jesse Chittams
- BECCA (Biostatistics, Evaluation, Collaboration, Consultation & Analysis) Lab, Office of Nursing Research (J.C.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Ruth L Myers
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana
| | - Susan E Hickman
- Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences (S.H.M.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics (S.H.M.), University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Hickman SE, Mitchell SL, Hanson LC, Tu W, Stump TE, Unroe KT. The design and conduct of a pragmatic cluster randomized trial of an advance care planning program for nursing home residents with dementia. Clin Trials 2022; 19:623-635. [PMID: 35815777 PMCID: PMC9691516 DOI: 10.1177/17407745221108992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS A significant number of people with Alzheimer's disease or related dementia diagnoses will be cared for in nursing homes near the end of life. Advance care planning (ACP), the process of eliciting and documenting patient-centered preferences for care, is considered essential to providing high quality care for this population. Nursing homes are currently required by regulations to offer ACP to residents and families, but no training requirements exist for nursing home staff, and approaches to fulfilling this regulatory and ethical responsibility vary. As a result, residents may receive care inconsistent with their goals, such as unwanted hospitalizations. Pragmatic trials offer a way to develop and test ACP in real-world settings to increase the likelihood of adoption of sustainable best practices. METHODS The "Aligning Patient Preferences-a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support (APPROACHES)" project is designed to pragmatically test and evaluate a staff-led program in 137 nursing homes (68 = intervention, 69 = control) owned by two nursing home corporations. Existing nursing home staff receive standardized training and implement the ACP Specialist program under the supervision of a corporate lead. The primary trial outcome is the annual rate of hospital transfers (admissions and emergency department visits). Consistent with the spirit of a pragmatic trial, study outcomes rely on data already collected for quality improvement, clinical, or billing purposes. Configurational analysis will also be performed to identify conditions associated with implementation. RESULTS Partnerships with large corporate companies enable the APPROACHES trial to rely on corporate infrastructure to roll out the intervention, with support for a corporate implementation lead who is charged with the initial introduction and ongoing support for nursing home-based ACP Specialists. These internal champions connect the project with other company priorities and use strategies familiar to nursing home leaders for the initiation of other programs. Standardized data collection across nursing homes also supports the conduct of pragmatic trials in this setting. DISCUSSION Many interventions to improve care in nursing homes have failed to demonstrate an impact or, if successful, maintain an impact over time. Pragmatic trials, designed to test interventions in real-world contexts that are evaluated through existing data sources collected routinely as part of clinical care, are well suited for the nursing home environment. A robust program that increases access to ACP for nursing home residents has the potential to increase goal-concordant care and is expected to reduce hospital transfers. If successful, the ACP Specialist Program will be primed for rapid translation into nursing home practice to reduce unwanted, burdensome hospitalizations and improve the quality of care for residents with dementia.
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Affiliation(s)
- Susan E Hickman
- School of Nursing, Indiana University, Indianapolis,
Indiana, U.S.,RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
| | - Susan L Mitchell
- Harvard Medical School, Boston, Massachusetts, U.S.,Beth Israel Deaconess Medical Center, Boston,
Massachusetts, U.S.,Marcus Institute for Aging Research, Boston, Massachusetts,
U.S
| | - Laura C Hanson
- School of Medicine, University of North Carolina, Chapel Hill,
North Carolina
| | - Wanzhu Tu
- IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S.,Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Timothy E Stump
- Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Kathleen T Unroe
- RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
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16
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Cole CS, Carpenter JS, Chen CX, Blackburn J, Hickman SE. Prevalence and Factors Associated with Pain in Nursing Home Residents: A Systematic Review of the Literature. J Am Med Dir Assoc 2022; 23:1916-1925.e1. [PMID: 36162443 DOI: 10.1016/j.jamda.2022.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To describe the pain prevalence in nursing home (NH) residents and the factors associated with the experience of pain. DESIGN Systematic review of descriptive studies. SETTING AND PARTICIPANTS Three electronic databases were searched from 2010 to September 2020 in English. Descriptive studies that examined pain in NH residents, reported pain prevalence, and/or associated factors were included. Studies that focused exclusively on a specific disease or type of care such as cancer or hospice were excluded. METHODS Two reviewers independently screened, selected, extracted data, and assessed risk of bias from included studies; narrative synthesis was performed. The review was guided by the Biopsychosocial Model of Chronic Pain for Older Adults. RESULTS Twenty-six studies met our inclusion criteria. Overall, the prevalence of current pain ranged from 22.2% to 85.0%, the prevalence of persistent pain ranged from 19.5% to 58.5%, and the prevalence of chronic pain ranged from 55.9% to 58.1%. A variety of pain scales were used reporting higher pain prevalence for those using self-report measures (31.8% to 78.8%) or proxy measures (29.5% to 85.0%) compared with using chart review (22.2% to 29.3%) as the source of pain information. The studies reviewed provide support that certain diseases and clinical conditions are associated with pain. Impairment in activities of daily living (ADL) (12 studies), cognition (9 studies), depression (9 studies), and arthritis (9 studies) are the most widely studied factors, whereas depression, ADL impairment, arthritis, dementia, and cognitive impairment present the strongest association with pain. CONCLUSION AND IMPLICATIONS This review highlights the complexities of pain in NH residents and has implications for both clinical practice and future research. Understanding the factors that underlie the experience of pain, such as depression, is useful for clinicians evaluating pain and tailoring management therapies. In addition, the gaps in knowledge uncovered in this review are important areas for future research.
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Affiliation(s)
- Connie S Cole
- School of Nursing, Indiana University, Indianapolis, IN, USA; RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University, Indianapolis, IN, USA.
| | | | - Chen X Chen
- School of Nursing, Indiana University, Indianapolis, IN, USA
| | - Justin Blackburn
- Richard Fairbanks School of Public Health, Indiana University Purdue University, Indianapolis, IN, USA
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, IN, USA; RESPECT (Research in Palliative and End-of-Life Communication and Training) Signature Center, Indiana University Purdue University, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
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17
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Kroenke K, Gao S, Mosesso KM, Hickman SE, Holtz LR, Torke AM, Johnson NM, Sachs GA. Prevalence and Predictors of Symptoms in Persons with Advanced Dementia Living in the Community. J Palliat Med 2022; 25:1376-1385. [PMID: 35357951 PMCID: PMC9492904 DOI: 10.1089/jpm.2021.0402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Behavioral, psychological, and physical symptoms are prevalent in advanced dementia, as well as major contributors to poor quality of life, health care costs, caregiver burden, and nursing home placement. Objectives: To determine the frequency and severity of symptoms in persons with advanced dementia living in the community, as well as the association between symptoms and satisfaction with care, and the identification of factors associated with symptom burden. Design: Baseline data from a clinical trial testing the effectiveness of collaborative care home-based management for patients with advanced dementia. Setting/Subjects: Two hundred and one patient-caregiver dyads from an urban area in the United States, who were still residing in the community. Measurements: Caregivers completed the Symptom Management in End-of-Life Dementia (SM-EOLD) and Satisfaction with Care in End-of-Life Dementia (SWC-EOLD) scales. Results: Patients' mean age was 83.1; 67.7% were women, and most were either White (50.2%) or African American (43.8%). Most (88.1%) had severe dementia (Functional Assessment Staging Tool [FAST] stage 6 or 7). SM-EOLD mean score was 29.3 (on 0-45 scale) and SWC-EOLD score was 32.6 (on 10-40 scale). Pain, agitation, anxiety, and resistiveness to care were present at least weekly in ≥40% of patients. Multivariable linear regression modeling showed that higher neuropsychiatric symptom severity (assessed by the Neuropsychiatric Inventory), increased caregiver strain, and higher medical comorbidity were all independently associated with increased symptom burden. Satisfaction with care was high and had only a modest correlation (r = 0.20) with symptom burden. Conclusions: Community-dwelling patients with advanced dementia and their caregivers may benefit from home-based palliative care interventions to identify and manage burdensome symptoms.
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Affiliation(s)
- Kurt Kroenke
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kelly M. Mosesso
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Susan E. Hickman
- Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Laura R. Holtz
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Alexia M. Torke
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Nina M. Johnson
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Greg A. Sachs
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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18
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Susan E Hickman
- School of Nursing, Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis
| | - Anne M Walling
- Division of General Internal Medicine, Health Services Research, University of California, Los Angeles
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19
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Abstract
Advance care planning (ACP) is an important component of person-centered care for older adults in nursing facilities. Although nursing facilities have a statutory obligation to offer ACP to residents, there are no minimum training requirements for staff. Lack of consistent ACP training contributes to significant variability in ACP conversation quality, inaccurate or incomplete documentation of preferences, and infrequent re-evaluation of prior decisions. Indiana added ACP training for nursing facility staff to the Value-Based Purchasing formula for 2019. Facilities received 5 points (of a 100-point total formula) if at least one staff member completed the designated ACP training during the year. ACP Foundations Training was developed by faculty at Indiana University and made available to all Indiana nursing facilities. A total of 1,087 participants, representing 94.2% (501 of 532) Indiana nursing facilities, completed the training. Approximately every participant (99.4%) agreed that the training had practical value. This academic-government partnership was successful in providing basic information about ACP to staff at most nursing facilities across Indiana and offers a model for states to provide critical educational content to nursing facility staff by incentivizing training. [Journal of Gerontological Nursing, 48(2), 31-35.].
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20
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Tu W, Li R, Stump TE, Fowler NR, Carnahan JL, Blackburn J, Sachs GA, Hickman SE, Unroe KT. Age-specific rates of hospital transfers in long-stay nursing home residents. Age Ageing 2022; 51:6430100. [PMID: 34850811 DOI: 10.1093/ageing/afab232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION hospital transfers and admissions are critical events in the care of nursing home residents. We sought to determine hospital transfer rates at different ages. METHODS a cohort of 1,187 long-stay nursing home residents who had participated in a Centers for Medicare and Medicaid demonstration project. We analysed the number of hospital transfers of the study participants recorded by the Minimum Data Set. Using a modern regression technique, we depicted the annual rate of hospital transfers as a smooth function of age. RESULTS transfer rates declined with age in a nonlinear fashion. Rates were the highest among residents younger than 60 years of age (1.30-2.15 transfers per year), relatively stable between 60 and 80 (1.17-1.30 transfers per year) and lower in those older than 80 (0.77-1.17 transfers per year). Factors associated with increased risk of transfers included prior diagnoses of hip fracture (annual incidence rate ratio or IRR: 2.057, 95% confidence interval (CI): [1.240, 3.412]), dialysis (IRR: 1.717, 95% CI: [1.313, 2.246]), urinary tract infection (IRR: 1.755, 95% CI: [1.361, 2.264]), pneumonia (IRR: 1.501, 95% CI: [1.072, 2.104]), daily pain (IRR: 1.297, 95% CI: [1.055,1.594]), anaemia (IRR: 1.229, 95% CI [1.068, 1.414]) and chronic obstructive pulmonary disease (IRR: 1.168, 95% CI: [1.010,1.352]). Transfer rates were lower in residents who had orders reflecting preferences for comfort care (IRR: 0.79, 95% CI: [0.665, 0.936]). DISCUSSION younger nursing home residents may require specialised interventions to reduce hospital transfers; declining transfer rates with the oldest age groups may reflect preferences for comfort-focused care.
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Affiliation(s)
- Wanzhu Tu
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Ruohong Li
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Timothy E Stump
- Department of Biostatistics & Health Data Science, Indianapolis, IN 46202, USA
| | - Nicole R Fowler
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Jennifer L Carnahan
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Justin Blackburn
- Department of Health Policy and Management, Indiana University Fairbanks School of Public Health, Indianapolis, IN 46202, USA
| | - Greg A Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN 46202, USA
| | - Kathleen T Unroe
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN 46202, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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21
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Hickman SE, Lum HD. Preparation Matters: What We Can Learn From an Olympic Swimmer About the Value of Advance Care Planning Interventions. Ann Intern Med 2021; 174:1618-1619. [PMID: 34461030 DOI: 10.7326/m21-3294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Susan E Hickman
- Indiana University School of Nursing, Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana
| | - Hillary D Lum
- University of Colorado Anschutz Medical Center, Aurora, Colorado
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22
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Gilbert FJ, Hickman SE, Baxter GC, Allajbeu I, James J, Caraco C, Vinnicombe S. Opportunities in cancer imaging: risk-adapted breast imaging in screening. Clin Radiol 2021; 76:763-773. [PMID: 33820637 DOI: 10.1016/j.crad.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/19/2021] [Indexed: 12/17/2022]
Abstract
In the UK, women between 50-70 years are invited for 3-yearly mammography screening irrespective of their likelihood of developing breast cancer. The only risk adaption is for women with >30% lifetime risk who are offered annual magnetic resonance imaging (MRI) and mammography, and annual mammography for some moderate-risk women. Using questionnaires, breast density, and polygenic risk scores, it is possible to stratify the population into the lowest 20% risk, who will develop <4% of cancers and the top 4%, who will develop 18% of cancers. Mammography is a good screening test but has low sensitivity of 60% in the 9% of women with the highest category of breast density (BIRADS D) who have a 2.5- to fourfold breast cancer risk. There is evidence that adding ultrasound to the screening mammogram can increase the cancer detection rate and reduce advanced stage interval and next round cancers. Similarly, alternative tests such as contrast-enhanced mammography (CESM) or abbreviated MRI (ABB-MRI) are much more effective in detecting cancer in women with dense breasts. Scintimammography has been shown to be a viable alternative for dense breasts or for follow-up in those with a personal history of breast cancer and scarring as result of treatment. For supplemental screening to be worthwhile in these women, new technologies need to reduce the number of stage II cancers and be cost effective when tested in large scale trials. This article reviews the evidence for supplemental imaging and examines whether a risk-stratified approach is feasible.
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Affiliation(s)
- F J Gilbert
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK; Department of Radiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - S E Hickman
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - G C Baxter
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - I Allajbeu
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK; Department of Radiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J James
- Nottingham Breast Institute, City Hospital, Nottingham, UK
| | - C Caraco
- Department of Radiology, University of Cambridge School of Clinical Medicine, Box 218, Level 5, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - S Vinnicombe
- Thirlestaine Breast Centre, Cheltenham, UK; Ninewells Hospital and Medical School, University of Dundee, UK
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Hickman SE, Steinberg K, Carney J, Lum HD. POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care. J Am Med Dir Assoc 2021; 22:1672-1677. [PMID: 34029523 DOI: 10.1016/j.jamda.2021.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/16/2021] [Accepted: 04/18/2021] [Indexed: 11/25/2022]
Abstract
POLST (Physician Orders for Life-Sustaining Treatment) is a medical order form used to document preferences about cardiopulmonary resuscitation (CPR), medical interventions such as hospitalization, care in the intensive care unit, and/or ventilation, as well as artificial nutrition. Programs based on the POLST paradigm are used in virtually every state under names that include POST (Physician Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and MOST (Medical Orders for Scope of Treatment), and these forms are used in the care of hundreds of thousands of geriatric patients every year. Although POLST is intended for persons who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition, some nursing homes and residential care settings use POLST to document CPR preferences for all residents, resulting in potentially inappropriate use with patients who are ineligible because they are too healthy. This article focuses on reasons that POLST is used as a default code status order form, the risks associated with this practice, and recommendations for nursing homes to implement appropriate use of POLST.
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Affiliation(s)
- Susan E Hickman
- Indiana University School of Nursing, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA.
| | - Karl Steinberg
- California State University, Institute for Palliative Care, Oceanside, CA, USA
| | - John Carney
- Center for Practical Bioethics, Kansas City, MO, USA
| | - Hillary D Lum
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO, USA; Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Hickman SE, Miech EJ, Stump TE, Fowler NR, Unroe KT. Identifying the Implementation Conditions Associated With Positive Outcomes in a Successful Nursing Facility Demonstration Project. Gerontologist 2021; 60:1566-1574. [PMID: 32440672 PMCID: PMC7731870 DOI: 10.1093/geront/gnaa041] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To identify the implementation barriers, facilitators, and conditions associated with successful outcomes from a clinical demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents in 19 Indiana nursing homes. RESEARCH DESIGN AND METHODS Optimizing Patient Transfers, Impacting Medical quality, Improving Symptoms-Transforming Institutional Care (OPTIMISTIC) is a multicomponent intervention that includes enhanced geriatric care, transition support, and palliative care. The configurational analysis was used to analyze descriptive and quantitative data collected during the project. The primary outcome was reductions in hospitalizations per 1,000 eligible resident days. RESULTS Analysis of barriers, facilitators, and conditions for success yielded a model with 2 solution pathways associated with a 10% reduction in potentially avoidable hospitalizations per 1,000 resident days: (a) lower baseline hospitalization rates and investment of senior management; or (b) turnover by the director of nursing during the observation period. Conditions for success were similar for a 20% reduction, with the addition of increased resident acuity. DISCUSSION AND IMPLICATIONS Key conditions for successful implementation of the OPTIMISTIC intervention include strong investment by senior leadership and an environment in which baseline hospitalization rates leave ample room for improvement. Turnover in the position of director of nursing also linked to successful implementation; this switch in leadership may represent an opportunity for culture change by bringing in new perspectives and viewpoints. These findings help define the conditions for the successful implementation of the OPTIMISTIC model and have implications for the successful implementation of interventions in the nursing facility more generally.
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Affiliation(s)
- Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute Incorporated, Indianapolis.,Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis
| | - Edward J Miech
- Center for Health Services Research, Regenstrief Institute Incorporated, Indianapolis, Indiana.,Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Timothy E Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Nicole R Fowler
- Indiana University Center for Aging Research, Regenstrief Institute Incorporated, Indianapolis.,Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis
| | - Kathleen T Unroe
- Indiana University Center for Aging Research, Regenstrief Institute Incorporated, Indianapolis.,Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis
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Hickman SE, Torke AM, Heim Smith N, Myers AL, Sudore RL, Hammes BJ, Sachs GA. Reasons for discordance and concordance between POLST orders and current treatment preferences. J Am Geriatr Soc 2021; 69:1933-1940. [PMID: 33760226 DOI: 10.1111/jgs.17097] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/21/2021] [Accepted: 02/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The reasons for discordance between advance care planning (ACP) documentation and current preferences are not well understood. The POLST form offers a unique opportunity to learn about the reasons for discordance and concordance that has relevance for POLST as well as ACP generally. DESIGN Qualitative descriptive including constant comparative analysis within and across cases. SETTING Twenty-six nursing facilities in Indiana. PARTICIPANTS Residents (n = 36) and surrogate decision-makers of residents without decisional capacity (n = 37). MEASUREMENTS A semi-structured interview guide was used to explore the reasons for discordance or concordance between current preferences and existing POLST forms. FINDINGS Reasons for discordance include: (1) problematic nursing facility practices related to POLST completion; (2) missing key information about POLST treatment decisions; (3) deferring to others; and (4) changes over time. Some participants were unable to explain the discordance due to a lack of insight or inability to remember details of the original POLST conversation. Explanations for concordance include: (1) no change in the resident's medical condition and/or the resident is unlikely to improve; (2) use of the substituted judgment standard for surrogate decision-making; and (3) fixed opinion about what is "right" with little to no insight. CONCLUSION Participant explanations for discordance between existing POLST orders and current preferences highlight the importance of adequate structures and processes to support high quality ACP in nursing facilities. Residents with stable or poor health may be more appropriate candidates for POLST than residents with a less clear prognosis, though preferences should be revisited periodically as well as when there is a change in condition to help ensure existing documentation is concordant with current treatment preferences.
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Affiliation(s)
- Susan E Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA.,Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Alexia M Torke
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Nicholette Heim Smith
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Anne L Myers
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, Wisconsin, USA
| | - Greg A Sachs
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA
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Hickman SE, Torke AM, Sachs GA, Sudore RL, Tang Q, Bakoyannis G, Heim Smith N, Myers AL, Hammes BJ. Factors associated with concordance between POLST orders and current treatment preferences. J Am Geriatr Soc 2021; 69:1865-1876. [PMID: 33760241 DOI: 10.1111/jgs.17095] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/04/2021] [Accepted: 02/16/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND POLST is widely used to document the treatment preferences of nursing facility residents as orders, but it is unknown how well previously completed POLST orders reflect current preferences (concordance) and what factors are associated with concordance. OBJECTIVES To describe POLST preference concordance and identify factors associated with concordance. DESIGN Chart reviews to document existing POLST orders and interviews to elicit current treatment preferences. SETTING POLST-using nursing facilities (n = 29) in Indiana. PARTICIPANTS Nursing facility residents (n = 123) and surrogates of residents without decisional capacity (n = 152). MEASUREMENTS Concordance was determined by comparing existing POLST orders for resuscitation, medical interventions, and artificial nutrition with current treatment preferences. Comfort-focused POLSTs contained orders for do not resuscitate, comfort measures, and no artificial nutrition. RESULTS Overall, 55.7% (123/221) of residents and 44.7% (152/340) of surrogates participated (total n = 275). POLST concordance was 44%, but concordance was higher for comfort-focused POLSTs (68%) than for non-comfort-focused POLSTs (27%) (p < 0.001). In the unadjusted analysis, increasing resident age (OR 1.04, 95% CI 1.01-1.07, p < 0.01), better cognitive functioning (OR 1.07, 95% CI 1.02-1.13, p < 0.01), surrogate as the decision-maker (OR 2.87, OR 1.73-4.75, p < 0.001), and comfort-focused POLSTs (OR 6.01, 95% CI 3.29-11.00, p < 0.01) were associated with concordance. In the adjusted multivariable model, only having an existing comfort-focused POLST was associated with higher odds of POLST concordance (OR 5.28, 95% CI 2.59-10.73, p < 0.01). CONCLUSIONS Less than half of all POLST forms were concordant with current preferences, but POLST was over five times as likely to be concordant when orders reflected preferences for comfort-focused care. Findings suggest a clear need to improve the quality of POLST use in nursing facilities and focus its use among residents with stable, comfort-focused preferences.
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Affiliation(s)
- Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA.,Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Alexia M Torke
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Greg A Sachs
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Giorgos Bakoyannis
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Nicholette Heim Smith
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Anne L Myers
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Bernard J Hammes
- A Division of C-TAC Innovations, Respecting Choices, La Crosse, Wisconsin, USA
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Hickman SE, Torke AM, Sachs GA, Sudore RL, Tang Q, Bakoyannis G, Smith NH, Myers AL, Hammes BJ. Do Life-sustaining Treatment Orders Match Patient and Surrogate Preferences? The Role of POLST. J Gen Intern Med 2021; 36:413-421. [PMID: 33111241 PMCID: PMC7878602 DOI: 10.1007/s11606-020-06292-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND It is essential to high-quality medical care that life-sustaining treatment orders match the current, values-based preferences of patients or their surrogate decision-makers. It is unknown whether concordance between orders and current preferences is higher when a POLST form is used compared to standard documentation practices. OBJECTIVE To assess concordance between existing orders and current preferences for nursing facility residents with and without POLST forms. DESIGN Chart review and interviews. SETTING Forty Indiana nursing facilities (29 where POLST is used and 11 where POLST is not in use). PARTICIPANTS One hundred sixty-one residents able to provide consent and 197 surrogate decision-makers of incapacitated residents with and without POLST forms. MAIN MEASUREMENTS Concordance was measured by comparing life-sustaining treatment orders in the medical record (e.g., orders about resuscitation, intubation, and hospitalization) with current preferences. Concordance was analyzed using population-averaged binary logistic regression. Inverse probability weighting techniques were used to account for non-response. We hypothesized that concordance would be higher in residents with POLST (n = 275) in comparison to residents without POLST (n = 83). KEY RESULTS Concordance was higher for residents with POLST than without POLST (59.3% versus 34.9%). In a model adjusted for resident, surrogate, and facility characteristics, the odds were 3.05 times higher that residents with POLST had orders for life-sustaining treatment match current preferences in comparison to residents without POLST (OR 3.05 95% CI 1.67-5.58, p < 0.001). No other variables were significantly associated with concordance. CONCLUSIONS Nursing facility residents with POLST are significantly more likely than residents without POLST to have concordance between orders in their medical records and current preferences for life-sustaining treatments, increasing the likelihood that their treatment preferences will be known and honored. However, findings indicate further systems change and clinical training are needed to improve POLST concordance.
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Affiliation(s)
- Susan E Hickman
- Indiana University School of Nursing, Department of Community & Health Systems, 1101 West 10th Street, IN, 46202, Indianapolis, USA. .,Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA. .,Indiana University School of Medicine, Division of General Internal Medicine & Geriatrics, 1101 West 10th Street, IN, 46202, Indianapolis, USA. .,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA.
| | - Alexia M Torke
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA.,Indiana University School of Medicine, Division of General Internal Medicine & Geriatrics, 1101 West 10th Street, IN, 46202, Indianapolis, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Greg A Sachs
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA.,Indiana University School of Medicine, Division of General Internal Medicine & Geriatrics, 1101 West 10th Street, IN, 46202, Indianapolis, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Rebecca L Sudore
- Division of Geriatrics, University of California San Francisco, School of Medicine, San Francisco, CA, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
| | - Giorgos Bakoyannis
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
| | - Nicholette Heim Smith
- Indiana University School of Nursing, Department of Community & Health Systems, 1101 West 10th Street, IN, 46202, Indianapolis, USA
| | - Anne L Myers
- Indiana University School of Nursing, Department of Community & Health Systems, 1101 West 10th Street, IN, 46202, Indianapolis, USA
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, WI, USA
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Hathaway EE, Carnahan JL, Unroe KT, Stump TE, Phillips EO, Hickman SE, Fowler NR, Sachs GA, Bateman DR. Nursing Home Transfers for Behavioral Concerns: Findings from the OPTIMISTIC Demonstration Project. J Am Geriatr Soc 2021; 69:415-423. [PMID: 33216954 PMCID: PMC10602584 DOI: 10.1111/jgs.16920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/19/2020] [Accepted: 09/26/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To characterize pretransfer on-site nursing home (NH) management, transfer disposition, and hospital discharge diagnoses of long-stay residents transferred for behavioral concerns. DESIGN This was a secondary data analysis of the Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care project, in which clinical staff employed in the NH setting conducted medical, transitional, and palliative care quality improvement initiatives and gathered data related to resident transfers to the emergency department/hospital setting. R software and Microsoft Excel were used to characterize a subset of transfers prompted by behavioral concerns. SETTING NHs in central Indiana were utilized (N = 19). PARTICIPANTS This study included long-stay NH residents with behavioral concerns prompting transfer for acute emergency department/hospital evaluation (N = 355 transfers). MEASUREMENTS The measures used in this study were symptoms prompting transfer, resident demographics and baseline characteristics (Minimum Data Set 3.0 variables including scores for the Cognitive Function Scale, ADL Functional Status, behavioral symptoms directed toward others, and preexisting psychiatric diagnoses), on-site management (e.g., medical evaluation in person or by phone, testing, and interventions), avoidability rating, transfer disposition (inpatient vs emergency department only), and hospital discharge diagnoses. RESULTS Over half of the transfers, 56%, had a medical evaluation before transfer, and diagnostic testing was conducted before 31% of transfers. After transfer, 80% were admitted. The most common hospital discharge diagnoses were dementia-related behaviors (27%) and altered mental status (27%), followed by a number of medical diagnoses. CONCLUSION Most transfers for behavioral concerns merited hospital admission, and medical discharge diagnoses were common. There remain significant opportunities to improve pretransfer management of NH transfers for behavioral concerns.
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Affiliation(s)
- Elizabeth E. Hathaway
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jennifer L. Carnahan
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T. Unroe
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Timothy E. Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erin O’Kelly Phillips
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
| | - Susan E. Hickman
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University School of Nursing, Indianapolis, IN, USA
| | - Nicole R. Fowler
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Greg A. Sachs
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel R. Bateman
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indiana University Center for Aging Research, Indianapolis, IN, USA
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Hofschulte-Beck SL, Hickman SE, Blackburn JL, Mack LM, Unroe KT. Attitudes and Experiences of Frontline Nursing Home Staff Toward Coronavirus Testing. J Am Med Dir Assoc 2020; 22:215-217. [PMID: 33253637 PMCID: PMC7643623 DOI: 10.1016/j.jamda.2020.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/29/2020] [Accepted: 11/01/2020] [Indexed: 11/20/2022]
Affiliation(s)
| | - Susan E Hickman
- Indiana University Center for Aging Research Regenstrief Institute Indiana University School of Nursing Indianapolis, IN, USA
| | | | - Laramie M Mack
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis, IN, USA
| | - Kathleen T Unroe
- Indiana University Center for Aging Research Regenstrief Institute Indiana University School of Medicine Indianapolis, IN, USA.
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Montgomery C, Hickman SE, Wilkins C, Fromme EK, Anderson S. Montgomery et al's Response to Morrison: Advance Directives/Care Planning: Clear, Simple, and Wrong (DOI: 10.1089/jpm.2020.0272). J Palliat Med 2020; 24:12-13. [PMID: 32881594 DOI: 10.1089/jpm.2020.0523] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Carole Montgomery
- Respecting Choices, a Division of C-TAC Innovations, Washington, DC, USA
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Christine Wilkins
- Advance Care Planning Program, NYU Langone Health, New York, New York, USA
| | - Erik K Fromme
- Serious Illness Care Program, Ariadne Labs and Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Stephanie Anderson
- Respecting Choices, a Division of C-TAC Innovations, Washington, DC, USA
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Unroe KT, Caterino JM, Stump TE, Tu W, Carnahan JL, Vest JR, Sachs GA, Hickman SE. Long‐Stay Nursing Facility Resident Transfers: Who Gets Admitted to the Hospital? J Am Geriatr Soc 2020; 68:2082-2089. [DOI: 10.1111/jgs.16633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Kathleen T. Unroe
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine and Internal Medicine The Ohio State University School of Medicine Columbus Ohio USA
| | - Timothy E. Stump
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
| | - Wanzhu Tu
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Jennifer L. Carnahan
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Joshua R. Vest
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
- Department of Health Policy and Management Indiana University Richard M. Fairbanks School of Public Health at Indiana University ‐ Purdue University Indianapolis Indianapolis Indiana USA
| | - Greg A. Sachs
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Susan E. Hickman
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
- Department of Community and Health Systems Indiana University School of Nursing Indianapolis Indiana USA
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Comer AR, Hickman SE, Slaven JE, Monahan PO, Sachs GA, Wocial LD, Burke ES, Torke AM. Assessment of Discordance Between Surrogate Care Goals and Medical Treatment Provided to Older Adults With Serious Illness. JAMA Netw Open 2020; 3:e205179. [PMID: 32427322 PMCID: PMC7237962 DOI: 10.1001/jamanetworkopen.2020.5179] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE An important aspect of high-quality care is ensuring that treatments are in alignment with patient or surrogate decision-maker goals. Treatment discordant with patient goals has been shown to increase medical costs and prolong end-of-life difficulties. OBJECTIVES To evaluate discordance between surrogate decision-maker goals of care and medical orders and treatments provided to hospitalized, incapacitated older patients. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included 363 patient-surrogate dyads. Patients were 65 years or older and faced at least 1 major medical decision in the medical and medical intensive care unit services in 3 tertiary care hospitals in an urban Midwestern area. Data were collected from April 27, 2012, through July 10, 2015, and analyzed from October 5, 2018, to December 5, 2019. MAIN OUTCOMES AND MEASURES Each surrogate's preferred goal of care was determined via interview during initial hospitalization and 6 to 8 weeks after discharge. Surrogates were asked to select the goal of care for the patient from 3 options: comfort-focused care, life-sustaining treatment, or an intermediate option. To assess discordance, the preferred goal of care as determined by the surrogate was compared with data from medical record review outlining the medical treatment received during the target hospitalization. RESULTS A total of 363 dyads consisting of patients (223 women [61.4%]; mean [SD] age, 81.8 [8.3] years) and their surrogates (257 women [70.8%]; mean [SD] age, 58.3 [11.2] years) were included in the analysis. One hundred sixty-nine patients (46.6%) received at least 1 medical treatment discordant from their surrogate's identified goals of care. The most common type of discordance involved full-code orders for patients with a goal of comfort (n = 41) or an intermediate option (n = 93). More frequent in-person contact between surrogate and patient (adjusted odds ratio [AOR], 0.43; 95% CI, 0.23-0.82), patient residence in an institution (AOR, 0.44; 95% CI, 0.23-0.82), and surrogate-rated quality of communication (AOR, 0.98; 95% CI, 0.96-0.99) were associated with lower discordance. Surrogate marital status (AOR for single vs married, 1.92; 95% CI, 1.01-3.66), number of family members involved in decisions (AOR for ≥2 vs 0-1, 1.84; 95% CI, 1.05-3.21), and religious affiliation (AOR for none vs any, 4.87; 95% CI, 1.12-21.09) were associated with higher discordance. CONCLUSIONS AND RELEVANCE This study found that discordance between surrogate goals of care and medical treatments for hospitalized, incapacitated patients was common. Communication quality is a modifiable factor associated with discordance that may be an avenue for future interventions.
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Affiliation(s)
- Amber R. Comer
- Department of Health Sciences, Indiana University School of Health and Human Sciences, Indianapolis
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
| | - Susan E. Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana
- Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis
| | - James E. Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Patrick O. Monahan
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Greg A. Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis
| | - Lucia D. Wocial
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana
- Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis
| | - Emily S. Burke
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
| | - Alexia M. Torke
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
- Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis
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Wocial LD, Slaven JE, Montz K, Monahan PO, Hickman SE, Callahan CM, Helft PR, Sachs GA, Inger L, Burke ES, Torke AM. Factors Associated with Physician Moral Distress Caring for Hospitalized Elderly Patients Needing a Surrogate Decision-maker: a Prospective Study. J Gen Intern Med 2020; 35:1405-1412. [PMID: 32096085 PMCID: PMC7210358 DOI: 10.1007/s11606-020-05652-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 07/11/2019] [Accepted: 12/10/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND When working with surrogate decision-makers, physicians often encounter ethical challenges that may cause moral distress which can have negative consequences for physicians. OBJECTIVE To determine frequency of and factors associated with physicians' moral distress caring for patients requiring a surrogate. DESIGN Prospective survey. PARTICIPANTS Physicians (n = 154) caring for patients aged 65 years and older and their surrogate decision-makers (n = 362 patient/surrogate dyads). Patients were admitted to medicine or medical intensive care services, lacked decisional capacity and had an identified surrogate. MAIN MEASURES Moral distress thermometer. KEY RESULTS Physicians experienced moral distress in the care of 152 of 362 patients (42.0%). In analyses adjusted for physician, patient, and surrogate characteristics, physician/surrogate discordance in preferences for the plan of care was not significantly associated with moral distress. Physicians were more likely to experience moral distress when caring for older patients (1.06, 1.02-1.10), and facing a decision about life-sustaining treatment (3.58, 1.54-8.32). Physicians were less likely to experience moral distress when caring for patients residing in a nursing home (0.40, 0.23-0.69), patients who previously discussed care preferences (0.56, 0.35-0.90), and higher surrogate ratings of emotional support from clinicians (0.94, 0.89-0.99). Physicians' internal discordance when they prefer a more comfort-focused plan than the patient is receiving was associated with significantly higher moral distress (2.22, 1.33-3.70) after adjusting for patient, surrogate, and physician characteristics. CONCLUSIONS Physician moral distress occurs more frequently when the physician is male, the patient is older or requires decisions about life-sustaining treatments. These findings may help target interventions to support physicians. Prior discussions about patient wishes is associated with lower distress and may be a target for patient-centered interventions.
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Affiliation(s)
- Lucia D Wocial
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, USA.
- Indiana University School of Nursing, Indianapolis, IN, USA.
| | | | - Kianna Montz
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | | | - Susan E Hickman
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, USA
- Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Christopher M Callahan
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
- IU Division of General Internal Medicine and Geriatrics, Indianapolis, IN, USA
| | - Paul R Helft
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, USA
- IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Greg A Sachs
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
- IU Division of General Internal Medicine and Geriatrics, Indianapolis, IN, USA
| | - Lev Inger
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Emily S Burke
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Alexia M Torke
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, USA
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
- IU Division of General Internal Medicine and Geriatrics, Indianapolis, IN, USA
- Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, Indianapolis, IN, USA
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Blackburn J, Stump TE, Carnahan JL, Hickman SE, Tu W, Fowler NR, Unroe KT. Reducing the Risk of Hospitalization for Nursing Home Residents: Effects and Facility Variation From OPTIMISTIC. J Am Med Dir Assoc 2020; 21:545-549.e1. [DOI: 10.1016/j.jamda.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/26/2022]
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Daddato AE, Griff M, Shanbhag P, Hickman SE, Lum HD. Appropriate Use of Physician Orders for Life-Sustaining Treatment in the Outpatient Setting. J Palliat Med 2020; 23:449-450. [PMID: 32216694 DOI: 10.1089/jpm.2019.0635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrea E Daddato
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Megan Griff
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., and Indiana University School of Nursing, Indianapolis, Indiana
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado
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Unroe KT, O'Kelly Phillips E, Effler S, Ersek MT, Hickman SE. Comfort Measures Orders and Hospital Transfers: Insights From the OPTIMISTIC Demonstration Project. J Pain Symptom Manage 2019; 58:559-566. [PMID: 31233842 DOI: 10.1016/j.jpainsymman.2019.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Nursing facility residents and their families may identify "comfort measures" as their overall goal of care, yet some hospital transfers still occur. OBJECTIVES Describe nursing facility residents with comfort measures and their hospital transfers. METHODS Mixed methods, including root cause analyses of transfers by registered nurses and interviews with a subset of health care providers and family members involved in transfers. Participants were residents in 19 central Indiana facilities with comfort measures orders who experienced unplanned transfers to the hospital between January 1, 2015 and June 30, 2016. Project demographic and clinical characteristics of the residents were obtained from the Minimum Data Set 3.0. Interviews were conducted with stakeholders involved in transfer decisions. Participants were prompted to reflect on reasons for the transfer and outcomes. Interviews were transcribed and coded using qualitative descriptive methods. RESULTS Residents with comfort measures orders (n = 177) experienced 204 transfers. Most events were assessed as unavoidable (77%). Communication among staff, or between staff and the resident/family, primary care provider, or hospital was the most frequently noted area needing improvement (59.5%). In interviews, participants (n = 11) highlighted multiple issues, including judgments about whether decisions were "good" or "bad," and factors that were important to decision-making, including communication, nursing facility capabilities, clinical situation, and goals of care. CONCLUSION Most transfers of residents with comfort measures orders were considered unavoidable. Nonetheless, we identified several opportunities for improving care processes, including communication and addressing acute changes in status.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA.
| | | | | | - Mary T Ersek
- Department of Veterans Affairs, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Susan E Hickman
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University School of Nursing, Indianapolis, Indiana, USA
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Hickman SE, Vandenbroucke A, Carney J, Sandler V, Lum HD, Hammes BJ. Artificial Nutrition Belongs on POLST. J Am Geriatr Soc 2019; 67:1985-1987. [PMID: 31412136 DOI: 10.1111/jgs.16091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 05/30/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Susan E Hickman
- School of Nursing and School of Medicine, Indiana University, Indianapolis, Indiana.,Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, Indiana
| | | | - John Carney
- Center for Practical Bioethics, Kansas City, Missouri
| | - Victor Sandler
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Hillary D Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Bernard J Hammes
- Respecting Choices, A Division of CTAC Innovations, La Crosse, Wisconsin
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Abstract
PROBLEM IDENTIFICATION Pediatric oncology phase 1 clinical trials (P1Ts) are essential to developing new anticancer therapies; however, they raise complex ethical concerns about balancing the need for this research with the well-being of participating children. The purpose of this integrative review was to synthesize and appraise the evidence of how P1T participation, which begins with consent and ends with the transition off the P1T, can affect the well-being (either positively or negatively) of children with cancer. The Resilience in Individuals and Families Affected by Cancer Framework, which has an outcome of well-being, was used to synthesize findings. LITERATURE SEARCH Articles on the experiences of child (n = 21) and adult (n = 31) P1T participants were identified through systematic searches. DATA EVALUATION Articles were evaluated on rigor and relevance to P1T participant experiences as high, medium, or low. SYNTHESIS Minimal empirical evidence was found regarding the effect of P1T participation on the well-being of children with cancer. Adult P1T participant experiences provide insights that could also be important to children's P1T experiences. IMPLICATIONS FOR PRACTICE To achieve a balanced approach in P1T consent discussions, nurses and healthcare providers who work with children considering participation in a P1T should share the potential effect of participation on participants' well-being.
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Hickman SE, Torke AM, Sachs GA, Sudore RL, Myers AL, Tang Q, Bakoyannis G, Hammes BJ. A Tool to Assess Patient and Surrogate Knowledge About the POLST (Physician Orders for Life-Sustaining Treatment) Program. J Pain Symptom Manage 2019; 57:1143-1150.e5. [PMID: 30853552 PMCID: PMC6857935 DOI: 10.1016/j.jpainsymman.2019.02.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
Abstract
CONTEXT It is especially important that patients are well informed when making high-stakes, preference-sensitive decisions like those on the Physician Orders for Life-Sustaining Treatment (POLST) form. However, there is currently no way to easily evaluate whether patients understand key concepts when making these important decisions. OBJECTIVES To develop a POLST knowledge survey. METHODS Expert (n = 62) ratings of key POLST facts were used to select items for a POLST knowledge survey. The survey was administered to nursing facility residents (n = 97) and surrogate decision-makers (n = 112). A subset (n = 135) were re-administered the survey after a standardized advance care planning discussion to assess the scale's responsiveness to change. RESULTS The 19-item survey demonstrated adequate reliability (α = 0.72.). Residents' scores (x = 11.4, standard deviation 3.3) were significantly lower than surrogate scores (x = 14.7, standard deviation 2.5) (P < 0.001). Scores for both groups increased significantly after administration of a standardized advance care planning discussion (P < 0.001). Although being a surrogate, age, race, education, cognitive functioning, and health literacy were significantly associated with higher POLST Knowledge Survey scores in univariate analyses, only being a surrogate (P < 0.001) and being white (P = 0.028) remained significantly associated with higher scores in multivariate analyses. CONCLUSION The 19-item POLST Knowledge Survey demonstrated adequate reliability and responsiveness to change. Findings suggest the survey could be used to identify knowledge deficits and provide targeted education to ensure adequate understanding of key clinical decisions when completing POLST.
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Affiliation(s)
- Susan E Hickman
- Indiana University School of Nursing, Department of Community & Health Systems, Indianapolis, Indiana, USA; IUPUI Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indianapolis, Indiana, USA.
| | - Alexia M Torke
- IUPUI Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indianapolis, Indiana, USA; Indiana University School of Medicine, Department of General Internal Medicine & Geriatrics, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA
| | - Greg A Sachs
- IUPUI Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indianapolis, Indiana, USA; Indiana University School of Medicine, Department of General Internal Medicine & Geriatrics, Indianapolis, Indiana, USA; Regenstrief Institute, Indianapolis, Indiana, USA
| | - Rebecca L Sudore
- University of California San Francisco School of Medicine, San Francisco, California, USA; San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Anne L Myers
- Indiana University School of Nursing, Department of Community & Health Systems, Indianapolis, Indiana, USA
| | - Qing Tang
- Indiana University Fairbanks School of Public Health and School of Medicine, Department of Biostatistics, Indianapolis, Indiana, USA
| | - Giorgos Bakoyannis
- Indiana University Fairbanks School of Public Health and School of Medicine, Department of Biostatistics, Indianapolis, Indiana, USA
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, Wisconsin, USA
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Abstract
OBJECTIVES This qualitative descriptive study explored provider-surrogate communication during Physician Orders for Life-Sustaining Treatment (POLST) discussions for patients with advanced dementia. METHODS Data from participant observations and audio-recordings of ten POLST discussions were analyzed using directed content analysis within the context of an existing conceptual model of Communication and Surrogate Decision Making. RESULTS Surrogates primarily focused on making sense of the clinical information about life-sustaining treatments during POLST conversations. Providers delivered clinical information about the trajectory of dementia, life-sustaining treatments, and/or features of POLST. They also demonstrated emotional support, by valuing what the surrogate said, acknowledging the surrogate's emotions, listening carefully, understanding the patient as a person, and eliciting questions. However, providers rarely conveyed comprehensive information about the patient's current condition and end-of-life treatment options. Also, open communication of expectations and preferred decision-making roles was rarely observed during the discussions. CONCLUSION Findings highlight areas that require providers' attention to conduct effective communication, such as delivering comprehensive information about life-sustaining treatments including discussion of risks and benefits in the context of dementia. Findings also support the use of the conceptual model as a framework to examine provider-surrogate communication in the context of POLST discussions, advanced dementia, and non-hospital settings. Additional research is necessary to confirm these findings in larger, more diverse groups of patients, surrogates, and providers.
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Affiliation(s)
- Hyejin Kim
- a Emory Universiry Nell Hodgson Woodruff School of Nursing, Center for Nursing Excellence in Palliative Care , Atlanta , GA , USA
| | - Christine Bradway
- b University of Pennsylvania School of Nursing, Behavioral Health Sciences , Philadelphia , PA , USA
| | - Susan E Hickman
- c Indiana University School of Nursing, Community and Health Systems , Indianapolis , IN , USA
| | - Mary Ersek
- b University of Pennsylvania School of Nursing, Behavioral Health Sciences , Philadelphia , PA , USA.,d Corporal Michael J. Crescenz Veteran Affairs Medical Center, Veteran Experience Center , Philadelphia , PA , USA
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Hickman SE, Unroe KT, Ersek M, Stump TE, Tu W, Ott M, Sachs GA. Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents. J Am Geriatr Soc 2019; 67:1649-1655. [DOI: 10.1111/jgs.15927] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Susan E. Hickman
- Department of Community Health Systems, School of Nursing Indiana University Indianapolis Indiana
- RESPECT (Research in Palliative and End‐of‐Life Communication and Training) Signature Center Indiana University Purdue University Indianapolis Indianapolis Indiana
| | - Kathleen T. Unroe
- RESPECT (Research in Palliative and End‐of‐Life Communication and Training) Signature Center Indiana University Purdue University Indianapolis Indianapolis Indiana
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
- Center for Aging Research, Regenstrief Institute Indianapolis Indiana
| | - Mary Ersek
- Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center Philadelphia Pennsylvania
- Biobehavioral Health Sciences, School of Nursing University of Pennsylvania Philadelphia Pennsylvania
| | - Timothy E. Stump
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
- Department of Biostatistics School of Medicine, Indiana University Indianapolis Indiana
| | - Wanzhu Tu
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
- Center for Aging Research, Regenstrief Institute Indianapolis Indiana
- Department of Biostatistics School of Medicine, Indiana University Indianapolis Indiana
| | - Monica Ott
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
| | - Greg A. Sachs
- RESPECT (Research in Palliative and End‐of‐Life Communication and Training) Signature Center Indiana University Purdue University Indianapolis Indianapolis Indiana
- Division of General Internal Medicine and Geriatrics, School of Medicine Indiana University Indianapolis Indiana
- Center for Aging Research, Regenstrief Institute Indianapolis Indiana
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Affiliation(s)
- Susan E. Hickman
- School of Nursing and Center for Ethics in Health Care, Oregon Health & Science University
| | - Virginia P. Tilden
- School of Nursing and Center for Ethics in Health Care, Oregon Health & Science University
- Currently University of Nebraska Medical Center College of Nursing
| | - Susan W. Tolle
- Center for Ethics in Health Care, and Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon, U.S.A
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Ersek M, Hickman SE, Thomas AC, Bernard B, Unroe KT. Stakeholder Perspectives on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) Project. Gerontologist 2019; 58:1177-1187. [PMID: 29045609 DOI: 10.1093/geront/gnx155] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Indexed: 01/12/2023] Open
Abstract
Background and Objectives The need to reduce burdensome and costly hospitalizations of frail nursing home residents is well documented. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project achieved this reduction through a multicomponent collaborative care model. We conducted an implementation-focused project evaluation to describe stakeholders' perspectives on (a) the most and least effective components of the intervention; (b) barriers to implementation; and (c) program features that promoted its adoption. Research Design and Methods Nineteen nursing homes participated in OPTIMISTIC. We conducted semistructured, qualitative interviews with 63 stakeholders: 23 nursing home staff and leaders, 4 primary care providers, 10 family members, and 26 OPTIMISTIC clinical staff. We used directed content analysis to analyze the data. Results We found universal endorsement of the value of in-depth advance care planning (ACP) discussions in reducing hospitalizations and improving care. Similarly, all stakeholder groups emphasized that nursing home access to specially trained, project registered nurses (RNs) and nurse practitioners (NPs) with time to focus on ACP, comprehensive resident assessment, and staff education was particularly valuable in identifying residents' goals for care. Challenges to implementation included inadequately trained facility staff and resistance to changing practice. In addition, the program sometimes failed to communicate its goals and activities clearly, leaving facilities uncertain about the OPTIMISTIC clinical staff's roles in the facilities. Discussion and Implications These findings are important for dissemination efforts related to the OPTIMISTIC care model and may be applicable to other innovations in nursing homes.
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Affiliation(s)
- Mary Ersek
- Department of Veterans Affairs, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia
| | | | - Anne C Thomas
- College of Nursing, Michigan State University, East Lansing, Michigan
| | | | - Kathleen T Unroe
- Regenstrief Institute, Indianapolis, Indiana
- School of Medicine, Indiana University, Indianapolis
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Crane S, Haase JE, Hickman SE. Parental Experiences of Child Participation in a Phase I Pediatric Oncology Clinical Trial: "We Don't Have Time to Waste". Qual Health Res 2019; 29:632-644. [PMID: 29642777 PMCID: PMC6167192 DOI: 10.1177/1049732318766513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Children with cancer are only eligible for phase I clinical trials (P1Ts) when no known curative therapy remains. However, the primary aims of P1Ts are not focused on directly benefiting participants. This raises ethical concerns that can be best evaluated by exploring the experiences of participants. An empirical phenomenology study, using an adapted Colaizzi method, was conducted of 11 parents' lived experiences of their child's participation in a pediatric oncology P1T. Study findings were that parents' experiences reflected what it meant to have a child fighting to survive high-risk cancer. Although elements specific to P1T participation were identified, more pervasive was parents' sense of running out of time to find an effective treatment and needing to use time they had with their child well. Even though some problems were identified, overall parents did not regret their child's P1T participation and would recommend P1Ts to other parents of children with cancer.
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Affiliation(s)
- Stacey Crane
- 1 Indiana University-Purdue University Indianapolis, Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indianapolis, Indiana, USA
| | - Joan E Haase
- 1 Indiana University-Purdue University Indianapolis, Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indianapolis, Indiana, USA
| | - Susan E Hickman
- 1 Indiana University-Purdue University Indianapolis, Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indianapolis, Indiana, USA
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Torke AM, Hickman SE, Hammes B, Counsell SR, Inger L, Slaven JE, Butler D. POLST Facilitation in Complex Care Management: A Feasibility Study. Am J Hosp Palliat Care 2018; 36:5-12. [PMID: 30153739 DOI: 10.1177/1049909118797077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) form is an advance care planning tool designed for seriously ill patients. The discussions needed for high-quality POLST decision-making are time intensive and often do not occur in the outpatient setting. OBJECTIVE: We conducted a single-arm feasibility study of POLST facilitation by nonphysicians using Respecting Choices Last Steps, a standardized, structured approach to facilitation of POLST conversations. SETTING/PARTICIPANTS: Community-dwelling adults aged 65 and older enrolled in a complex care management program in a Midwestern urban hospital. MEASUREMENTS: We assessed the feasibility and acceptability by determining the proportion of eligible patients who enrolled and completed the study, by adherence to the Respecting Choices protocol, and by responses to qualitative and quantitative survey items about the intervention. RESULTS: We enrolled 18 (58.1%) of 31 eligible patients, with a mean age of 77.8 years (standard deviation: 6.95); 12 were African American. The POLST facilitation was delivered to all 18; 10 (55.6%) completed POLST forms. Direct observation of intervention delivery using a checklist found 85% of the required elements were performed by facilitators. We completed 6- to 8-week follow-up interviews in 16 of 18 patients (88.9%). We found 87.5% of decision makers agreed or strongly agreed that "Talking about the (POLST) form helped me think about what I really want." CONCLUSIONS: The POLST facilitation can be successfully delivered to frail older adults in a complex care management setting, with high fidelity to protocol. Further research is needed to demonstrate the effects of this approach on decision quality and other patient-reported outcomes.
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Affiliation(s)
- Alexia M Torke
- 1 Center for Aging Research, Regenstrief Institute, Inc, Indiana University, Indianapolis, IN, USA.,2 Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, IN, USA.,3 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,4 Research in Palliative and End of Life Communication and Training (RESPECT) Center, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Susan E Hickman
- 3 Charles Warren Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.,4 Research in Palliative and End of Life Communication and Training (RESPECT) Center, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA.,5 School of Nursing, Indiana University, Indianapolis, IN, USA
| | | | - Steven R Counsell
- 1 Center for Aging Research, Regenstrief Institute, Inc, Indiana University, Indianapolis, IN, USA.,2 Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, IN, USA
| | - Lev Inger
- 1 Center for Aging Research, Regenstrief Institute, Inc, Indiana University, Indianapolis, IN, USA
| | - James E Slaven
- 7 Department of Biostatistics, Indiana University, Indianapolis, IN, USA
| | - Dawn Butler
- 2 Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, IN, USA
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Unroe KT, Fowler NR, Carnahan JL, Holtz LR, Hickman SE, Effler S, Evans R, Frank KI, Ott ML, Sachs G. Improving Nursing Facility Care Through an Innovative Payment Demonstration Project: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Phase 2. J Am Geriatr Soc 2018; 66:1625-1631. [PMID: 30019762 DOI: 10.1111/jgs.15462] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/27/2018] [Accepted: 05/04/2018] [Indexed: 11/27/2022]
Abstract
Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) is a 2-phase Center for Medicare and Medicaid Innovations demonstration project now testing a novel Medicare Part B payment model for nursing facilities and practitioners in 40 Indiana nursing facilities. The new payment codes are intended to promote high-quality care in place for acutely ill long-stay residents. The focus of the initiative is to reduce hospitalizations through the diagnosis and on-site management of 6 common acute clinical conditions (linked to a majority of potentially avoidable hospitalizations of nursing facility residents): pneumonia, urinary tract infection, skin infection, heart failure, chronic obstructive pulmonary disease or asthma, and dehydration. This article describes the OPTIMISTIC Phase 2 model design, nursing facility and practitioner recruitment and training, and early experiences implementing new Medicare payment codes for nursing facilities and practitioners. Lessons learned from the OPTIMISTIC experience may be useful to others engaged in multicomponent quality improvement initiatives.
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Affiliation(s)
- Kathleen T Unroe
- School of Medicine, Department of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, Indianapolis, Indiana.,Regenstrief Institute, Center for Aging Research, Indianapolis, Indiana, Indianapolis, Indiana
| | - Nicole R Fowler
- School of Medicine, Department of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, Indianapolis, Indiana.,Regenstrief Institute, Center for Aging Research, Indianapolis, Indiana, Indianapolis, Indiana
| | - Jennifer L Carnahan
- School of Medicine, Department of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, Indianapolis, Indiana.,Regenstrief Institute, Center for Aging Research, Indianapolis, Indiana, Indianapolis, Indiana
| | - Laura R Holtz
- Regenstrief Institute, Center for Aging Research, Indianapolis, Indiana, Indianapolis, Indiana
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, Indiana, Indianapolis, Indiana
| | - Shannon Effler
- Regenstrief Institute, Center for Aging Research, Indianapolis, Indiana, Indianapolis, Indiana
| | | | - Kathryn I Frank
- School of Medicine, Department of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, Indianapolis, Indiana
| | - Monica L Ott
- School of Medicine, Department of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, Indianapolis, Indiana
| | - Greg Sachs
- School of Medicine, Department of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, Indianapolis, Indiana.,Regenstrief Institute, Center for Aging Research, Indianapolis, Indiana, Indianapolis, Indiana
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Unroe KT, Hickman SE, Carnahan JL, Hass Z, Sachs G, Arling G. Investigating the Avoidability of Hospitalizations of Long Stay Nursing Home Residents: Opportunities for Improvement. Innov Aging 2018; 2:igy017. [PMID: 30480137 PMCID: PMC6234922 DOI: 10.1093/geroni/igy017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Indexed: 11/18/2022] Open
Abstract
Background and Objectives To examine the relationship between hospital diagnoses associated with hospital transfers of long stay nursing home residents, ratings of avoidability of transfer, and RN-identified quality improvement opportunities. Research Design and Methods Prospective clinical demonstration project, named OPTIMISTIC, with trained RNs embedded in nursing homes that performed root cause analyses for 1,931 transfers to the hospital between November 2014 and July 2016. OPTIMISTIC RNs also rated whether transfers were avoidable, identified quality improvement opportunities, and recorded hospital diagnoses. Resident characteristics were obtained from Minimum Data Set assessments. Relationships between six hospital diagnoses commonly considered “potentially avoidable” and OPTIMISTIC RN root cause analysis findings were examined. Facilities were participating in the OPTIMISTIC demonstration project designed to reduce hospital transfers during the study period. Results Twenty-five percent of acute transfers associated with six common diagnoses were considered definitely or probably avoidable by project RNs versus 22% of transfers associated with other diagnoses. The most common quality improvement opportunity identified for transfers rated as avoidable was that the condition could have been managed safely if appropriate resources were available, a factor cited in 45% of transfers associated with any of the six diagnoses. Problems with communication among stakeholders were the most commonly noted area for improvement (48%) for transfers associated with other diagnoses. Many other areas for quality improvement were noted, including earlier detection of change in status and the need for understanding patient preferences or a palliative care plan. Discussion and Implications Although some nursing home transfers may later be deemed potentially avoidable based on post-transfer hospital diagnosis from Medicare claims data, OPTIMISTIC nurses caring for these residents at time of transfer categorized the majority of these transfers as unavoidable irrespective of the hospital diagnosis. Multiple quality improvement opportunities were identified associated with these hospital transfers, whether the transfer was considered potentially avoidable or unavoidable.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis.,Regenstrief Institute, IU Center for Aging Research, Indianapolis, Indiana
| | | | - Jennifer L Carnahan
- Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis.,Regenstrief Institute, IU Center for Aging Research, Indianapolis, Indiana
| | - Zach Hass
- Purdue University, West Lafayette, Indiana
| | - Greg Sachs
- Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis.,Regenstrief Institute, IU Center for Aging Research, Indianapolis, Indiana
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Abstract
BACKGROUND The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is used across the country to document the treatment preferences of seriously ill or frail patients as medical orders. The National POLST Paradigm Task Force maintains consensus-based standards for POLST programs and uses these to determine whether a state POLST program is developing, endorsed, or mature. OBJECTIVES To evaluate state program form adherence to national standards. DESIGN Document review. MEASUREMENTS Forms from endorsed/mature (n = 21) and developing (n = 23) states were compared with national standards to assess adherence to required and optional form elements. RESULTS Required elements were present on 84% of endorsed/mature state POLST forms and 73% of the developing state POLST forms. Compliance with required elements in endorsed states ranged from 50% to 100%. Three endorsed/mature states (14%) had forms that met all of the required elements fully and 14 (67%) had forms that met the all of the elements fully or partially. CONCLUSIONS There is variability in adherence to required and optional standards as well as challenges in interpreting and applying existing standards. Although there may be legal and logistical barriers to the existence of a national POLST form, standardization remains an important goal to support patient-centered care.
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Affiliation(s)
- Susan E Hickman
- 1 Department of Community and Health Systems, Indiana University School of Nursing , Indianapolis, Indiana.,2 Indiana University-Purdue University (IUPUI) Research in Palliative and End-of-Life Communication and Training (RESPECT) Center , Indianapolis, Indiana
| | - Rebecca Critser
- 2 Indiana University-Purdue University (IUPUI) Research in Palliative and End-of-Life Communication and Training (RESPECT) Center , Indianapolis, Indiana
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Hickman SE, Sudore RL, Sachs GA, Torke AM, Myers AL, Tang Q, Bakoyannis G, Hammes BJ. Use of the Physician Orders for Scope of Treatment Program in Indiana Nursing Homes. J Am Geriatr Soc 2018; 66:1096-1100. [PMID: 29566429 DOI: 10.1111/jgs.15338] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/20/2018] [Accepted: 02/04/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess the use of the Indiana Physician Orders for Scope of Treatment (POST) form to record nursing home (NH) resident treatment preferences and associated practices. DESIGN Survey. SETTING Indiana NHs. PARTICIPANTS Staff responsible for advance care planning in 535 NHs. MEASUREMENTS Survey about use of the Indiana POST, related policies, and educational activities. METHODS NHs were contacted by telephone or email. Nonresponders were sent a brief postcard survey. RESULTS Ninety-one percent (n=486) of Indiana NHs participated, and 79% had experience with POST. Of the 65% of NHs that complete POST with residents, 46% reported that half or more residents had a POST form. POST was most often completed at the time of admission (68%). Only 52% of participants were aware of an existing facility policy regarding use of POST; 80% reported general staff education on POST. In the 172 NHs not using POST, reasons for not using it included unfamiliarity with the tool (23%) and lack of facility policies (21%). CONCLUSION Almost 3 years after a grassroots campaign to introduce the voluntary Indiana POST program, a majority of NHs were using POST to support resident care. Areas for improvement include creating policies on POST for all NHs, training staff on POST conversations, and considering processes that may enhance the POST conversation, such as finding an optimal time to engage in conversations about treatment preferences other than a potentially rushed admission process.
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Affiliation(s)
- Susan E Hickman
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana.,Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana
| | - Rebecca L Sudore
- School of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, California
| | - Greg A Sachs
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana, Indianapolis, Indiana
| | - Alexia M Torke
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana.,Division of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana, Indianapolis, Indiana
| | - Anne L Myers
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana
| | - Qing Tang
- Department of Biostatistics, School of Medicine, Indiana University, Indianapolis, Indiana.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Giorgos Bakoyannis
- Department of Biostatistics, School of Medicine, Indiana University, Indianapolis, Indiana.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, Wisconsin
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Unroe KT, Carnahan JL, Hickman SE, Sachs GA, Hass Z, Arling G. The Complexity of Determining Whether a Nursing Home Transfer Is Avoidable at Time of Transfer. J Am Geriatr Soc 2018; 66:895-901. [PMID: 29437221 DOI: 10.1111/jgs.15286] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/29/2017] [Accepted: 12/20/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the relationship between nursing facility resident risk conditions and signs and symptoms at time of acute transfer and diagnosis of conditions associated with potentially avoidable acute transfers (pneumonia, urinary tract infection, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or asthma, dehydration, pressure sores). DESIGN As part of a demonstration project to reduce potentially avoidable hospital transfers, Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project clinical staff collected data on residents who transferred to the emergency department (ED) or hospital. Cross-tabulations were used to identify associations between risk conditions or symptoms and hospital diagnoses or death. Mixed-effects logistic regression models were used to describe the significance of risk conditions, signs, or symptoms as predictors of potentially avoidable hospital diagnoses or death. SETTING Indiana nursing facilities (N=19). PARTICIPANTS Long-stay nursing facility residents (N=1,174), who experienced 1,931 acute transfers from November 2014 to July 2016. MEASUREMENTS Participant symptoms, transfers, risk factors, and hospital diagnoses. RESULTS We found that 44% of acute transfers were associated with 1 of 6 potentially avoidable diagnoses. Symptoms before transfer did not discriminate well among hospital diagnoses. Symptoms mapped into multiple diagnoses and most hospital diagnoses had multiple associated symptoms. For example, more than two-thirds of acute transfers of residents with a history of CHF and COPD were for reasons other than exacerbations of those two conditions. CONCLUSION Although it is widely recognized that many transfers of nursing facility residents are potentially avoidable, determining "avoidability" at time of transfer is complex. Symptoms and risk conditions were only weakly predictive of hospital diagnoses.
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Affiliation(s)
- Kathleen T Unroe
- School of Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Indiana University, Indianapolis, Indiana
| | - Jennifer L Carnahan
- School of Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Indiana University, Indianapolis, Indiana
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, Indiana
| | - Greg A Sachs
- School of Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Indiana University, Indianapolis, Indiana
| | - Zachary Hass
- School of Nursing, Purdue University, West Lafayette, Indiana
| | - Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana
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