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Akré ERL, Chyn D, Carlos HA, Barnato AE, Skinner J. Measuring Local-Area Racial Segregation for Medicare Hospital Admissions. JAMA Netw Open 2024; 7:e247473. [PMID: 38639935 PMCID: PMC11031679 DOI: 10.1001/jamanetworkopen.2024.7473] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/06/2023] [Accepted: 02/21/2024] [Indexed: 04/20/2024] Open
Abstract
Importance Considerable racial segregation exists in US hospitals that cannot be explained by where patients live. Approaches to measuring such segregation are limited. Objective To measure how and where sorting of older Black patients to different hospitals occurs within the same health care market. Design, Setting, and Participants This retrospective cross-sectional study used 2019 Medicare claims data linked to geographic data. Hospital zip code markets were based on driving time. The local hospital segregation (LHS) index was defined as the difference between the racial composition of a hospital's admissions and the racial composition of the hospital's market. Assessed admissions were among US Medicare fee-for-service enrollees aged 65 or older living in the 48 contiguous states with at least 1 hospitalization in 2019 at a hospital with at least 200 hospitalizations. Data were analyzed from November 2022 to January 2024. Exposure Degree of residential segregation, ownership status, region, teaching hospital designation, and disproportionate share hospital status. Main Outcomes and Measures The LHS index by hospital and a regional LHS index by hospital referral region. Results In the sample of 1991 acute care hospitals, 4 870 252 patients (mean [SD] age, 77.7 [8.3] years; 2 822 006 [56.0%] female) were treated, including 11 435 American Indian or Alaska Native patients (0.2%), 129 376 Asian patients (2.6%), 597 564 Black patients (11.9%), 395 397 Hispanic patients (7.8), and 3 818 371 White patients (75.8%). In the sample, half of hospitalizations among Black patients occurred at 235 hospitals (11.8% of all hospitals); 878 hospitals (34.4%) exhibited a negative LHS score (ie, admitted fewer Black patients relative to their market area) while 1113 hospitals (45.0%) exhibited a positive LHS (ie, admitted more Black patients relative to their market area); of all hospitals, 79.4% exhibited racial admission patterns significantly different from their market. Hospital-level LHS was positively associated with government hospital status (coefficient, 0.24; 95% CI, 0.10 to 0.38), while New York, New York; Chicago, Illinois; and Detroit, Michigan, hospital referral regions exhibited the highest regional LHS measures, with hospital referral region LHS scores of 0.12, 0.16, and 0.21, respectively. Conclusions and Relevance In this cross-sectional study, a novel measure of LHS was developed to quantify the extent to which hospitals were admitting a representative proportion of Black patients relative to their market areas. A better understanding of hospital choice within neighborhoods would help to reduce racial inequities in health outcomes.
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Affiliation(s)
- Ellesse-Roselee L. Akré
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Deanna Chyn
- The Dartmouth Institute for Health Policy, and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | | | - Amber E. Barnato
- The Dartmouth Institute for Health Policy, and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy, and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Economics, Dartmouth College, Hanover, New Hampshire
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Chuang E, Gugliuzza S, Ahmad A, Aboodi M, Gong MN, Barnato AE. "Postponing it Any Later Would not be so Great": A Cognitive Interview Study of How Physicians Decide to Initiate Goals of Care Discussions in the Hospital. Am J Hosp Palliat Care 2023:10499091231222926. [PMID: 38111300 DOI: 10.1177/10499091231222926] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND There are missed opportunities to discuss goals and preferences for care with seriously ill patients in the acute care setting. It is unknown which factors most influence clinician decision-making about communication at the point of care. OBJECTIVE This study utilized a cognitive-interviewing technique to better understand what leads clinicians to decide to have a goals of care (GOC) discussion in the acute care setting. METHODS A convenience sample of 15 oncologists, intensivists and hospitalists were recruited from a single academic medical center in a large urban area. Participants completed a cognitive interview describing their thought process when deciding whether to engage in GOC discussions in clinical vignettes. RESULTS 6 interconnected factors emerged as important in determining how likely the physician was to consider engaging in GOC at that time; (1) the participants' mental model of GOC, (2) timing of GOC related to stability, acuity and reversibility of the patient's condition, (3) clinical factors such as uncertainty, prognosis and recency of diagnosis, (4) patient factors including age and emotional state, (5) participants' role on the care team, and (6) clinician factors such as emotion and communication skill level. CONCLUSION Participants were hesitant to commit to the present moment as the right time for GOC discussions based on variations in clinical presentation. Clinical decision support systems that include more targeted information about risk of clinical deterioration and likelihood of reversal of the acute condition may prompt physicians to discuss GOC, but more support for managing discomfort with uncertainty is also needed.
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Affiliation(s)
- Elizabeth Chuang
- Department of Medicine, Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sabrina Gugliuzza
- Department of Internal Medicine, NYU Langone Health, Mineola, NY, USA
| | - Ammar Ahmad
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, New York, NY, USA
| | - Michael Aboodi
- Division of Pulmonary and Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Michelle Ng Gong
- Department of Medicine, Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Mosley EA, Zite N, Dehlendorf C, Deal A, O'Leary R, Achilles S, Barnato AE, Hall D, Borrero S. Development of My Decision/Mi Decisión, a web-based decision aid to support permanent contraception decision making. PEC Innov 2023; 3:100203. [PMID: 37693728 PMCID: PMC10483066 DOI: 10.1016/j.pecinn.2023.100203] [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] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
Objective To develop a patient-centered, web-based decision aid to support informed and value-concordant decision making among Medicaid enrollees considering tubal sterilization. Methods We used the Ottawa Decision Support Framework and the International Patient Decision Aids Standards (IPDAS) to guide systematic development of our decision aid. We interviewed 15 obstetrician-gynecologists and 40 women, who had considered or were considering tubal sterilization. A Steering Committee-comprising healthcare providers, social scientists, reproductive health and justice advocates, and people with lived experience-provided feedback and direction. We developed English and Spanish prototypes, which were beta tested with 24 women. Results The resulting web-based My Decision/Mi Decisión tool (English/Spanish) includes written and video information about tubal sterilization procedures; an interactive table of contraception options; values clarification exercises; reflection and deliberation; knowledge checks; and a summary report to share with one's provider. Users found the decision aid to be informative, engaging, easy to use, and helpful in informing contraception decision making. Conclusion My Decision/Mi Decisión is a scalable tool that could be implemented widely to support informed decision making about tubal sterilization. Innovation This is a novel and timely web-based decision tool for tubal sterilization, when demand for permanent contraception is rapidly increasing post-Dobbs. While designed for Medicaid enrollees, further investigation will explore more generalized use.
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Affiliation(s)
- Elizabeth A. Mosley
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Center for Innovative Research on Gender Health Equity, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Nikki Zite
- Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine, Knoxville, TN 37920, USA
| | - Christine Dehlendorf
- Departments of Family & Community Medicine, Obstetrics, Gynecology & Reproductive Sciences, Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Ashley Deal
- Dezudio, Pittsburgh, PA 15221, USA
- Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Raelynn O'Leary
- Dezudio, Pittsburgh, PA 15221, USA
- Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Sharon Achilles
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Bill and Melinda Gates Foundation, Seattle, WA 98102, USA
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Daniel Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15213, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15213, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15213, USA
| | - Sonya Borrero
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Center for Innovative Research on Gender Health Equity, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Khayal IS, Butcher RL, McLeish CH, Shentu Y, Barnato AE. Organizational Intent, Organizational Structures, and Reviewer Mental Models Influence Mortality Review Processes. Mayo Clin Proc Innov Qual Outcomes 2023; 7:515-523. [PMID: 37969423 PMCID: PMC10632187 DOI: 10.1016/j.mayocpiqo.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Objective To identify the factors that influence the mortality review process at health systems, including how mortality review is conducted, cases are adjudicated, and results are used. Methods We conducted a qualitative analysis of the mortality review processes of 6 US health systems from February 1, 2021 to June 31, 2021. The data sources included individual and small-group semi-structured interviews with mortality review team members and a content analysis of site artifacts (eg, guiding principles, chart abstraction forms, review workflows, and clinical pathways developed from past mortality reviews). We analyzed each site's mortality review process, goals and incentives for mortality review, historical and evolving aspects of mortality review, personnel involved, and post-review use of findings. Results Across the 6 systems, we interviewed a total of 24 mortality review experts and analyzed 26 site documents. We identified 3 thematic factors that influence mortality review processes: organizational intent, organizational structures for mortality review, and the mental models of individuals involved in the review process. Two subthemes emerged within organizational intent: (1) identifying preventable deaths to lower (clinical or financial) risk and (2) using death cases to guide system improvement. Sites varied in governance and decision rights concerning mortality review and adjudication, with 2 subthemes within organizational structures: (1) centralized-hierarchical and (2) decentralized or multidisciplinary. The analysis of mental models of participating reviewers revealed 2 themes: (1) confirmation of preventability and (2) identification of patterns or "signals." Conclusion Understanding the factors that influence mortality review allows health systems to better leverage mortality review for institutional improvement and to develop training that builds shared mental models to enhance the review process.
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Affiliation(s)
- Inas S. Khayal
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Computer Science, Dartmouth College, Hanover, NH
| | - Rebecca L. Butcher
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Center for Program Design and Evaluation, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Colin H. McLeish
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Tuck School of Business, Hanover, NH
| | - Yujia Shentu
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Neurosurgery, The University of Texas McGovern Medical School, Houston
| | - Amber E. Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Section of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
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Drummond DK, Kaur-Gill S, Murray GF, Schifferdecker KE, Butcher R, Perry AN, Brooks GA, Kapadia NS, Barnato AE. Problematic Integration: Racial Discordance in End-of-Life Decision Making. Health Commun 2023; 38:2730-2741. [PMID: 35981599 DOI: 10.1080/10410236.2022.2111631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We describe racially discordant oncology encounters involving EOL decision-making. Fifty-eight provider interviews were content analyzed using the tenets of problematic integration theory. We found EOL discussions between non-Black providers and their Black patients were often complex and anxiety-inducing. That anxiety consisted of (1) ontological uncertainty in which providers characterized the nature of Black patients as distrustful, especially in the context of clinical trials; (2) ontological and epistemological uncertainty in which provider intercultural incompetency and perceived lack of patient health literacy were normalized and intertwined with provider assumptions about patients' religion and support systems; (3) epistemological uncertainty as ambivalence in which providers' feelings conflicted when deciding whether to speak with family members they perceived as lacking health literacy; (4) divergence in which the provider advised palliative care while the family desired surgery or cancer-directed medical treatment; and (5) impossibility when an ontological uncertainty stance of Black distrust was seen as natural by providers and therefore impossible to change. Some communication strategies used were indirect stereotyping, negotiating, asking a series of value questions, blame-guilt framing, and avoidance. We concluded that provider perceptions of Black distrust, religion, and social support influenced their ability to communicate effectively with patients.
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Affiliation(s)
| | | | | | - Karen E Schifferdecker
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Center for Program Design & Evaluation, Dartmouth College
| | - Rebecca Butcher
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Center for Program Design & Evaluation, Dartmouth College
| | - Amanda N Perry
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Department of Medicine, Geisel School of Medicine, Dartmouth College
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Department of Medicine, Geisel School of Medicine, Dartmouth College
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Department of Medicine, Geisel School of Medicine, Dartmouth College
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Mohan D, O'Malley AJ, Chelen J, MacMartin M, Murphy M, Rudolph M, Engel JA, Barnato AE. Using a Video Game Intervention to Increase Hospitalists' Advance Care Planning Conversations with Older Adults: a Stepped Wedge Randomized Clinical Trial. J Gen Intern Med 2023; 38:3224-3234. [PMID: 37429972 PMCID: PMC10651818 DOI: 10.1007/s11606-023-08297-y] [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: 01/01/2023] [Accepted: 06/16/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Guidelines recommend Advance Care Planning (ACP) for seriously ill older adults to increase the patient-centeredness of end-of-life care. Few interventions target the inpatient setting. OBJECTIVE To test the effect of a novel physician-directed intervention on ACP conversations in the inpatient setting. DESIGN Stepped wedge cluster-randomized design with five 1-month steps (October 2020-February 2021), and 3-month extensions at each end. SETTING A total of 35/125 hospitals staffed by a nationwide physician practice with an existing quality improvement initiative to increase ACP (enhanced usual care). PARTICIPANTS Physicians employed for ≥ 6 months at these hospitals; patients aged ≥ 65 years they treated between July 2020-May 2021. INTERVENTION Greater than or equal to 2 h of exposure to a theory-based video game designed to increase autonomous motivation for ACP; enhanced usual care. MAIN MEASURE ACP billing (data abstractors blinded to intervention status). RESULTS A total of 163/319 (52%) invited, eligible hospitalists consented to participate, 161 (98%) responded, and 132 (81%) completed all tasks. Physicians' mean age was 40 (SD 7); most were male (76%), Asian (52%), and reported playing the game for ≥ 2 h (81%). These physicians treated 44,235 eligible patients over the entire study period. Most patients (57%) were ≥ 75; 15% had COVID. ACP billing decreased between the pre- and post-intervention periods (26% v. 21%). After adjustment, the homogeneous effect of the game on ACP billing was non-significant (OR 0.96; 95% CI 0.88-1.06; p = 0.42). There was effect modification by step (p < 0.001), with the game associated with increased billing in steps 1-3 (OR 1.03 [step 1]; OR 1.15 [step 2]; OR 1.13 [step 3]) and decreased billing in steps 4-5 (OR 0.66 [step 4]; OR 0.95 [step 5]). CONCLUSIONS When added to enhanced usual care, a novel video game intervention had no clear effect on ACP billing, but variation across steps of the trial raised concerns about confounding from secular trends (i.e., COVID). TRIAL REGISTRATION Clinicaltrials.gov; NCT04557930, 9/21/2020.
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Room 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice and Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Julia Chelen
- Advanced Communications Research Group, National Institute of Standards and Technology, U.S. Department of Commerce, Boulder, CO, USA
| | - Meredith MacMartin
- Department of Medicine and The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Megan Murphy
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - Jaclyn A Engel
- Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice and Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Bobak CA, Mohan D, Murphy MA, Barnato AE, O'Malley AJ. Constructing within and between hospital physician social networks for modeling physician research participation. BMC Med Res Methodol 2023; 23:253. [PMID: 37898745 PMCID: PMC10613378 DOI: 10.1186/s12874-023-02069-2] [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: 03/31/2023] [Accepted: 10/12/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Physician participation in clinical trials is essential for the progress of modern medicine. However, the demand for physician research partners is outpacing physicians' interest in participating in scientific studies. Understanding the factors that influence physician participation in research is crucial to addressing this gap. METHODS In this study, we used a physician's social network, as constructed from patient billing data, to study if the research choices of a physician's immediate peers influence their likelihood to participate in scientific research. We analyzed data from 348 physicians across 40 hospitals. We used logistic regression models to examine the relationship between a physician's participation in clinical trials and the participation of their social network peers, adjusting for age, years of employment, and influences from other hospital facilities. RESULTS We found that the likelihood of a physician participating in clinical trials increased dramatically with the proportion of their social network-defined colleagues at their primary hospital who were participating ([Formula: see text] for a 1% increase in the proportion of participating peers, [Formula: see text]). Additionally, physicians who work regularly at multiple facilities were more likely to participate ([Formula: see text], [Formula: see text]) and increasingly so as the extent to which they have social network ties to colleagues at hospitals other than their primary hospital increases ([Formula: see text], [Formula: see text]). These findings suggest an inter-hospital peer participation process. CONCLUSION Our study provides evidence that the social structure of a physician's work-life is associated with their decision to participate in scientific research. The results suggest that interventions aimed at increasing physician participation in clinical trials could leverage the social networks of physicians to encourage participation. By identifying factors that influence physician participation in research, we can work towards closing the gap between the demand for physician research partners and the number of physicians willing to participate in scientific studies.
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Affiliation(s)
- Carly A Bobak
- Research Computing at Information, Technology and Consulting, Dartmouth College, Hanover, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Megan A Murphy
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA.
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA.
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Khayal IS, O'Malley AJ, Barnato AE. Clinically informed machine learning elucidates the shape of hospice racial disparities within hospitals. NPJ Digit Med 2023; 6:190. [PMID: 37828119 PMCID: PMC10570342 DOI: 10.1038/s41746-023-00925-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/20/2023] [Indexed: 10/14/2023] Open
Abstract
Racial disparities in hospice care are well documented for patients with cancer, but the existence, direction, and extent of disparity findings are contradictory across the literature. Current methods to identify racial disparities aggregate data to produce single-value quality measures that exclude important patient quality elements and, consequently, lack information to identify actionable equity improvement insights. Our goal was to develop an explainable machine learning approach that elucidates healthcare disparities and provides more actionable quality improvement information. We infused clinical information with engineering systems modeling and data science to develop a time-by-utilization profile per patient group at each hospital using US Medicare hospice utilization data for a cohort of patients with advanced (poor-prognosis) cancer that died April-December 2016. We calculated the difference between group profiles for people of color and white people to identify racial disparity signatures. Using machine learning, we clustered racial disparity signatures across hospitals and compared these clusters to classic quality measures and hospital characteristics. With 45,125 patients across 362 hospitals, we identified 7 clusters; 4 clusters (n = 190 hospitals) showed more hospice utilization by people of color than white people, 2 clusters (n = 106) showed more hospice utilization by white people than people of color, and 1 cluster (n = 66) showed no difference. Within-hospital racial disparity behaviors cannot be predicted from quality measures, showing how the true shape of disparities can be distorted through the lens of quality measures. This approach elucidates the shape of hospice racial disparities algorithmically from the same data used to calculate quality measures.
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Affiliation(s)
- Inas S Khayal
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA.
- Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA.
- Department of Computer Science, Dartmouth College, Hanover, NH, 03755, USA.
- Cancer Population Sciences Program, Norris Cotton Cancer Center, Lebanon, NH, 03756, USA.
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA
- Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA
- Department of Computer Science, Dartmouth College, Hanover, NH, 03755, USA
- Department of Mathematics, Dartmouth College, Hanover, NH, 03755, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA
- Cancer Population Sciences Program, Norris Cotton Cancer Center, Lebanon, NH, 03756, USA
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
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Wasp GT, Kaur-Gill S, Anderson EC, Vergo MT, Chelen J, Tosteson T, Barr PJ, Barnato AE. Evaluating Physician Emotion Regulation in Serious Illness Conversations Using Multimodal Assessment. J Pain Symptom Manage 2023; 66:351-360.e1. [PMID: 37433418 PMCID: PMC10574810 DOI: 10.1016/j.jpainsymman.2023.07.001] [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: 06/01/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/13/2023]
Abstract
CONTEXT Emotion regulation by the physician can influence the effectiveness of serious illness conversations. The feasibility of multimodal assessment of emotion regulation during these conversations is unknown. OBJECTIVES To develop and assess an experimental framework for evaluating physician emotion regulation during serious illness conversations. METHODS We developed and then assessed a multimodal assessment framework for physician emotion regulation using a cross-sectional, pilot study on physicians trained in the Serious Illness Conversation Guide (SICG) in a simulated, telehealth encounter. Development of the assessment framework included a literature review and subject matter expert consultations. Our predefined feasibility endpoints included: an enrollment rate of ≥60% of approached physicians, >90% completion rate of survey items, and <20% missing data from wearable heart rate sensors. To describe physician emotion regulation, we performed a thematic analysis of the conversation, its documentation, and physician interviews. RESULTS Out of 12 physicians approached, 11 (92%) SICG-trained physicians enrolled in the study: five medical oncology and six palliative care physicians. All 11 completed the survey (100% completion rate). Two sensors (chest band, wrist sensor) had <20% missing data during study tasks. The forearm sensor had >20% missing data. The thematic analysis found that physicians': 1) overarching goal was to move beyond prognosis to reasonable hope; 2) tactically focused on establishing a trusting, supportive relationship; and 3) possessed incomplete awareness of their emotion regulation strategies. CONCLUSION Our novel, multimodal assessment of physician emotion regulation was feasible in a simulated SICG encounter. Physicians exhibited an incomplete understanding of their emotion regulation strategies.
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Affiliation(s)
- Garrett T Wasp
- Section of Oncology, Department of Medicine (G.T.W.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA; Dartmouth Cancer Center (DCC) (G.T.W., T.T., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA.
| | - Satveer Kaur-Gill
- The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Eric C Anderson
- Center for Interdisciplinary Population and Health Research (E.C.A), Maine Health Institute for Research, Portland, Maine, USA; Tufts University School of Medicine (E.C.A.), Boston, MA, USA
| | - Maxwell T Vergo
- Section of Palliative Care, Department of Medicine (M.T.V., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA
| | - Julia Chelen
- The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Tor Tosteson
- Dartmouth Cancer Center (DCC) (G.T.W., T.T., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA; Biomedical Data Science (T.T., P.J.B.), Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Paul J Barr
- The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA; Biomedical Data Science (T.T., P.J.B.), Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Center for Technology and Behavioral Health (P.J.B.), Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Amber E Barnato
- Dartmouth Cancer Center (DCC) (G.T.W., T.T., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA; The Dartmouth Institute for Health Policy & Clinical Practice (G.T.W., S.K.G., J.C., P.J.B., A.E.B.), Geisel School of Medicine, Lebanon, New Hampshire, USA; Section of Palliative Care, Department of Medicine (M.T.V., A.E.B.), Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, USA
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10
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MacMartin MA, Sacks OA, Austin AM, Chakraborti G, Stedina EA, Skinner JS, Barnato AE. Association Between Opening a Palliative Care Unit and Hospital Care for Patients With Serious Illness. J Palliat Med 2023; 26:1240-1246. [PMID: 37040303 DOI: 10.1089/jpm.2022.0447] [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] [Indexed: 04/12/2023] Open
Abstract
Background: Palliative care units (PCUs) are devoted to intensive management of symptoms and other palliative care needs. We examined the association between opening a PCU and acute care processes at a single U.S. academic medical center. Methods: We retrospectively compared acute care processes for seriously ill patients admitted before and after the opening of a PCU at a single academic medical center. Outcomes included rates of change in code status to do-not-resuscitate (DNR) and comfort measures only (CMO) status, and time to DNR and CMO. We calculated unadjusted and adjusted rates and used logistic regression to assess interaction between care period and palliative care consultation. Results: There were 16,611 patients in the pre-PCU period and 18,305 patients in the post-PCU period. The post-PCU cohort was slightly older, with a higher Charlson index (p < 0.001 for both). Post-PCU, unadjusted rates of DNR and CMO increased from 16.4% to 18.3% (p < 0.001) and 9.3% to 11.5% (p < 0.001), respectively. Post-PCU, median time to DNR was unchanged (0 days), and time to CMO decreased from 6 to 5 days. The adjusted odds ratio was 1.08 (p = 0.01) for DNR and 1.19 (p < 0.001) for CMO. Significant interaction between care period and palliative care consultation for DNR (p = 0.04) and CMO (p = 0.01) suggests an important role for palliative care engagement. Conclusions: The opening of a PCU at a single center was associated with increased rates of DNR and CMO status for seriously ill patients.
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Affiliation(s)
- Meredith A MacMartin
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Section of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Olivia A Sacks
- Department of Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Gouri Chakraborti
- Analytics Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Elizabeth A Stedina
- Analytics Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Department of Economics, Dartmouth College, Hanover, New Hampshire, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Section of Palliative Care, Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
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11
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Schifferdecker KE, Butcher RL, Murray GF, Knutzen KE, Kapadia NS, Brooks GA, Wasp GT, Eggly S, Hanson LC, Rocque GB, Perry AN, Barnato AE. Structure and integration of specialty palliative care in three NCI-designated cancer centers: a mixed methods case study. BMC Palliat Care 2023; 22:59. [PMID: 37189073 PMCID: PMC10185464 DOI: 10.1186/s12904-023-01182-9] [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: 11/23/2022] [Accepted: 05/04/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Early access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration. METHODS Mixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites' palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices. RESULTS Sites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of "favorable" organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care. CONCLUSION Integration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.
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Affiliation(s)
- Karen E Schifferdecker
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Rebecca L Butcher
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Genevra F Murray
- New York University School of Global Public Health, 708 Broadway, New York, NY, 10003, USA
| | - Kristin E Knutzen
- Emory Rollins School of Public Health, 1518 Clitton Rd. NE, Atlanta, GA, 30322, USA
| | - Nirav S Kapadia
- Dartmouth Health Department of Medicine, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Gabriel A Brooks
- Dartmouth Health Department of Medicine, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Garrett T Wasp
- Dartmouth Health Department of Medicine, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Susan Eggly
- Wayne State University School of Medicine, Karmanos Cancer Institute, Mid-Med Lofts, Suite 3000, 87 E Canfield, Detroit, MI, 48201, USA
| | - Laura C Hanson
- University of North Carolina-Chapel Hill School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Gabrielle B Rocque
- University of Alabama at Birmingham, 500 Second Street South, Birmingham, AL, 35233, USA
| | - Amanda N Perry
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA
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12
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Saunders CH, Durand MA, Scalia P, Kirkland KB, MacMartin MA, Barnato AE, Milne DW, Collison J, Bennett A, Wasp G, Nelson E, Elwyn G. "It helps us say what's important..." Developing Serious Illness Topics: A clinical visit agenda-setting tool. Patient Educ Couns 2023; 113:107764. [PMID: 37150152 DOI: 10.1016/j.pec.2023.107764] [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] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/13/2023] [Accepted: 04/16/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Skillful communication with attention to patient and care partner priorities can help people with serious illnesses. Few patient-facing agenda-setting tools exist to facilitate such communication. OBJECTIVE To develop a tool to facilitate prioritization of patient and care partner concerns during serious illness visits. PATIENT OR FAMILY INVOLVEMENT Two family members of seriously ill individuals advised. METHODS We performed a literature review and developed a prototype agenda-setting tool. We modified the tool based on cognitive interviews with patients, families and clinicians. We piloted the tool with patients, care partners and clinicians to gain an initial impression of its perceived value. RESULTS Interviews with eight patients, eight care partners and seven clinicians, resulted in refinements to the initial tool, including supplementation with visual cues. In the pilot test, seven clinicians used the tool with 11 patients and 12 family members. Qualitatively, patients and care partners reported the guide helped them consider and assert their priorities. Clinicians reported the tool complemented usual practice. Most participants reported no distress, disruption or confusion. DISCUSSION Patients, care partners and clinicians appreciated centering patient priorities in serious illness visits using the agenda-setting tool. More thorough evaluation is required. PRACTICAL VALUE The agenda-setting tool may operationalize elements of good serious illness care.
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Affiliation(s)
- Catherine H Saunders
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA.
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA
| | - Peter Scalia
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; McGill Faculty of Medicine and Health Sciences, 1010 Sherbrooke West, Suite 1230, Montreal, H3A 2R7, QC Canada
| | - Kathryn B Kirkland
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA
| | - Meredith A MacMartin
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA
| | - David Wilson Milne
- Patient and Family Advisors, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA
| | - Joan Collison
- Patient and Family Advisors, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA
| | - Ashleigh Bennett
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; Nova Southeastern University, Department of Public Health, Dr. Kiran C. Patel College of Osteopathic Medicine, US
| | - Garrett Wasp
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA
| | - Eugene Nelson
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA
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13
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Murphy AC, Schultz KC, Gao S, Morales AM, Barnato AE, Fanning JB, Hall DE. Prudence in end-of-life decision making: A virtue-based analysis of physician communication with patients and surrogates. SSM Qual Res Health 2022; 2:100182. [PMID: 36582622 PMCID: PMC9797053 DOI: 10.1016/j.ssmqr.2022.100182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite significant improvements in end-of-life care over several decades, belated hospice referrals and hospital staffing patterns make challenging end-of-life conversations between strangers unsurprising, especially when the interaction is time-sensitive. Understanding how physicians perform under these circumstances is relevant to patient quality and medical education. This study is a secondary analysis of transcripts from a simulation that placed 88 intensivists, hospitalists, and ED physicians in the setting of responding to a nurse's call to evaluate a floor patient for impending respiratory collapse. A philosophical account of prudence guided the analytical approach and was operationalized through behavior-based and exemplar-based qualitative coding strategies. Exemplary performances and specific behaviors were then compared with preferred outcomes. Results indicate that exemplary performance correlated with a cluster of 3 behaviors that predicted the desired outcomes, but did not determine them: (1) directly affirming the likelihood that the patient will die in the near term; (2) explicitly soliciting the patient's preferences for care; and (3) asking what other family and friends should be involved. The current study implies that educational initiatives aimed at improving end-of-life conversations should expose clinicians both to technical competencies and to the virtues required to employ these competencies well.
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Affiliation(s)
- Alan C. Murphy
- Kaiser Permanente Baldwin Park, 1011 Baldwin Park Blvd, Baldwin Park, CA 91706, USA,Corresponding author. (A.C. Murphy)
| | - Kevan C. Schultz
- Center for Social and Urban Research, University of Pittsburgh, 3343 Forbes Avenue, Pittsburgh, PA, 15260, USA
| | - ShaSha Gao
- VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA, 15240, USA
| | - Andre M. Morales
- Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, 1313 21st Ave South, Nashville, TN, 37203, USA
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, 1 Medical Center Drive, Lebanon, NH, 03766, USA
| | - Joseph B. Fanning
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 400, Nashville, TN, 37203, USA
| | - Daniel E. Hall
- General Surgery, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA, 15240, USA,General Surgery, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
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14
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Wasp GT, Kaur S, Andersen E, Vergo MT, Chelen J, Tosteson T, Barr PJ, Barnato AE. Evaluating clinician emotion regulation during a serious illness conversation in oncology using multimodal assessment: A pilot study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
439 Background: Clinician emotion regulation (ER), self and the patient’s, likely moderates successful prognostic discussions with patients, yet challenges around its evaluation limit its investigation. We performed a pilot study to develop and assess an experimental framework that uses multimodal assessment (self-report, observer, and biometric data) to measure clinician ER during a simulated, serious illness conversation (SIC). Methods: We developed our experimental framework in four steps: 1) drafted a patient case and assessment framework; 2) refined the data collection strategy using a multidisciplinary research team; 3) trained our actor; and 4) iteratively piloted the case to optimize data collection. For the assessment, we conducted a cross-sectional, case series pilot study with physicians trained in SIC to assess its feasibility and acceptability, defined a priori as an enrollment rate >60% of approached clinicians, > 90% completion rate of survey items, < 20% missing data from wearable heart rate variability (HRV) sensors. To characterize clinician ER strategies, we analyzed the visit dialogue, physician interviews performed while watching the visit back, and physician SIC documentation generated post visit. We used a hybrid approach of inductive and deductive coding and theme development based on preexisting ER theory. Results: The development phase yielded two major modifications: 1) abandoned use of AppleWatch since it did not provide continuous HRV measurement; and 2) used telehealth with video given context of COVID-19 pandemic. We approached 12 physicians and 11 enrolled, of which 5 were female and 10 white, 5 were medical oncologists, and 6 specialty palliative care physicians. All participants completed all study survey items. The results of our three HRV sensors were as follows: Empatica E4 and Polar H10 met our pre-specified HRV collection in all 11 resting tasks and SIC encounters, and the Scoche R24 the benchmark in 7/11 resting tasks and 4/11 of simulated encounters. Preliminary qualitative analysis suggests investigators can characterize clinician use of intrapersonal and interpersonal ER strategies. Conclusions: The use of multimodal assessment of clinician ER in a simulated, telehealth SIC visit was acceptable and feasible.
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Affiliation(s)
| | - Satveer Kaur
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Eric Andersen
- Center for Interdisciplinary Population and Health Research, Maine Health Institute for Research, Portland, ME
| | | | - Julia Chelen
- National Institute of Standards and Technology, Boulder, CO
| | | | - Paul J. Barr
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
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15
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Khayal IS, Barnato AE. What is in the palliative care 'syringe'? A systems perspective. Soc Sci Med 2022; 305:115069. [PMID: 35691210 DOI: 10.1016/j.socscimed.2022.115069] [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: 02/25/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/18/2022]
Abstract
The diffusion of palliative care has been rapid, yet uncertainty remains regarding palliative care's "active ingredients." The National Consensus Project Guidelines for Quality Palliative Care identified eight domains of palliative care. Despite these identified domains, when pressed to describe the specific maneuvers used in clinical encounters, palliative care providers acknowledge that "it's complex." The field of systems has been used to explain complexity across many different types of systems. Specifically, engineering systems develop a representation of a system that helps manage complexity to help humans better understand the system. Our goal was to develop a system model of what palliative care providers do such that the elements of the model can be described concretely and sequentially, aggregated to describe the high-level domains currently described by palliative care, and connected to the complexity described by providers and the literature. Our study design combined methodological elements from both qualitative research and systems engineering modeling. The model drew on participant observation and debriefing semi-structured interviews with interdisciplinary palliative care team members by a systems engineer. The setting was an interdisciplinary palliative care service in a US rural academic medical center. In the developed system model, we identified 59 functions provided to patients, families, non-palliative care provider(s), and palliative care provider(s). The high-level functions related to measurement, decision-making, and treatment address up to 8 states of an individual, including an overall holistic state, physical state, psychological state, spiritual state, cultural state, personal environment state, and clinical environment state. In contrast to previously described expert consensus domain-based descriptions of palliative care, this model more directly connects palliative care provider functions to emergent behaviors that may explain system-level mechanisms of action for palliative care. Thus, a systems modeling approach provides insights into the challenges surrounding the recurring question of what is in the palliative care "syringe."
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Affiliation(s)
- Inas S Khayal
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Computer Science, Dartmouth College, Hanover, NH, USA.
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Section of Palliative Care, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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16
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Saunders CH, Durand MA, Kirkland KB, MacMartin MA, Barnato AE, Elwyn G. Psychometric assessment of the consideRATE questions, a new measure of serious illness experience, with an online simulation study. Patient Educ Couns 2022; 105:2581-2589. [PMID: 35260261 DOI: 10.1016/j.pec.2022.01.002] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To assess the psychometric properties of the consideRATE questions, a measure of serious illness experience. METHODS We recruited people at least 50 years old via paid panels online, with US-Census-based quotas. We randomized participants to a patient experience story at two time points. Participants completed a series of measures, including the consideRATE questions. We assessed convergent (Pearson's correlation), discriminative (one-way ANOVA with Tukey's test for multiple comparisons) and divergent (Pearson's correlation) validity. We also assessed intra-rater reliability (intra-class correlation) and responsiveness to change (t-tests). RESULTS We included 809 individuals in our analysis. We established convergent validity (r = 0.77; p < 0.001); discriminative validity (bad/neutral stories [mean diff=0.4; p < 0.001]; neutral/ good stories [mean diff=1.3; p < 0.001]) and moderate divergent validity (r = 0.57; p < 0.001). We established sensitivity to change in all stories (bad/good [mean diff=1.52; p < 0.001]; good/bad [mean diff= -1.68; p < 0.001]; neutral/bad [mean diff= -0.57; p < 0.001]; good/neutral [mean diff= -1.11; p < 0.001]; neutral/good [mean diff= 1.1; p < 0.001]) but one (bad/neutral [mean diff= 0.4; p < 0.07]). Intra-rater reliability was demonstrated between time points (r = 0.77; p < 0.001). CONCLUSIONS the consideRATE questions were reliable and valid in a simulated online test. PRACTICE IMPLICATIONS the consideRATE questions may be a practical way to measure serious illness experience and the effectiveness of interventions to improve it.
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Affiliation(s)
- Catherine H Saunders
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA.
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA.
| | - Kathryn B Kirkland
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA.
| | | | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA; Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, USA.
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, USA.
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17
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Barnato AE, Johnson GR, Birkmeyer JD, Skinner JS, O'Malley AJ, Birkmeyer NJO. Advance Care Planning and Treatment Intensity Before Death Among Black, Hispanic, and White Patients Hospitalized with COVID-19. J Gen Intern Med 2022; 37:1996-2002. [PMID: 35412179 PMCID: PMC9002036 DOI: 10.1007/s11606-022-07530-4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/29/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access. OBJECTIVE To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19. DESIGN Retrospective cohort analysis of manually abstracted electronic medical records. PATIENTS 7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 MAIN MEASURES: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR). KEY RESULTS Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9-1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6-1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)). CONCLUSIONS Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, USA
| | | | - John D Birkmeyer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Sound Physicians, Tacoma, WA, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Economics, Dartmouth College, Hanover, NH, USA
| | - Allistair James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Nancy J O Birkmeyer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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18
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Khayal IS, Brooks GA, Barnato AE. Development of dynamic health care delivery heatmaps for end-of-life cancer care: a cohort study. BMJ Open 2022; 12:e056328. [PMID: 35589364 PMCID: PMC9121487 DOI: 10.1136/bmjopen-2021-056328] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 05/05/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Measures of variation in end-of-life (EOL) care intensity across hospitals are typically summarised using unidimensional measures. These measures do not capture the full dimensionality of complex clinical care trajectories over time that are needed to inform quality improvement efforts. The objective is to develop a novel visual map of EOL care trajectories that illustrates multidimensional utilisation over time. SETTING United States' National Cancer Institute or National Comprehensive Cancer Network (NCI/NCCN)-designated hospitals. PARTICIPANTS We identified Medicare claims for fee-for-service beneficiaries with poor prognosis cancers who died between April and December 2016 and received the preponderance of treatment in the last 6 months of life at an NCI/NCCN-designated hospital. DESIGN For each beneficiary, we transformed each Medicare claim into two elements to generate a two-dimensional individual-level heatmap. On the y-axis, each claim was classified into a categorical description of the service delivered by a healthcare resource. On the x-axis, the date for each claim was converted into the day number prior to death it occurred on. We then summed up individual-level heatmaps of patients attributed to each hospital to generate two-dimensional hospital-level heatmaps. We used four case studies to illustrate the feasibility of interpreting these heatmaps and to shed light on how they might be used to guide value-based, quality improvement initiatives. RESULTS We identified nine distinct EOL care delivery patterns from hospital-level heatmaps based on signal intensity and patterns for inpatient, outpatient and home-based hospice services. We illustrate that in most cases, heatmaps illustrating patterns of multidimensional healthcare utilisation over time provide more information about care trajectories and highlight more heterogeneity than current unidimensional measures. CONCLUSIONS This study illustrates the feasibility of representing multidimensional EOL utilisation over time as a heatmap. These heatmaps may provide potentially actionable insights into hospital-level care delivery patterns, and the approach may generalise to other serious illness populations.
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Affiliation(s)
- Inas S Khayal
- The Dartmouth Institute for Health Policy & Clinical Practice and Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Department of Computer Science, Dartmouth College, Hanover, New Hampshire, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Section of Medical Oncology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Section of Palliative Care, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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19
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Anderko RR, Gómez H, Canna SW, Shakoory B, Angus DC, Yealy DM, Huang DT, Kellum JA, Carcillo JA, Angus DC, Barnato AE, Eaton TL, Gimbel E, Huang DT, Keener C, Kellum JA, Landis K, Pike F, Stapleton DK, Weissfeld LA, Willochell M, Wofford KA, Yealy DM, Kulstad E, Watts H, Venkat A, Hou PC, Massaro A, Parmar S, Limkakeng AT, Brewer K, Delbridge TR, Mainhart A, Chawla LS, Miner JR, Allen TL, Grissom CK, Swadron S, Conrad SA, Carlson R, LoVecchio F, Bajwa EK, Filbin MR, Parry BA, Ellender TJ, Sama AE, Fine J, Nafeei S, Terndrup T, Wojnar M, Pearl RG, Wilber ST, Sinert R, Orban DJ, Wilson JW, Ufberg JW, Albertson T, Panacek EA, Parekh S, Gunn SR, Rittenberger JS, Wadas RJ, yEdwards AR, Kelly M, Wang HE, Holmes TM, McCurdy MT, Weinert C, Harris ES, Self WH, Phillips CA, Migues RM. Sepsis with liver dysfunction and coagulopathy predicts an inflammatory pattern of macrophage activation. Intensive Care Med Exp 2022; 10:6. [PMID: 35190900 PMCID: PMC8861227 DOI: 10.1186/s40635-022-00433-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/07/2022] [Indexed: 12/30/2022] Open
Abstract
Background Interleukin-1 receptor antagonists can reduce mortality in septic shock patients with hepatobiliary dysfunction and disseminated intravascular coagulation (HBD + DIC), an organ failure pattern with inflammatory features consistent with macrophage activation. Identification of clinical phenotypes in sepsis may allow for improved care. We aim to describe the occurrence of HBD + DIC in a contemporary cohort of patients with sepsis and determine the association of this phenotype with known macrophage activation syndrome (MAS) biomarkers and mortality. We performed a retrospective nested case–control study in adult septic shock patients with concurrent HBD + DIC and an equal number of age-matched controls, with comparative analyses of all-cause mortality and circulating biomarkers between the groups. Multiple logistic regression explored the effect of HBD + DIC on mortality and the discriminatory power of the measured biomarkers for HBD + DIC and mortality. Results Six percent of septic shock patients (n = 82/1341) had HBD + DIC, which was an independent risk factor for 90-day mortality (OR = 3.1, 95% CI 1.4–7.5, p = 0.008). Relative to sepsis controls, the HBD + DIC cohort had increased levels of 21 of the 26 biomarkers related to macrophage activation (p < 0.05). This panel was predictive of both HBD + DIC (sensitivity = 82%, specificity = 84%) and mortality (sensitivity = 92%, specificity = 90%). Conclusion The HBD + DIC phenotype identified patients with high mortality and a molecular signature resembling that of MAS. These observations suggest trials of MAS-directed therapies are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00433-y.
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20
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Barnato AE, Birkmeyer JD, Skinner JS, O'Malley AJ, Birkmeyer NJO. Treatment intensity and mortality among COVID-19 patients with dementia: A retrospective observational study. J Am Geriatr Soc 2022; 70:40-48. [PMID: 34480354 PMCID: PMC8742761 DOI: 10.1111/jgs.17463] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 03/18/2021] [Revised: 07/26/2021] [Accepted: 08/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND We sought to determine whether dementia is associated with treatment intensity and mortality in patients hospitalized with COVID-19. METHODS This study includes review of the medical records for patients >60 years of age (n = 5394) hospitalized with COVID-19 from 132 community hospitals between March and June 2020. We examined the relationships between dementia and treatment intensity (including intensive care unit [ICU] admission and mechanical ventilation [MV] and care processes that may influence them, including advance care planning [ACP] billing and do-not-resuscitate [DNR] orders) and in-hospital mortality adjusting for age, sex, race/ethnicity, comorbidity, month of hospitalization, and clustering within hospital. We further explored the effect of ACP conversations on the relationship between dementia and outcomes, both at the individual patient level (effect of having ACP) and at the hospital level (effect of being treated at a hospital with low: <10%, medium 10%-20%, or high >20% ACP rates). RESULTS Ten percent (n = 522) of the patients had documented dementia. Dementia patients were older (>80 years: 60% vs. 27%, p < 0.0001), had a lower burden of comorbidity (3+ comorbidities: 31% vs. 38%, p = 0.003), were more likely to have ACP (28% vs. 17%, p < 0.0001) and a DNR order (52% vs. 22%, p < 0.0001), had similar rates of ICU admission (26% vs. 28%, p = 0.258), were less likely to receive MV (11% vs. 16%, p = 0.001), and more likely to die (22% vs. 14%, p < 0.0001). Differential treatment intensity among patients with dementia was concentrated in hospitals with low, dementia-biased ACP billing practices (risk-adjusted ICU use: 21% vs. 30%, odds ratio [OR] = 0.6, p = 0.016; risk-adjusted MV use: 6% vs. 16%, OR = 0.3, p < 0.001). CONCLUSIONS Dementia was associated with lower treatment intensity and higher mortality in patients hospitalized with COVID-19. Differential treatment intensity was concentrated in low ACP billing hospitals suggesting an interplay between provider bias and "preference-sensitive" care for COVID-19.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - John D Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Sound Physicians, Tacoma, Washington, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Department of Economics, Dartmouth College, Hanover, New Hampshire, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Nancy J O Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
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21
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Abstract
Background: Little is known regarding the fidelity of delivery of guideline-recommended components of palliative care in "real world" encounters. Objective: To develop a qualitative coding framework to identify components of clinical palliative care in clinical documentation across care settings. Design: Retrospective review of palliative care clinical documentation from medical providers, with directed qualitative content analysis to identify components of clinical care documented. Setting/Subjects: Purposively sampled deceased patients seen by palliative care at a US academic medical center between 7/1/2011-7/1/2018. Main Outcomes and Measures: The outcome of this work is a coding framework for use in future research. We assessed the robustness of the framework using Cohen's kappa. Results: We reviewed sixty-two encounters from twenty-six patients. We identified 7 major themes in documentation: (1) addressing physical symptoms, (2) addressing psychological symptoms, (3) establishing illness understanding, (4) supporting decision making, (5) end-of-life planning, (6) understanding psychosocial context, and (7) care coordination. Interrater reliability varied widely between components, with Cohen's kappa ranging from -.51 to 1. Conclusions: This pilot study provides a coding framework to measure documentation of clinical palliative care components. Several components could not be reliably identified using this framework, suggesting the need for additional measurement strategies.
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Affiliation(s)
- Meredith A MacMartin
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,22916Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,22916Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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22
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Wasp GT, Knutzen KE, Murray GF, Brody-Bizar OC, Liu MA, Pollak KI, Tulsky JA, Schenker Y, Barnato AE. Systemic Therapy Decision Making in Advanced Cancer: A Qualitative Analysis of Patient-Oncologist Encounters. JCO Oncol Pract 2021; 18:e1357-e1366. [PMID: 34855459 PMCID: PMC9377707 DOI: 10.1200/op.21.00377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM). METHODS We performed content analysis of outpatient oncology encounters at two US National Cancer Institute-designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis. RESULTS Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation. CONCLUSION In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.
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Affiliation(s)
- Garrett T Wasp
- Section of Oncology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Kristin E Knutzen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Genevra F Murray
- Department of General Internal Medicine, Boston Medical Center, Boston, MA
| | | | - Matthew A Liu
- University of California San Diego School of Medicine, La Jolla, CA
| | | | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Yael Schenker
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
| | - Amber E Barnato
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.,Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
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23
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Wasp GT, Cullinan AM, Chamberlin MD, Hayes C, Barnato AE, Vergo MT. Implementation and Impact of a Serious Illness Communication Training for Hematology-Oncology Fellows. J Cancer Educ 2021; 36:1325-1332. [PMID: 32504362 DOI: 10.1007/s13187-020-01772-8] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Effective communication between providers and patients with serious illness is critical to ensure that treatment is aligned with patient goals. We developed and tested an implementation strategy for incorporating the previously developed Serious Illness Conversation Guide (SICG), a clinician script, into hematology-oncology fellowship training at a single US academic medical center. Between December 2017 and April 2018, we trained 8 oncology fellows to use and document the SICG. The training included associated communication skills-such as handling emotion and headlining-over 7 didactic sessions. Implementation strategies included training 4 oncology faculty as coaches to re-enforce fellows' skills and an electronic medical record template to document the SICG. We assessed effectiveness using 4 approaches: (1) SICG template use among fellows in the 12 months following training, (2) fellow confidence pre- and post-intervention via survey, (3) performance in 2 simulated patient encounters, and (4) semi-structured interviews after 12 months. Fellows successfully implemented the SICG in simulated patient encounters, though only 2 of 6 fellows documented any SICG in the clinical practice. Most fellows reported greater confidence in their communication after training. Thematic analysis of interviews revealed the following: (1) positive training experience, (2) improved patient preference elicitation, (3) selected SICG components used in a single encounter, (4) prioritize other clinical duties, (5) importance of emotion handling skills, (6) no faculty coaching receive outside training. Despite acquisition of communication skills, promoting new clinical behaviors remains challenging. More work is needed to identify which implementation strategies are required in this learner population.
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Affiliation(s)
- Garrett T Wasp
- Department of Internal Medicine, Section of Oncology, Dartmouth-Hitchcock Medical Center (DHMC), 1 Medical Center Dr., Lebanon, NH, 03766, USA.
| | - Amelia M Cullinan
- Department of Internal Medicine, Section of Palliative Medicine, DHMC, 1 Medical Center Dr., Lebanon, NH, USA
| | - Mary D Chamberlin
- Department of Internal Medicine, Section of Oncology, Dartmouth-Hitchcock Medical Center (DHMC), 1 Medical Center Dr., Lebanon, NH, 03766, USA
| | - Christi Hayes
- Department of Internal Medicine, Section of Hematology, DHMC, 1 Medical Center Dr., Lebanon, NH, USA
| | - Amber E Barnato
- Department of Internal Medicine, Section of Palliative Medicine, DHMC, 1 Medical Center Dr., Lebanon, NH, USA
- The Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maxwell T Vergo
- Department of Internal Medicine, Section of Palliative Medicine, DHMC, 1 Medical Center Dr., Lebanon, NH, USA
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24
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Mohan D, Chang CC, Fischhoff B, Rosengart MR, Angus DC, Yealy DM, Barnato AE. Outcomes after a Digital Behavior Change Intervention to Improve Trauma Triage: An Analysis of Medicare Claims. J Surg Res 2021; 268:532-539. [PMID: 34464890 PMCID: PMC8678167 DOI: 10.1016/j.jss.2021.07.029] [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: 04/01/2021] [Revised: 07/20/2021] [Accepted: 07/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Under-triage in trauma remains prevalent, in part because of decisions made by physicians at non-trauma centers. We developed two digital behavior change interventions to recalibrate physician heuristics (pattern recognition), and randomized 688 emergency medicine physicians to use the interventions or to a control. In this observational follow-up, we evaluated whether exposure to the interventions changed physician performance in practice. METHODS We obtained 2016 - 2018 Medicare claims for severely injured patients, linked the names of trial participants to National Provider Identifiers (NPIs), and identified claims filed by trial participants for injured patients presenting to non-trauma centers in the year before and after their trial. The primary outcome measure was the triage status of severely injured patients. RESULTS We linked 670 (97%) participants to NPIs, identified claims filed for severely injured patients by 520 (76%) participants, and claims filed at non-trauma centers by 228 (33%). Most participants were white (64%), male (67%), and had more than three years of experience (91%). Patients had a median Injury Severity Score of 16 (IQR 16 - 17), and primarily sustained neuro-trauma. After adjustment, patients treated by physicians randomized to the interventions experienced less under-triage in the year after the trial than before (41% versus 58% [-17%], P = 0.015); patients treated by physicians randomized to the control experienced no difference in under-triage (49% versus 56% [-7%], P = 0.35). The difference-in-the-difference was non-significant (10%, P = 0.18). CONCLUSIONS It was feasible to track trial participants' performance in national claims. Sample size limitations constrained causal inference about the effect of the interventions.
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,.
| | - Chung-Chou Chang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Environmental Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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25
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Kulkarni SS, Briggs A, Sacks OA, Rosengart MR, White DB, Barnato AE, Peitzman AB, Mohan D. Inner Deliberations of Surgeons Treating Critically-ill Emergency General Surgery Patients: A Qualitative Analysis. Ann Surg 2021; 274:1081-1088. [PMID: 31714316 PMCID: PMC7944485 DOI: 10.1097/sla.0000000000003669] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND 30% of elderly patients who require emergency general surgery (EGS) die in the year after the operation. Preoperative discussions can determine whether patients receive preference-sensitive care. Theoretically, surgeons frame their conversations after systematically assessing the risks and benefits of management options based on the clinical characteristics of each case. However, little is known about how surgeons actually deliberate about those options. OBJECTIVE To identify variables that influence surgeons' assessment of management options for critically-ill EGS patients. METHODS We conducted semi-structured interviews with 40 general surgeons in western Pennsylvania who worked in a variety of hospital settings. Interviews explored perioperative decision-making by asking surgeons to think aloud about selected memorable cases and a standardized case vignette of a frail patient with acute mesenteric ischemia. We used constant comparative methods to analyze interview transcripts and inductively developed a framework for the decision-making process. RESULTS Surgeons averaged 13 years (standard deviation (SD) 10.4) of experience; 40% specialized in trauma/acute care surgery. Important themes regarding the main topic of "perioperative decision-making" included many considerations beyond the clinical characteristics of cases. Surgeons described the importance of variables ranging from the availability of institutional resources to professional norms. Surgeons often remarked on their desire to achieve individual flow, team efficiency, and concordant expectations of treatment and prognosis with patients. CONCLUSIONS This is the first study to explore how surgeons decide among management options for critically-ill EGS patients. Surgeons' decision-making reflected a broad array of clinical, personal, and institutional variables. Effective interventions to ensure preference-sensitive care for EGS patients must address all of these variables.
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Affiliation(s)
| | - Alexandra Briggs
- Division of Trauma & Acute Care Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Olivia A. Sacks
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Douglas B. White
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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26
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Sacks OA, Barnato AE, Skinner JS, Birkmeyer JD, Fowler A, Birkmeyer N. Elevated Risk of COVID-19 Infection for Hospital-Based Health Care Providers. J Gen Intern Med 2021; 36:3642-3643. [PMID: 34405347 PMCID: PMC8370456 DOI: 10.1007/s11606-021-07088-7] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/28/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Olivia A Sacks
- Department of Surgery, Boston Medical Center, Boston, MA, USA.
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Economics, Dartmouth College, Hanover, NH, USA
| | | | | | - Nancy Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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27
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Mohan D, MacMartin MA, Chelen JSC, Maezes CB, Barnato AE. Development of a theory-based video-game intervention to increase advance care planning conversations by healthcare providers. Implement Sci Commun 2021; 2:117. [PMID: 34645515 PMCID: PMC8513300 DOI: 10.1186/s43058-021-00216-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/06/2021] [Accepted: 09/14/2021] [Indexed: 11/28/2022] Open
Abstract
Background Hospitalization offers an opportunity for healthcare providers to initiate advance care planning (ACP) conversations, yet such conversations occur infrequently. Barriers to these conversations include attitudes, skill, and time. Our objective was to develop a theory-based, provider-level intervention to increase the frequency of ACP conversations in hospitals. Methods We followed a systematic process to develop a theory-based, provider-level intervention to increase ACP conversations between providers and their hospitalized patients. Using principles established in Intervention Mapping and the Behavior Change Wheel, we identified a behavioral target, a theory of behavior change, behavior change techniques, and a mode of delivery. We addressed a limitation of these two processes of intervention development by also establishing a framework of design principles to structure the selection of intervention components. We partnered with a game development company to translate the output into a video game. Results We identified willingness to engage in ACP conversations as the primary contributor to ACP behavior, and attitudes as a modifiable source of this willingness. We selected self-determination theory, and its emphasis on increasing autonomous motivation, as a relevant theory of behavior change and means of changing attitudes. Second, we mapped the components of autonomous motivation (i.e., autonomy, competence, and relatedness) to relevant behavior change techniques (e.g., identity). Third, we decided to deliver the intervention using a video game and to use the narrative engagement framework, which describes the use of stories to educate, model behavior, and immerse the user, to structure our selection of intervention components. Finally, in collaboration with a game development company, we used this framework to develop an adventure video game (Hopewell Hospitalist). Conclusions The systematic development of a theory-based intervention facilitates the mechanistic testing of the efficacy of the intervention, including the specification of hypotheses regarding mediators and moderators of outcomes. The intervention will be tested in a randomized clinical trial. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00216-8.
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Meredith A MacMartin
- Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Julia S C Chelen
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Carolyn B Maezes
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Amber E Barnato
- Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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28
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Chelen JSC, White DB, Zaza S, Perry AN, Feifer DS, Crawford ML, Barnato AE. US Ventilator Allocation and Patient Triage Policies in Anticipation of the COVID-19 Surge. Health Secur 2021; 19:459-467. [PMID: 34107775 PMCID: PMC10773001 DOI: 10.1089/hs.2020.0166] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
Before the predicted March 2020 surge of COVID-19, US healthcare organizations were charged with developing resource allocation policies. We assessed policy preparedness and substantive triage criteria within existing policies using a cross-sectional survey distributed to public health personnel and healthcare providers between March 23 and April 23, 2020. Personnel and providers from 68 organizations from 34 US states responded. While half of the organizations did not yet have formal allocation policies, all but 4 were in the process of developing policies. Using manual abstraction and natural language processing, we summarize the origins and features of the policies. Most policies included objective triage criteria, specified inapplicable criteria, separated triage and clinical decision making, detailed reassessment plans, offered an appeals process, and addressed palliative care. All but 1 policy referenced a sequential organ failure assessment score as a triage criterion, and 10 policies categorically excluded patients. Six policies were almost identical, tracing their origins to influenza planning. This sample of policies reflects organizational strategies of exemplar-based policy development and the use of objective criteria in triage decisions, either before or instead of clinical judgment, to support ethical distribution of resources. Future guidance is warranted on how to adapt policies across disease type, choose objective criteria, and specify processes that rely on clinical judgments.
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Affiliation(s)
- Julia S. C. Chelen
- Julia S. C. Chelen, PhD, is a Research Associate; Amanda N. Perry, CCRP is a Research Project Specialist; Maia L. Crawford, MS, is Research Project Manager; and Amber E. Barnato, MD, MPH, MS, FACPM, is a Professor and Director, Health Policy & Clinical Practice; all at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. Amber E. Barnato is also Professor of Medicine, Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, NH. Douglas B. White, MD, MAS, is Vice Chair and Professor of Critical Care Medicine and Director, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA. Stephanie Zaza, MD, MPH, is President, Board of Regents, American College of Preventive Medicine, Washington, DC. Deborah S. Feifer is a Presidential Scholar, Dartmouth College, Hanover, NH. The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Agency for Healthcare Research and Quality or other sources of support
| | - Douglas B. White
- Julia S. C. Chelen, PhD, is a Research Associate; Amanda N. Perry, CCRP is a Research Project Specialist; Maia L. Crawford, MS, is Research Project Manager; and Amber E. Barnato, MD, MPH, MS, FACPM, is a Professor and Director, Health Policy & Clinical Practice; all at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. Amber E. Barnato is also Professor of Medicine, Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, NH. Douglas B. White, MD, MAS, is Vice Chair and Professor of Critical Care Medicine and Director, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA. Stephanie Zaza, MD, MPH, is President, Board of Regents, American College of Preventive Medicine, Washington, DC. Deborah S. Feifer is a Presidential Scholar, Dartmouth College, Hanover, NH. The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Agency for Healthcare Research and Quality or other sources of support
| | - Stephanie Zaza
- Julia S. C. Chelen, PhD, is a Research Associate; Amanda N. Perry, CCRP is a Research Project Specialist; Maia L. Crawford, MS, is Research Project Manager; and Amber E. Barnato, MD, MPH, MS, FACPM, is a Professor and Director, Health Policy & Clinical Practice; all at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. Amber E. Barnato is also Professor of Medicine, Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, NH. Douglas B. White, MD, MAS, is Vice Chair and Professor of Critical Care Medicine and Director, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA. Stephanie Zaza, MD, MPH, is President, Board of Regents, American College of Preventive Medicine, Washington, DC. Deborah S. Feifer is a Presidential Scholar, Dartmouth College, Hanover, NH. The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Agency for Healthcare Research and Quality or other sources of support
| | - Amanda N. Perry
- Julia S. C. Chelen, PhD, is a Research Associate; Amanda N. Perry, CCRP is a Research Project Specialist; Maia L. Crawford, MS, is Research Project Manager; and Amber E. Barnato, MD, MPH, MS, FACPM, is a Professor and Director, Health Policy & Clinical Practice; all at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. Amber E. Barnato is also Professor of Medicine, Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, NH. Douglas B. White, MD, MAS, is Vice Chair and Professor of Critical Care Medicine and Director, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA. Stephanie Zaza, MD, MPH, is President, Board of Regents, American College of Preventive Medicine, Washington, DC. Deborah S. Feifer is a Presidential Scholar, Dartmouth College, Hanover, NH. The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Agency for Healthcare Research and Quality or other sources of support
| | - Deborah S. Feifer
- Julia S. C. Chelen, PhD, is a Research Associate; Amanda N. Perry, CCRP is a Research Project Specialist; Maia L. Crawford, MS, is Research Project Manager; and Amber E. Barnato, MD, MPH, MS, FACPM, is a Professor and Director, Health Policy & Clinical Practice; all at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. Amber E. Barnato is also Professor of Medicine, Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, NH. Douglas B. White, MD, MAS, is Vice Chair and Professor of Critical Care Medicine and Director, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA. Stephanie Zaza, MD, MPH, is President, Board of Regents, American College of Preventive Medicine, Washington, DC. Deborah S. Feifer is a Presidential Scholar, Dartmouth College, Hanover, NH. The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Agency for Healthcare Research and Quality or other sources of support
| | - Maia L. Crawford
- Julia S. C. Chelen, PhD, is a Research Associate; Amanda N. Perry, CCRP is a Research Project Specialist; Maia L. Crawford, MS, is Research Project Manager; and Amber E. Barnato, MD, MPH, MS, FACPM, is a Professor and Director, Health Policy & Clinical Practice; all at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. Amber E. Barnato is also Professor of Medicine, Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, NH. Douglas B. White, MD, MAS, is Vice Chair and Professor of Critical Care Medicine and Director, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA. Stephanie Zaza, MD, MPH, is President, Board of Regents, American College of Preventive Medicine, Washington, DC. Deborah S. Feifer is a Presidential Scholar, Dartmouth College, Hanover, NH. The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Agency for Healthcare Research and Quality or other sources of support
| | - Amber E. Barnato
- Julia S. C. Chelen, PhD, is a Research Associate; Amanda N. Perry, CCRP is a Research Project Specialist; Maia L. Crawford, MS, is Research Project Manager; and Amber E. Barnato, MD, MPH, MS, FACPM, is a Professor and Director, Health Policy & Clinical Practice; all at The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. Amber E. Barnato is also Professor of Medicine, Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, NH. Douglas B. White, MD, MAS, is Vice Chair and Professor of Critical Care Medicine and Director, Program on Ethics and Decision Making in Critical Illness, Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA. Stephanie Zaza, MD, MPH, is President, Board of Regents, American College of Preventive Medicine, Washington, DC. Deborah S. Feifer is a Presidential Scholar, Dartmouth College, Hanover, NH. The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Agency for Healthcare Research and Quality or other sources of support
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Gilstrap L, Austin AM, O'Malley AJ, Gladders B, Barnato AE, Tosteson A, Skinner J. Association Between Beta-Blockers and Mortality and Readmission in Older Patients with Heart Failure: an Instrumental Variable Analysis. J Gen Intern Med 2021; 36:2361-2369. [PMID: 34100232 PMCID: PMC8342662 DOI: 10.1007/s11606-021-06901-7] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 04/30/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND The demographics of heart failure are changing. The rate of growth of the "older" heart failure population, specifically those ≥ 75, has outpaced that of any other age group. These older patients were underrepresented in the early beta-blocker trials. There are several reasons, including a decreased potential for mortality benefit and increased risk of side effects, why the risk/benefit tradeoff may be different in this population. OBJECTIVE We aimed to determine the association between receipt of a beta-blocker after heart failure discharge and early mortality and readmission rates among patients with heart failure and reduced ejection fraction (HFrEF), specifically patients aged 75+. DESIGN AND PARTICIPANTS We used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of beneficiaries with ≥ 1 hospitalization for HFrEF between 2008 and 2016 to run an instrumental variable analysis. MAIN MEASURE The primary measure was 90-day, all-cause mortality; the secondary measure was 90-day, all-cause readmission. KEY RESULTS Using the two-stage least squared methodology, among all HFrEF patients, receipt of a beta-blocker within 30-day of discharge was associated with a - 4.35% (95% CI - 6.27 to - 2.42%, p < 0.001) decrease in 90-day mortality and a - 4.66% (95% CI - 7.40 to - 1.91%, p = 0.001) decrease in 90-day readmission rates. Even among patients ≥ 75 years old, receipt of a beta-blocker at discharge was also associated with a significant decrease in 90-day mortality, - 4.78% (95% CI - 7.19 to - 2.40%, p < 0.001) and 90-day readmissions, - 4.67% (95% CI - 7.89 to - 1.45%, p < 0.001). CONCLUSION Patients aged ≥ 75 years who receive a beta-blocker after HFrEF hospitalization have significantly lower 90-day mortality and readmission rates. The magnitude of benefit does not appear to wane with age. Absent a strong contraindication, all patients with HFrEF should attempt beta-blocker therapy at/after hospital discharge, regardless of age.
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Affiliation(s)
- Lauren Gilstrap
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. .,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Barbara Gladders
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Anna Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Knutzen KE, Sacks OA, Brody-Bizar OC, Murray GF, Jain RH, Holdcroft LA, Alam SS, Liu MA, Pollak KI, Tulsky JA, Barnato AE. Actual and Missed Opportunities for End-of-Life Care Discussions With Oncology Patients: A Qualitative Study. JAMA Netw Open 2021; 4:e2113193. [PMID: 34110395 PMCID: PMC8193430 DOI: 10.1001/jamanetworkopen.2021.13193] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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] [Received: 01/11/2021] [Accepted: 04/13/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Early discussion of end-of-life (EOL) care preferences improves clinical outcomes and goal-concordant care. However, most EOL discussions occur approximately 1 month before death, despite most patients desiring information earlier. Objective To describe successful navigation and missed opportunities for EOL discussions (eg, advance care planning, palliative care, discontinuation of disease-directed treatment, hospice care, and after-death wishes) between oncologists and outpatients with advanced cancer. Design, Setting, and Participants This study is a secondary qualitative analysis of outpatient visits audio-recorded between November 2010 and September 2014 for the Studying Communication in Oncologist-Patient Encounters randomized clinical trial. The study was conducted at 2 US academic medical centers. Participants included medical, gynecological, and radiation oncologists and patients with stage IV malignant neoplasm, whom oncologists characterized as being ones whom they "…would not be surprised if they were admitted to an intensive care unit or died within one year." Data were analyzed between January 2018 and August 2020. Exposures The parent study randomized participants to oncologist- and patient-directed interventions to facilitate discussion of emotions. Encounters were sampled across preintervention and postintervention periods and all 4 treatment conditions. Main Outcomes and Measures Secondary qualitative analysis was done of patient-oncologist dyads with 3 consecutive visits for EOL discussions, and a random sample of 7 to 8 dyads from 4 trial groups was analyzed for missed opportunities. Results The full sample included 141 patients (54 women [38.3%]) and 39 oncologists (8 women [19.5%]) (mean [SD] age for both patients and oncologists, 56.3 [10.0] years). Of 423 encounters, only 21 (5%) included EOL discussions. Oncologists reevaluated treatment options in response to patients' concerns, honored patients as experts on their goals, or used anticipatory guidance to frame treatment reevaluation. In the random sample of 31 dyads and 93 encounters, 35 (38%) included at least 1 missed opportunity. Oncologists responded inadequately to patient concerns over disease progression or dying, used optimistic future talk to address patient concerns, or expressed concern over treatment discontinuation. Only 4 of 23 oncologists (17.4%) had both an EOL discussion and a missed opportunity. Conclusions and Relevance Opportunities for EOL discussions were rarely realized, whereas missed opportunities were more common, a trend that mirrored oncologists' treatment style. There remains a need to address oncologists' sensitivity to EOL discussions, to avoid unnecessary EOL treatment.
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Affiliation(s)
- Kristin E. Knutzen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Olivia A. Sacks
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | | | - Genevra F. Murray
- Department of General Medicine, Boston Medical Center, Boston, Massachusetts
| | - Raina H. Jain
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | | | - Shama S. Alam
- Pharmaceutical Product Development, Evidera, Bethesda, Maryland
| | - Matthew A. Liu
- School of Medicine, University of California, San Diego, La Jolla
| | | | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Amber E. Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Barnato AE, Khayal IS. The power of specialty palliative care: moving towards a systems perspective. Lancet Haematol 2021; 8:e376-e381. [PMID: 33894172 DOI: 10.1016/s2352-3026(21)00099-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 12/21/2022]
Abstract
Three palliative care clinical trials were presented at the 2020 American Society for Clinical Oncology Annual Meeting. The heterogeneity in populations, models of care, study design, and assessment of clinical outcomes across these three studies show the broad opportunities for research into interventions for palliative care. In this Viewpoint, we summarise the characteristics of these studies, discuss their novel features and lingering questions, and offer a suggestion for further expanding the focus of clinical trials for delivery of palliative care in the future. We particularly argue that the propensity to characterise palliative care as if it was a clinical or biomedical intervention hampers the design and evaluation of complex clinical interventions that influence clinicians, systems for health-care delivery, individual patients, and their families.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Section of Palliative Care, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; Cancer Population Sciences Program, Norris Cotton Cancer Center, Lebanon, NH, USA.
| | - Inas S Khayal
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Computer Science, Dartmouth College, Hanover, NH, USA; Cancer Population Sciences Program, Norris Cotton Cancer Center, Lebanon, NH, USA
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Saunders CH, Durand MA, Scalia P, Kirkland KB, MacMartin MA, Barnato AE, Milne DW, Collison J, Jaggars A, Butt T, Wasp G, Nelson E, Elwyn G. User-Centered Design of the consideRATE Questions, a Measure of People's Experiences When They Are Seriously Ill. J Pain Symptom Manage 2021; 61:555-565.e5. [PMID: 32814165 PMCID: PMC9162500 DOI: 10.1016/j.jpainsymman.2020.08.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 06/22/2020] [Accepted: 08/01/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT No brief patient-reported experience measure focuses on the most significant concerns of seriously ill individuals. OBJECTIVES The objective of the study was to develop the consideRATE questions. METHODS This user-centered design study had three phases. We reviewed the literature and consulted stakeholders, including caregivers, clinicians, and researchers, to identify the elements of care most important to patients (Phase 1). We refined items based on cognitive interviews with patients, families, and clinicians (Phase 2). We piloted the measure with patients and families (Phase 3). RESULTS Phase 1 resulted in seven questions addressing the following elements: 1) care team attention to patients' physical symptoms, 2) emotional symptoms, 3) environment of care, 4) respect for patients' priorities, 5) communication about future plans, 6) communication about financial and similar affairs, and 7) communication about illness trajectory. Phase 2 participants included eight patients, eight family members, and seven clinicians. We added an open-text comment option. We did not identify any other issues that were important enough to participants to include. Response choices ranged from one (very bad) to four (very good), with a not applicable option (does not apply). Phase 3 involved 15 patients and 16 family members and demonstrated the acceptability of the consideRATE questions. Most reported that the questions were not distressing, disruptive, or confusing. Completion time averaged 2.4 minutes (range 1-5). CONCLUSION Our brief patient-reported serious illness experience measure is based on what matters most to patients, families, and clinicians. It was acceptable to patients and families in a regional sample. It has promise for use in clinical settings.
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Affiliation(s)
- Catherine H Saunders
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA; Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Peter Scalia
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Kathryn B Kirkland
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA; Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - David W Milne
- Patient and Family Advisors, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Joan Collison
- Patient and Family Advisors, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Ashleigh Jaggars
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Tanya Butt
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Garrett Wasp
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA; Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Eugene Nelson
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
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Morales A, Schultz KC, Gao S, Murphy A, Barnato AE, Fanning JB, Hall DE. Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations. Palliat Med Rep 2021; 2:71-83. [PMID: 33860283 PMCID: PMC8043084 DOI: 10.1089/pmr.2020.0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
Importance: Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. Objective: To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Design, Setting, and Participants: Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Exposures: Data were analyzed by physician specialty. Main Outcome Measure: Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. Results: There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for "comfort as a goal of care," "noncurative goals of care," and "oblique references to death" emerged as significantly different between physician types. Conclusions and Relevance: This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty.
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Affiliation(s)
- Andre Morales
- Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevan C. Schultz
- University Center for Social and Urban Research (UCSUR), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shasha Gao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | | | - Amber E. Barnato
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Joseph B. Fanning
- Department of Medicine, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel E. Hall
- Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Mohan D, Sacks OA, O'Malley J, Rudolph M, Bynum J, Murphy M, Barnato AE. A New Standard for Advance Care Planning (ACP) Conversations in the Hospital: Results from a Delphi Panel. J Gen Intern Med 2021; 36:69-76. [PMID: 32816240 PMCID: PMC7859119 DOI: 10.1007/s11606-020-06150-0] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 07/22/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Fewer than half of the US population has an advance healthcare directive. Hospitalizations offer a key opportunity for clinicians to engage patients in advance care planning (ACP) conversations. Guidelines suggest screening for the presence of "serious illness" but do not further specify how to prioritize the 12.4 million patients hospitalized each year. OBJECTIVE To establish a normative standard for prioritizing hospitalized patients for ACP conversations. DESIGN AND SETTING A modified Delphi study, with three iterative rounds of online surveys. PARTICIPANTS Multi-disciplinary group of US-based clinicians with research and practical expertise in ACP. MAIN MEASURES Indirect and direct elicitation of short-term and 1-year risk of mortality that prompt experts to prioritize ACP conversations for hospitalized adults. MAIN RESULTS Fifty-seven of 108 (52%) candidate panelists completed round 1, and 47 completed rounds 2 and 3. Panelists were primarily physicians (84%), with significant experience (mean years 23 [SD 9.8]), who either taught (55%) and/or performed research about ACP (55%). In round 1, > 70% of panelists agreed that all hospitalized adults ≥ 65 years should have an ACP conversation before discharge, but disagreed about the timing and content of the conversation. By round 3, > 70% of participants agreed that patients with either high (> 10%) short-term or high (≥ 34%) 1-year risk of mortality should have a goals of care conversation (i.e., focused on preferences for near-term treatment), while patients with low (≤ 10%) short-term and low (< 19%) 1-year risk of mortality warranted an ACP conversation (i.e., focused on preferences for future care) before discharge. LIMITATIONS Use of case vignettes to elicit clinician judgment; response rate. CONCLUSIONS Panelists agreed that clinicians should have an ACP conversation with all hospitalized adults over 65 years in an ACP conversation, adjusting the content and timing of the conversation conditional on the patient's risk of short-term and 1-year mortality.
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Olivia A Sacks
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - Julie Bynum
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Megan Murphy
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Sacks OA, Knutzen KE, Rudolph MA, Mohan D, Barnato AE. Advance Care Planning and Professional Satisfaction From "Doing the Right Thing": Interviews With Hospitalist Chiefs. J Pain Symptom Manage 2020; 60:e31-e34. [PMID: 32653552 PMCID: PMC7643036 DOI: 10.1016/j.jpainsymman.2020.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Olivia A Sacks
- Department of Surgery, Boston Medical Center, Boston, MA
| | - Kristin E Knutzen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.
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Knutzen KE, Schifferdecker KE, Murray GF, Alam SS, Brooks GA, Kapadia NS, Butcher R, Barnato AE. Role of norms in variation in cancer centers' end-of-life quality: qualitative case study protocol. BMC Palliat Care 2020; 19:136. [PMID: 32854691 PMCID: PMC7453548 DOI: 10.1186/s12904-020-00641-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/01/2020] [Accepted: 08/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background A critical barrier to improving the quality of end-of-life (EOL) cancer care is our lack of understanding of the mechanisms underlying variation in EOL treatment intensity. This study aims to fill this gap by identifying 1) organizational and provider practice norms at major US cancer centers, and 2) how these norms influence provider decision making heuristics and patient expectations for EOL care, particularly for minority patients with advanced cancer. Methods This is a multi-center, qualitative case study at six National Comprehensive Cancer Network (NCCN) and National Cancer Institute (NCI) Comprehensive Cancer Centers. We will theoretically sample centers based upon National Quality Forum (NQF) endorsed EOL quality metrics and demographics to ensure heterogeneity in EOL intensity and region. A multidisciplinary team of clinician and non-clinician researchers will conduct direct observations, semi-structured interviews, and artifact collection. Participants will include: 1) cancer center and clinical service line administrators; 2) providers from medical, surgical, and radiation oncology; palliative or supportive care; intensive care; hospital medicine; and emergency medicine who see patients with cancer and have high clinical practice volume or high local influence (provider interviews and observations); and 3) adult patients with metastatic solid tumors and whom the provider would not be surprised if they died in the next 12 months and their caregivers (patient and caregiver interviews). Leadership interviews will probe about EOL institutional norms and organization. We will observe inpatient and outpatient care for two weeks. Provider interviews will use vignettes to probe explicit and implicit motivations for treatment choices. Semi-structured interviews with patients near EOL, or their family members and caregivers will explore past, current, and future decisions related to their cancer care. We will import transcribed field notes and interviews into Dedoose software for qualitative data management and analysis, and we will develop and apply a deductive and inductive codebook to the data. Discussion This study aims to improve our understanding of organizational and provider practice norms pertinent to EOL care in U.S. cancer centers. This research will ultimately be used to inform a provider-oriented intervention to improve EOL care for racial and ethnic minority patients with advanced cancer. Trial registration Clinicaltrials.gov; NCT03780816; December 19, 2018.
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Affiliation(s)
- Kristin E Knutzen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Karen E Schifferdecker
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Genevra F Murray
- Department of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Shama S Alam
- Evidera, Pharmaceutical Product Development, Bethesda, MD, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine, Hanover, NH, USA.,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine, Hanover, NH, USA.,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Rebecca Butcher
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA. .,Department of Medicine, Geisel School of Medicine, Hanover, NH, USA. .,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
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37
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Affiliation(s)
- Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
- The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Section of Palliative Care, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Rak KJ, Ashcraft LE, Kuza CC, Fleck JC, DePaoli LC, Angus DC, Barnato AE, Castle NG, Hershey TB, Kahn JM. Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study. Am J Respir Crit Care Med 2020; 201:823-831. [PMID: 32023081 DOI: 10.1164/rccm.201910-2006oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Rationale: Patients receiving prolonged mechanical ventilation experience low survival rates and incur high healthcare costs. However, little is known about how to optimally organize and manage their care.Objectives: To identify a set of effective care practices for patients receiving prolonged mechanical ventilation.Methods: We performed a focused ethnographic evaluation at eight long-term acute care hospitals in the United States ranking in either the lowest or highest quartile of risk-adjusted mortality in at least four of the five years between 2007 and 2011.Measurements and Main Results: We conducted 329 hours of direct observation, 196 interviews, and 39 episodes of job shadowing. Data were analyzed using thematic content analysis and a positive-negative deviance approach. We found that high- and low-performing hospitals differed substantially in their approach to care. High-performing hospitals actively promoted interdisciplinary communication and coordination using a range of organizational practices, including factors related to leadership (e.g., leaders who communicate a culture of quality improvement), staffing (e.g., lower nurse-to-patient ratios and ready availability of psychologists and spiritual care providers), care protocols (e.g., specific yet flexible respiratory therapy-driven weaning protocols), team meetings (e.g., interdisciplinary meetings that include direct care providers), and the physical plant (e.g., large workstations that allow groups to interact). These practices were believed to facilitate care that is simultaneously goal directed and responsive to individual patient needs, leading to more successful liberation from mechanical ventilation and improved survival.Conclusions: High-performing long-term acute care hospitals employ several organizational practices that may be helpful in improving care for patients receiving prolonged mechanical ventilation.
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Affiliation(s)
- Kimberly J Rak
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Laura Ellen Ashcraft
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Courtney C Kuza
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jessica C Fleck
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lisa C DePaoli
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Amber E Barnato
- Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; and
| | - Nicholas G Castle
- Department of Health Policy, Management, and Leadership, West Virginia University School of Public Health, Morgantown, West Virginia
| | - Tina B Hershey
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Jeremy M Kahn
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Gilstrap L, Skinner JS, Gladders B, O'Malley AJ, Barnato AE, Tosteson ANA, Austin AM. Opportunities and Challenges of Claims-Based Quality Assessment: The Case of Postdischarge β-Blocker Treatment in Patients With Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Qual Outcomes 2020; 13:e006180. [PMID: 32148101 DOI: 10.1161/circoutcomes.119.006180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Indexed: 01/06/2023]
Abstract
BACKGROUND To combat the high cost and increasing burden of quality reporting, the Medicare Payment Advisory (MedPAC) has recommended using claims data wherever possible to measure clinical quality. In this article, we use a cohort of Medicare beneficiaries with heart failure with reduced ejection fraction and existing quality metrics to explore the impact of changes in quality metric methodology on measured quality performance, the association with patient outcomes, and hospital rankings. METHODS AND RESULTS We used 100% Medicare Parts A and B and a random 40% sample of Part D from 2008 to 2015 to create (1) a cohort of 295 494 fee-for-service beneficiaries with ≥1 hospitalization for heart failure with reduced ejection fraction and (2) a cohort of 1079 hospitals with ≥11 heart failure with reduced ejection fraction admissions in 2014 and 2015. We used Part D data to calculate β-blocker use after discharge and β-blocker use over time. We then varied the quality metric methodologies to explore the impact on measured performance. We then used multivariable time-to-event analyses to explore the impact of metric methodology on the association between quality performance and patient outcomes and Kendall's Tau to describe impact of quality metric methodology on hospital rankings. We found that quality metric methodology had a significant impact on measured quality performance. The association between quality performance and readmissions was sensitive to changes in methodology but the association with 1-year mortality was not. Changes in quality metric methodology also had a substantial impact on hospital quality rankings. CONCLUSIONS This article highlights how small changes in quality metric methodology can have a significant impact on measured quality performance, the association between quality performance and utilization-based outcomes, and hospital rankings. These findings highlight the need for standardized quality metric methodologies, better case-mix adjustment and cast further doubt on the use of utilization-based outcomes as quality metrics in chronic diseases.
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Affiliation(s)
- Lauren Gilstrap
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH (L.G., B.G.).,The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (L.G.)
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Barbara Gladders
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH (L.G., B.G.)
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH.,Department of Biomedical Data Science (A.J.O.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice (L.G., J.S.S., A.J.O., A.E.B., A.N.A.T., A.M.A.), Geisel School of Medicine at Dartmouth, Lebanon, NH
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Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Bekelman JE, Nelson JB, Bynum JPW, Barnato AE, Kahn JM. Patterns of stereotactic body radiation therapy: The influence of lung cancer treatment on prostate cancer treatment. Urol Oncol 2020; 38:37.e21-37.e27. [PMID: 31699490 PMCID: PMC6954961 DOI: 10.1016/j.urolonc.2019.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 05/23/2019] [Revised: 08/30/2019] [Accepted: 09/28/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Technology availability and prior experience with novel cancer treatments may partially drive their use. We sought to examine this issue in the context of stereotactic body radiation therapy (SBRT) by studying how its use for an established indication (lung cancer) impacts its use for an emerging indication (prostate cancer). METHODS Using SEER-Medicare from 2007 to 2011, we developed prostate cancer-specific physician-hospital networks. Our primary dependent variable was SBRT use for prostate cancer and our primary independent variable was SBRT use for lung cancer, both at the network level. To assess the influence of SBRT availability and experiential use, we generated predicted probabilities of SBRT use for prostate cancer stratified by a network's use of lung cancer SBRT, adjusting for network characteristics. To assess intensity of use, we examined the correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT within a network. RESULTS We identified 316 networks that served 41,034 prostate cancer and 83,433 lung cancer patients. A network was significantly more likely to use SBRT for prostate cancer if that network used SBRT for lung cancer (e.g., in 2011, odds ratio [OR] 12.7; 95% confidence interval [CI] 3.9-41.8). The Pearson's correlation between the proportion of prostate cancer patients and lung cancer patients receiving SBRT in a network was 0.34, which was not statistically significant (P = 0.12). CONCLUSIONS SBRT availability and experiential use for lung cancer influences its use for prostate cancer, but intensity of use for one does not relate to intensity of use for the other.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA.
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Dwight E Heron
- Department of Radiation Oncology-Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA
| | - Chung-Chou H Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Julie P W Bynum
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Dartmouth Institute Geisel School of Medicine, Lebanon, NH
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Kahn JM, Rak KJ, Kuza CC, Ashcraft LE, Barnato AE, Fleck JC, Hershey TB, Hravnak M, Angus DC. Determinants of Intensive Care Unit Telemedicine Effectiveness. An Ethnographic Study. Am J Respir Crit Care Med 2020; 199:970-979. [PMID: 30352168 DOI: 10.1164/rccm.201802-0259oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [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
RATIONALE Telemedicine is an increasingly common care delivery strategy in the ICU. However, ICU telemedicine programs vary widely in their clinical effectiveness, with some studies showing a large mortality benefit and others showing no benefit or even harm. OBJECTIVES To identify the organizational factors associated with ICU telemedicine effectiveness. METHODS We performed a focused ethnographic evaluation of 10 ICU telemedicine programs using site visits, interviews, and focus groups in both facilities providing remote care and the target ICUs. Programs were selected based on their change in risk-adjusted mortality after adoption (decreased mortality, no change in mortality, and increased mortality). We used a constant comparative approach to guide data collection and analysis. MEASUREMENTS AND MAIN RESULTS We conducted 460 hours of direct observation, 222 interviews, and 18 focus groups across six telemedicine facilities and 10 target ICUs. Data analysis revealed three domains that influence ICU telemedicine effectiveness: 1) leadership (i.e., the decisions related to the role of the telemedicine, conflict resolution, and relationship building), 2) perceived value (i.e., expectations of availability and impact, staff satisfaction, and understanding of operations), and 3) organizational characteristics (i.e., staffing models, allowed involvement of the telemedicine unit, and new hire orientation). In the most effective telemedicine programs these factors led to services that are viewed as appropriate, integrated, responsive, and consistent. CONCLUSIONS The effectiveness of ICU telemedicine programs may be influenced by several potentially modifiable factors within the domains of leadership, perceived value, and organizational structure.
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Affiliation(s)
- Jeremy M Kahn
- 1 Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,2 Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Kimberly J Rak
- 1 Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Courtney C Kuza
- 1 Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Laura Ellen Ashcraft
- 1 Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amber E Barnato
- 2 Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.,3 The Dartmouth Institute of Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; and
| | - Jessica C Fleck
- 1 Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tina B Hershey
- 2 Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Marilyn Hravnak
- 4 Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Derek C Angus
- 1 Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,2 Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Jacobs BL, Yabes JG, Lopa SH, Heron DE, Chang CCH, Bekelman JE, Nelson JB, Bynum JPW, Barnato AE, Kahn JM. The Development and Validation of Prostate Cancer-specific Physician-Hospital Networks. Urology 2020; 138:37-44. [PMID: 31945379 DOI: 10.1016/j.urology.2019.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/18/2019] [Revised: 11/16/2019] [Accepted: 11/26/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To develop prostate cancer-specific physician-hospital networks to define hospital-based units that more accurately group hospitals, providers, and the patients they serve. METHODS Using Surveillance, Epidemiology, and End Results-Medicare, we identified men diagnosed with localized prostate cancer between 2007 and 2011. We created physician-hospital networks by assigning each patient to a physician and each physician to a hospital based on treatment patterns. We assessed content validity by examining characteristics of hospitals anchoring the physician-hospital networks and of the patients associated with these hospitals. RESULTS We identified 42,963 patients associated with 344 physician-hospital networks. Networks anchored by a teaching hospital (compared to a nonteaching hospital) had higher median numbers of prostate cancer patients (117 [interquartile range {71-189} vs 82 {50-126}]) and treating physicians (7 [4-11] vs 4 [3-6]) (both P <0.001). On average, patients traveled farther to networks anchored by a teaching hospital (49 miles [standard deviation] [207] vs 41 [183]; P <.001). Hospitals known as high-volume centers for robotic prostatectomies, proton-beam therapy, and active surveillance had network rates for these procedures well above the mean. Hospitals known as safety net providers served higher proportions of minorities. CONCLUSION We empirically developed prostate-cancer specific physician-hospital networks that exhibit content validity and are relevant from a clinical and policy perspective. They have the potential to become targets for policy interventions focused on improving the delivery of prostate cancer care.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA.
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA
| | - Chung-Chou H Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Julie P W Bynum
- Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Wasp GT, Alam SS, Brooks GA, Khayal IS, Kapadia NS, Carmichael DQ, Austin AM, Barnato AE. End-of-life quality metrics among medicare decedents at minority-serving cancer centers: A retrospective study. Cancer Med 2020; 9:1911-1921. [PMID: 31925998 PMCID: PMC7050066 DOI: 10.1002/cam4.2752] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 06/24/2019] [Revised: 11/02/2019] [Accepted: 11/11/2019] [Indexed: 11/24/2022] Open
Abstract
Background We calculated the performance of National Cancer Institute (NCI)/National Comprehensive Cancer Network (NCCN) cancer centers’ end‐of‐life (EOL) quality metrics among minority and white decedents to explore center‐attributable sources of EOL disparities. Methods We conducted a retrospective cohort study of Medicare beneficiaries with poor‐prognosis cancers who died between April 1, 2016 and December 31, 2016 and had any inpatient services in the last 6 months of life. We attributed patients’ EOL treatment to the center at which they received the preponderance of EOL inpatient services and calculated eight risk‐adjusted metrics of EOL quality (hospice admission ≤3 days before death; chemotherapy last 14 days of life; ≥2 emergency department (ED) visits; intensive care unit (ICU) admission; or life‐sustaining treatment last 30 days; hospice referral; palliative care; advance care planning last 6 months). We compared performance between patients across and within centers. Results Among 126,434 patients, 10,119 received treatment at one of 54 NCI/NCCN centers. In aggregate, performance was worse among minorities for ED visits (10.3% vs 7.4%, P < .01), ICU admissions (32.9% vs 30.4%, P = .03), no hospice referral (39.5% vs 37.0%, P = .03), and life‐sustaining treatment (19.4% vs 16.2%, P < .01). Despite high within‐center correlation for minority and white metrics (0.61‐0.79; P < .01), five metrics demonstrated worse performance as the concentration of minorities increased: ED visits (P = .03), ICU admission (P < .01), no hospice referral (P < .01), and life‐sustaining treatments (P < .01). Conclusion EOL quality metrics vary across NCI/NCCN centers. Within center, care was similar for minority and white patients. Minority‐serving centers had worse performance on many metrics.
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Affiliation(s)
- Garrett T Wasp
- Department of Medicine, Geisel School of Medicine, Hanover, NH, USA.,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Shama S Alam
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Gabriel A Brooks
- Department of Medicine, Geisel School of Medicine, Hanover, NH, USA.,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Inas S Khayal
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Nirav S Kapadia
- Department of Medicine, Geisel School of Medicine, Hanover, NH, USA.,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Donald Q Carmichael
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Andrea M Austin
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Amber E Barnato
- Department of Medicine, Geisel School of Medicine, Hanover, NH, USA.,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Mohan D, Wallace DJ, Kerti SJ, Angus DC, Rosengart MR, Barnato AE, Yealy DM, Fischhoff B, Chang CC, Kahn JM. Association of Practitioner Interfacility Triage Performance With Outcomes for Severely Injured Patients With Fee-for-Service Medicare Insurance. JAMA Surg 2019; 154:e193944. [PMID: 31642889 DOI: 10.1001/jamasurg.2019.3944] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Despite evidence that treatment of severely injured patients at trauma centers is associated with reduced mortality, nearly half of all such patients are treated at nontrauma centers (undertriaged). Little is known about whether interfacility undertriage occurs because of practitioner decision-making or institutional and regional factors. Objectives To assess the associations between variation in triage practitioners at nontrauma centers and between practitioner-level variation and patient outcomes after injury. Design, Setting, and Participants This retrospective cohort study used Medicare claims data from severely injured patients presenting to nontrauma centers and the practitioners who evaluated them in the emergency department from January 1, 2010, to October 15, 2015. Data analysis was performed from January 15, 2018, to March 21, 2019. Main Outcomes and Measures Proportion of variation in undertriage associated with practitioners, practitioner rates of undertriage, practitioner characteristics associated with undertriage, and 30-day case-fatality rate. Results A total of 124 008 severely injured patients (mean [SD] age, 81 [8.4] years; 67 253 [54.2%] female) and the 25 376 practitioners (5564 [21.9%] female) who evaluated the patients in the emergency department of nontrauma centers were included in the study. Undertriage occurred among 85 403 patients (68.9%), with 40.6% of total variation associated with practitioners, 37.8% with hospitals, and 6.7% with regions. Compared with physicians with National Provider Identification (NPI) enumeration before 2007, those with an NPI enumerated between 2007 and 2010 had an undertriage risk ratio (RR) of 0.98 (95% CI, 0.97-0.99), and those with an NPI enumerated after 2010 had an undertriage RR of 0.96 (95% CI, 0.94-0.99). Hospitals with neurosurgeons had an undertriage RR of 1.51 (95% CI, 1.45-1.57) compared with those that did not; hospitals with spine surgeons had an undertriage RR of 1.10 (95% CI, 1.06-1.13); hospitals with general surgeons had an undertriage RR of 1.13 (95% CI, 1.09-1.17). Compared with practitioners who undertriaged 25% or less of patients, a statistically significant increase was found in the odds of death for patients treated by practitioners with a triage rate of less than 25% to 50% (odds ratio [OR], 1.08; 95% CI, 1.05-1.20) and less than 50% to 75% undertriage (OR, 1.12; 95% CI, 1.09-1.26) but not undertriage at greater than 75% (OR, 1.03, 95% CI, 1.00-1.18). In sensitivity analyses to adjust for unmeasured confounding, the association between triage practices and the case fatality rate became monotonic; compared with patients treated by practitioners with an undertriage rate of 25% or less, the odds of case fatality were 1.13 (95% CI, 1.05-1.21; P = .001) among patients treated by practitioners with undertriage rates less than 25% to 50%, 1.22 (95% CI, 1.13-1.32; P < .001) for patients treated by practitioners with undertriage rates less than 50% to 75%, and 1.20 (95% CI, 1.10-1.30; P < .001) for patients treated by practitioners with undertriage rates greater than 75%. Conclusions and Relevance The findings suggest that individual practitioner practices are an important source of variation in triage and represent a potential locus of intervention to reduce preventable deaths after injury.
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David J Wallace
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samantha J Kerti
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew R Rosengart
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amber E Barnato
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Environmental Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Chung-Chou Chang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Jacobs BL, Lopa SH, Yabes JG, Nelson JB, Barnato AE, Degenholtz HB. Change in Functional Status After Prostate Cancer Treatment Among Medicare Advantage Beneficiaries. Urology 2019; 131:104-111. [PMID: 31181274 DOI: 10.1016/j.urology.2019.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 03/10/2019] [Revised: 05/06/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine the relationship between treatment and subsequent functional status among prostate cancer patients. METHODS Using Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data, we identified men 65 years or older diagnosed with prostate cancer between 1998 and 2009 (follow-up through 2010) who were treated with conservative management, surgery, or radiation. Our primary outcome was functional status as measured by activities of daily living. Secondary outcomes included physical component summary and mental component summary scores, which are both calculated from the Short Form 36 (SF-36) and the Veterans RAND 12-item health survey (VR-12) questionnaires. We included patients who completed 2 surveys and performed propensity score analyses to match patients 1:5 with noncancer controls. We used generalized linear mixed effects models, accounting for clustering due to insurance plan. RESULTS We identified 408 patients of whom 143 (35%) underwent conservative management, 59 (14%) underwent surgery, and 206 (51%) underwent radiation. Among conservative management and radiation patients, changes in functional status mirrored that of their noncancer controls (all P > .05). Among surgery patients, changes in activities of daily living scores were not significant, but physical component summary (mean difference = 4.5, P < .001) and mental component summary (mean difference = 3.3, P = .01) scores declined slightly more than for their noncancer peers. CONCLUSION Surgery patients had a slight decline in their general functional status whereas conservative management and radiation patients had no differences in functional status compared with their noncancer peers. Although the functional status of surgery patients declined more than that of their noncancer peers, this difference may not be clinically significant.
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Affiliation(s)
- Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA.
| | - Samia H Lopa
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Jonathan G Yabes
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; Dartmouth Institute Geisel School of Medicine, Lebanon, NH
| | - Howard B Degenholtz
- Department of Health Policy Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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Ellis EM, Barnato AE, Chapman GB, Dionne-Odom JN, Lerner JS, Peters E, Nelson WL, Padgett L, Suls J, Ferrer RA. Toward a Conceptual Model of Affective Predictions in Palliative Care. J Pain Symptom Manage 2019; 57:1151-1165. [PMID: 30794937 DOI: 10.1016/j.jpainsymman.2019.02.008] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/24/2019] [Accepted: 02/10/2019] [Indexed: 10/27/2022]
Abstract
CONTEXT Being diagnosed with cancer often forces patients and families to make difficult medical decisions. How patients think they and others will feel in the future, termed affective predictions, may influence these decisions. These affective predictions are often biased, which may contribute to suboptimal care outcomes by influencing decisions related to palliative care and advance care planning. OBJECTIVES This study aimed to translate perspectives from the decision sciences to inform future research about when and how affective predictions may influence decisions about palliative care and advance care planning. METHODS A systematic search of two databases to evaluate the extent to which affective predictions have been examined in the palliative care and advance care planning context yielded 35 relevant articles. Over half utilized qualitative methodologies (n = 21). Most studies were conducted in the U.S. (n = 12), Canada (n = 7), or European countries (n = 10). Study contexts included end of life (n = 10), early treatment decisions (n = 10), pain and symptom management (n = 7), and patient-provider communication (n = 6). The affective processes of patients (n = 20), caregivers (n = 16), and/or providers (n = 12) were examined. RESULTS Three features of the palliative care and advance care planning context may contribute to biased affective predictions: 1) early treatment decisions are made under heightened emotional states and with insufficient information; 2) palliative care decisions influence life domains beyond physical health; and 3) palliative care decisions involve multiple people. CONCLUSION Biases in affective predictions may serve as a barrier to optimal palliative care delivery. Predictions are complicated by intense emotions, inadequate prognostic information, involvement of many individuals, and cancer's effect on non-health life domains. Applying decision science frameworks may generate insights about affective predictions that can be harnessed to solve challenges associated with optimal delivery of palliative care.
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Affiliation(s)
- Erin M Ellis
- National Cancer Institute, Bethesda, Maryland, USA.
| | | | | | | | | | | | | | - Lynne Padgett
- Washington D.C. Veteran's Affairs Medical Center, Washington, District of Columbia, USA
| | - Jerry Suls
- National Cancer Institute, Bethesda, Maryland, USA
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Barnato AE, O’Malley AJ, Skinner JS, Birkmeyer JD. Use of Advance Care Planning Billing Codes for Hospitalized Older Adults at High Risk of Dying: A National Observational Study. J Hosp Med 2019; 14:229-231. [PMID: 30933674 PMCID: PMC6446938 DOI: 10.12788/jhm.3150] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/20/2018] [Indexed: 11/20/2022]
Abstract
We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated "surprise question" (SQ; "Would you be surprised if the patient died in the next year?") for inpatient admissions served to prime hospitalists and triggered an icon next to the patient's name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered "no" and 4.1% SQ-prompted who answered "yes" (for non-SQ prompted cases, the fraction was 3.5%; P < .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Corresponding Author: Amber E. Barnato, MD, MPH; E-mail: ; Telephone: 650-653-0829; Twitter: @abarnato
| | - A James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Economics, Dartmouth College, Hanover New Hampshire
| | - John D Birkmeyer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Sound Physicians, Tacoma, Washington
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Dionne-Odom JN, Ejem D, Wells R, Barnato AE, Taylor RA, Rocque GB, Turkman YE, Kenny M, Ivankova NV, Bakitas MA, Martin MY. How family caregivers of persons with advanced cancer assist with upstream healthcare decision-making: A qualitative study. PLoS One 2019; 14:e0212967. [PMID: 30865681 PMCID: PMC6415885 DOI: 10.1371/journal.pone.0212967] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/12/2019] [Indexed: 12/27/2022] Open
Abstract
Aims Numerous healthcare decisions are faced by persons with advanced cancer from diagnosis to end-of-life. The family caregiver role in these decisions has focused on being a surrogate decision-maker, however, little is known about the caregiver’s role in supporting upstream patient decision-making. We aimed to describe the roles of family caregivers in assisting community-dwelling advanced cancer patients with healthcare decision-making across settings and contexts. Methods Qualitative study using one-on-one, semi-structured interviews with community-dwelling persons with metastatic cancer (n = 18) and their family caregivers (n = 20) recruited from outpatient oncology clinics of a large tertiary care academic medical center, between October 2016 and October 2017. Transcribed interviews were analyzed using a thematic analysis approach. Findings Caregivers averaged 56 years and were mostly female (95%), white (85%), and the patient’s partner/spouse (70%). Patients averaged 58 years and were mostly male (67%) in self-reported “fair” or “poor” health (50%) with genitourinary (33%), lung (17%), and hematologic (17%) cancers. Themes describing family member roles in supporting patients’ upstream healthcare decision-making were: 1) seeking information about the cancer, its trajectory, and treatments options; 2) ensuring family and healthcare clinicians have a common understanding of the patient’s treatment plan and condition; 3) facilitating discussions with patients about their values and the framing of their illness; 5) posing “what if” scenarios about current and potential future health states and treatments; 6) addressing collateral decisions (e.g., work arrangements) resulting from medical treatment choices; 6) originating healthcare-related decision points, including decisions about seeking emergency care; and 7) making healthcare decisions for patients who preferred to delegate healthcare decisions to their family caregivers. Conclusions These findings highlight a previously unreported and understudied set of critical decision partnering roles that cancer family caregivers play in patient healthcare decision-making. Optimizing these roles may represent novel targets for early decision support interventions for family caregivers.
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Affiliation(s)
- J. Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- * E-mail:
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Amber E. Barnato
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, United States of America
| | - Richard A. Taylor
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Gabrielle B. Rocque
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Yasemin E. Turkman
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Matthew Kenny
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Nataliya V. Ivankova
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Marie A. Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Michelle Y. Martin
- Center for Innovation in Health Equity Research, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
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Abstract
The principal policy tool for respecting the preferences of patients facing serious illnesses that can prompt decisions regarding end-of-life care is the advance directive (AD) for health care. AD policies, decision aids for facilitating ADs, and clinical processes for interpreting ADs all treat patients as rational actors who will make appropriate choices, if provided relevant information. We review barriers to following this model, leading us to propose replacing the goal of rational choice with that of value awareness, enabling patients (and, where appropriate, their surrogates) to be as rational as they can and want to be when making these fateful choices. We propose approaches, and supporting research, suited to individuals’ cognitive, affective, and social circumstances, resources, and desires.
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Affiliation(s)
- Baruch Fischhoff
- Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Amber E Barnato
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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50
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Mohan D, Fischhoff B, Angus DC, Rosengart MR, Wallace DJ, Yealy DM, Farris C, Chang CCH, Kerti S, Barnato AE. Serious games may improve physician heuristics in trauma triage. Proc Natl Acad Sci U S A 2018; 115:9204-9209. [PMID: 30150397 PMCID: PMC6140476 DOI: 10.1073/pnas.1805450115] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Trauma triage depends on fallible human judgment. We created two "serious" video game training interventions to improve that judgment. The interventions' central theoretical construct was the representativeness heuristic, which, in trauma triage, would mean judging the severity of an injury by how well it captures (or "represents") the key features of archetypes of cases requiring transfer to a trauma center. Drawing on clinical experience, medical records, and an expert panel, we identified features characteristic of representative and nonrepresentative cases. The two interventions instantiated both kinds of cases. One was an adventure game, seeking narrative engagement; the second was a puzzle-based game, emphasizing analogical reasoning. Both incorporated feedback on diagnostic errors, explaining their sources and consequences. In a four-arm study, they were compared with an intervention using traditional text-based continuing medical education materials (active control) and a no-intervention (passive control) condition. A sample of 320 physicians working at nontrauma centers in the United States was recruited and randomized to a study arm. The primary outcome was performance on a validated virtual simulation, measured as the proportion of undertriaged patients, defined as ones who had severe injuries (according to American College of Surgeons guidelines) but were not transferred. Compared with the control group, physicians exposed to either game undertriaged fewer such patients [difference = -18%, 95% CI: -30 to -6%, P = 0.002 (adventure game); -17%, 95% CI: -28 to -6%, P = 0.003 (puzzle game)]; those exposed to the text-based education undertriaged similar proportions (difference = +8%, 95% CI: -3 to +19%, P = 0.15).
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Affiliation(s)
- Deepika Mohan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15213
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA 15213;
- Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA 15213
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261
| | | | - David J Wallace
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | | | - Chung-Chou H Chang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261
| | - Samantha Kerti
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261
| | - Amber E Barnato
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH 03766
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