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Smirnova N, Lange AV, Glickman A, Desanto K, McDermott CL, Sullivan DR, Bekelman DB, Kavalieratos D. Criteria for Enrollment of Patients With COPD in Palliative Care Trials: A Systematic Review. J Pain Symptom Manage 2024; 67:e891-e905. [PMID: 38280439 PMCID: PMC11088983 DOI: 10.1016/j.jpainsymman.2024.01.028] [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: 09/19/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 01/29/2024]
Abstract
CONTEXT Use of palliative care interventions in chronic obstructive pulmonary disease (COPD) has increased in recent years and inclusion criteria used to identify patients with COPD appropriate for palliative care vary widely. We evaluated the inclusion criteria to identify ways to improve enrollment opportunities for patients with COPD. OBJECTIVES To determine inclusion criteria used to select patients with COPD for palliative care trials. METHODS A systematic review was conducted to determine criteria used to select patients with COPD for palliative care randomized controlled trials. A narrative synthesis was conducted for all trials. RESULTS Inclusion criteria were highly heterogeneous. Most studies (n = 11, 79%) used a combination of criteria to identify patients with COPD. Commonly used criteria included hospitalization for an acute exacerbation of COPD (n = 8, 57%), home supplemental oxygen use (n = 8, 57%), and spirometry values confirming COPD (n = 6, 43%). Three studies (21.4%) used Modified Medical Research Council score and two studies (21%) used physician prognosis or a performance scale. CONCLUSION The most common criteria, a hospitalization for acute exacerbation of COPD or supplemental oxygen use at home, both have the benefit of selecting patients who have a higher symptom burden or higher healthcare utilization who might therefore benefit more from palliative care. By describing the landscape and variability of previously used inclusion criteria, this article serves as a resource for clinicians and researchers. Developing a consistent set of inclusion criteria in the future would help generate generalizable results that can be translated into clinical practice to improve the lives of patients with COPD. PROSPERO REGISTRATION NUMBER CRD42022306752.
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Affiliation(s)
- Natalia Smirnova
- Division of Pulmonary, Allergy and Critical Care Medicine (N.S.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine (A.V.L.), University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Amanda Glickman
- Division of General Internal Medicine (A.G., D.B.B.), University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kristen Desanto
- Strauss Health Sciences Library (K.D.), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cara L McDermott
- Division of Geriatrics (C.L.M.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Donald R Sullivan
- Division of Pulmonary, Allergy and Critical Care Medicine (D.R.S.), Oregon Health and Science University, Portland, Oregon, USA; Center to Improve Veteran Involvement in their Care (CIVIC) (D.R.S.), VA Portland Health Care System, Portland, Oregon, USA; Knight Cancer Institute (D.R.S.), Oregon Health and Science University, Portland, Oregon, USA
| | - David B Bekelman
- Division of General Internal Medicine (A.G., D.B.B.), University of Colorado School of Medicine, Aurora, Colorado, USA; Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs (D.B.B.), Denver, Aurora, Colorado, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine (D.K.), Emory University School of Medicine, Atlanta, Georgia, USA; Rollins School of Public Health (D.K.), Emory University, Atlanta, Georgia, USA
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Ma JE, Schlichte L, Haverfield M, Gambino J, Lange A, Blanchard K, Morgan B, Bekelman DB. Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy. J Am Geriatr Soc 2024. [PMID: 38593240 DOI: 10.1111/jgs.18913] [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: 09/05/2023] [Revised: 03/07/2024] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Documenting goals of care in the electronic health record is meant to relay patient preferences to other clinicians. Evaluating the content and documentation of nurse and social worker led goals of care conversations can inform future goals of care initiative efforts. METHODS As part of the ADvancing symptom Alleviation with Palliative Treatment trial, this study analyzed goals of care conversations led by nurses and social workers and documented in the electronic health record. Informed by a goals of care communication guide, we identified five goals of care components: illness understanding, goals and values, end of life planning, surrogate, and advance directives. Forty conversation transcripts underwent content analysis. Through an iterative team process, we defined documentation accuracy as four categories: (1) Complete-comprehensive accurate documentation of the conversation, (2) Incomplete-partial documentation of the conversation, (3) Missing-discussed and not documented, and (4) Incorrect-misrepresented in documentation. We also defined-Not Discussed-for communication guide questions that were not discussed nor documented. A constant comparative approach was used to determine the presence or absence of conversation content in the documentation. RESULTS All five goals of care components were discussed in 67% (27/40) of conversation transcripts. Compared to the transcripts, surrogate (37/40, 93%) and advance directives (36/40, 90%) were often documented completely. Almost 40% of goals and values (15/40, 38%) and half of end of life planning (19/40, 48%) were incomplete. Illness understanding was missing (13/40, 33%), not discussed (13/40, 33%), or incorrect (2/40, 5%). CONCLUSION Nurse and social worker led goals of care conversations discussed and documented most components of the goals of care communication guide. Further research may guide how best to determine the relative importance of accuracy, especially in the broad setting of incomplete, missing, and incorrect EHR documentation.
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Affiliation(s)
- Jessica E Ma
- Geriatric Research Education and Clinical Center, Durham VA Health System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Marie Haverfield
- Department of Communication Studies, San José State University, San Jose, California, USA
| | | | - Allison Lange
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kelly Blanchard
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Brianne Morgan
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - David B Bekelman
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Glickman A, Mikulich-Gilbertson S, Abshire Saylor M, DeGroot L, Bekelman DB. Relationship Status and Quality Are Associated With Perceived Benefits of Caregiving for People With Heart Failure. J Cardiovasc Nurs 2024:00005082-990000000-00179. [PMID: 38509047 DOI: 10.1097/jcn.0000000000001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
BACKGROUND "Benefit finding" is a strengths-based strategy for coping with medical illness that may be particularly useful for caregivers of people with heart failure given the highly fluctuating disease course. OBJECTIVE The aim of this study was to investigate benefit finding's association with the caregiver-care recipient relationship, depression, and burden at baseline and longitudinally. METHODS This is a longitudinal observational study of caregivers' benefit finding, relationship quality, depression, and burden. Correlation and multiple regression analyses identify baseline associations and predictors of 12-month change in benefit finding. RESULTS At baseline (n = 100; median, 60 years [interquartile range, 46-69]; 81% female, 70% partner/spouse), increased benefit finding correlated with higher relationship quality (r = 0.53; 95% confidence interval [CI], 0.38-0.67), lower depression (r = -0.33; 95% CI, -0.49 to -0.14), and lower burden (r = -0.31; 95% CI, -0.47 to -0.11). Twelve-month change in benefit finding was predicted by change in relationship quality (ß = 7.12; 95% CI, 0.62-13.61) but not depression or burden. CONCLUSIONS Relationship quality and benefit finding changed together over time. Interventions strengthening the caregiver-care recipient bond may be especially impactful for heart failure caregivers.
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Bekelman DB, Feser W, Morgan B, Welsh CH, Parsons EC, Paden G, Baron A, Hattler B, McBryde C, Cheng A, Lange AV, Au DH. Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease: The ADAPT Randomized Clinical Trial. JAMA 2024; 331:212-223. [PMID: 38227034 PMCID: PMC10792473 DOI: 10.1001/jama.2023.24035] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 11/01/2023] [Indexed: 01/17/2024]
Abstract
Importance Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life. Objective Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care. Design, Setting, and Participants Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated. Intervention The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health. Main Outcomes and Measures The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change ≥4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms. Results Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months. Conclusions and Relevance For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care. Trial Registration ClinicalTrials.gov Identifier: NCT02713347.
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Affiliation(s)
- David B. Bekelman
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - William Feser
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora
| | - Brianne Morgan
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
| | - Carolyn H. Welsh
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Elizabeth C. Parsons
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
| | - Grady Paden
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Anna Baron
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora
| | - Brack Hattler
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Connor McBryde
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Andrew Cheng
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Allison V. Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - David H. Au
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care Systems, Aurora, Colorado
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle
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Paek M, Rinderle T, Resnick R, Bekelman DB. Palliative Care Issues in Aortic Stenosis #467. J Palliat Med 2023; 26:1578-1580. [PMID: 37955887 DOI: 10.1089/jpm.2023.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
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Ha DM, Nunnery MA, Klocko RP, Haverhals LM, Bekelman DB, New ML, Randhawa SK, Stevens-Lapsley JE, Studts JL, Prochazka AV, Keith RL. Lung cancer survivors' views on telerehabilitation following curative intent therapy: a formative qualitative study. BMJ Open 2023; 13:e073251. [PMID: 37355268 PMCID: PMC10314696 DOI: 10.1136/bmjopen-2023-073251] [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: 02/27/2023] [Accepted: 06/09/2023] [Indexed: 06/26/2023] Open
Abstract
OBJECTIVES To inform personalised home-based rehabilitation interventions, we sought to gain in-depth understanding of lung cancer survivors' (1) attitudes and perceived self-efficacy towards telemedicine; (2) knowledge of the benefits of rehabilitation and exercise training; (3) perceived facilitators and preferences for telerehabilitation; and (4) health goals following curative intent therapy. DESIGN We conducted semi-structured interviews guided by Bandura's Social Cognitive Theory and used directed content analysis to identify salient themes. SETTING One USA Veterans Affairs Medical Center. PARTICIPANTS We enrolled 20 stage I-IIIA lung cancer survivors who completed curative intent therapy in the prior 1-6 months. Eighty-five percent of participants had prior experience with telemedicine, but none with telerehabilitation or rehabilitation for lung cancer. RESULTS Participants viewed telemedicine as convenient, however impersonal and technologically challenging, with most reporting low self-efficacy in their ability to use technology. Most reported little to no knowledge of the potential benefits of specific exercise training regimens, including those directed towards reducing dyspnoea, fatigue or falls. If they were to design their own telerehabilitation programme, participants had a predominant preference for live and one-on-one interaction with a therapist, to enhance therapeutic relationship and ensure correct learning of the training techniques. Most participants had trouble stating their explicit health goals, with many having questions or concerns about their lung cancer status. Some wanted better control of symptoms and functional challenges or engage in healthful behaviours. CONCLUSIONS Features of telerehabilitation interventions for lung cancer survivors following curative intent therapy may need to include strategies to improve self-efficacy and skills with telemedicine. Education to improve knowledge of the benefits of rehabilitation and exercise training, with alignment to patient-formulated goals, may increase uptake. Exercise training with live and one-on-one therapist interaction may enhance learning, adherence, and completion. Future work should determine how to incorporate these features into telerehabilitation.
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Affiliation(s)
- Duc M Ha
- Section of Pulmonary and Critical Care, Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mary A Nunnery
- Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care, Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Robert P Klocko
- Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care, Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Leah M Haverhals
- Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care, Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
- Division of Health Care Policy and Research, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - David B Bekelman
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care, Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Melissa L New
- Section of Pulmonary and Critical Care, Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Simran K Randhawa
- Surgical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
- Division of Thoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jennifer E Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Geriatric Research, Education, and Clinical Center, Research Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Jamie L Studts
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Allan V Prochazka
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Robert L Keith
- Section of Pulmonary and Critical Care, Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Lange AV, Mehta AB, Bekelman DB. How Important is Spirometry for Identifying Patients with COPD Appropriate for Palliative Care? J Pain Symptom Manage 2023; 65:e181-e187. [PMID: 36423798 PMCID: PMC10998735 DOI: 10.1016/j.jpainsymman.2022.11.016] [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: 09/21/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Providing palliative care to patients with chronic obstructive pulmonary disease (COPD) is a priority. Spirometry demonstrating airflow limitation is a diagnostic test for COPD and a common inclusion criterion for palliative care research. However, requiring spirometry with airflow limitation may exclude appropriate patients unable to complete spirometry, or patients with preserved-ratio impaired spirometry and symptoms or imaging consistent with COPD. MEASURES To determine differences in quality of life (QOL) and symptoms between patients with COPD identified based on International Classification of Diseases (ICD) codes and spirometry with airflow limitation compared to ICD codes only. INTERVENTION Patients with COPD enrolled in a palliative care trial were included. Patients were at high risk of hospitalization and death and reported poor QOL. Baseline measures of QOL (Functional Assessment of Cancer Therapy-General (FACT-G), the Clinical COPD Questionnaire, and Quality of Life at the End of Life), and symptoms (Patient Health Questionnaire-8, Generalized Anxiety Disorder-7, fatigue, Insomnia Severity Index) were compared. OUTCOMES Two hundred eight patients with COPD were predominantly male, White, and average age was 68.4. Between patients with ICD codes and spirometry with airflow limitation compared to patients with ICD codes only, there were no significant differences in FACT-G (59.0 vs. 55.0, P = 0.33), other measures of QOL, or symptoms between groups. CONCLUSION These results imply that spirometry may not need to be a requirement for inclusion into palliative care research or clinical care for patients with poor quality of life and at high risk for adverse outcomes.
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Affiliation(s)
- Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine (A.L., A.M.); University of Colorado Anschutz Medical Campus; Aurora, Colorado.
| | - Anuj B Mehta
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine (A.L., A.M.); University of Colorado Anschutz Medical Campus; Aurora, Colorado; Division of Pulmonary and Critical Care Medicine, Department of Medicine (A.M.), Denver Health and Hospital Authority; Denver, Colorado
| | - David B Bekelman
- Medical Service (D.B.), Rocky Mountain Regional Veterans Affairs Medical Center; Aurora, Colorado; Denver-Seattle Center of Innovation (D.B.); Rocky Mountain Regional Veterans Affairs Medical Center; Aurora, Colorado; Division of General Internal Medicine, Department of Medicine (D.B.); University of Colorado Anschutz Medical Campus; Aurora, Colorado
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Deng LR, Doyon KJ, Masters KS, Steinhauser KE, Langner PR, Siler S, Bekelman DB. How Does Spiritual Well-Being Change Over Time Among US Patients with Heart Failure and What Predicts Change? J Relig Health 2022:10.1007/s10943-022-01712-4. [PMID: 36478542 DOI: 10.1007/s10943-022-01712-4] [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] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 06/17/2023]
Abstract
Few studies have examined how spiritual well-being changes over time in patients with heart failure. We conducted a secondary analysis of data from the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) trial (N = 314). Spiritual well-being was measured using the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) at baseline and 12-month follow-up. Of the 165 patients with spiritual well-being data at follow-up, 65 (39%) experienced probable clinically meaningful changes (> 0.5 SD) in spiritual well-being (35 improved, 30 declined). Increased pain (p = 0.04), decreased dyspnea (p < 0.01), and increased life completion (p = 0.02) were associated with improvement in overall spiritual well-being. Exploratory analyses found different predictors for FACIT-Sp subscales.
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Affiliation(s)
- Lubin R Deng
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System, 1700 N Wheeling St, P1-151, Aurora, CO, 80045, USA.
- Department of Statistics, Columbia University, New York, NY, USA.
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Katherine J Doyon
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kevin S Masters
- Department of Psychology, University of Colorado Denver, Denver, CO, USA
| | - Karen E Steinhauser
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Paula R Langner
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System, 1700 N Wheeling St, P1-151, Aurora, CO, 80045, USA
| | - Shaunna Siler
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - David B Bekelman
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System, 1700 N Wheeling St, P1-151, Aurora, CO, 80045, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Portz JD, Powers J, Baldwin M, Gleason K, Casillas A, Bekelman DB, Boxer R, Bayliss E, Palen TE. How can patient portals support caregivers of older adults near the end-of-life? A mixed-methods study. J Am Geriatr Soc 2022; 70:2431-2435. [PMID: 35488465 PMCID: PMC9378599 DOI: 10.1111/jgs.17818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/07/2022] [Accepted: 03/25/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, School of Medicine, University of Colorado, Aurora, Colorado
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - J.D. Powers
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Megan Baldwin
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Kathy Gleason
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - David B. Bekelman
- Division of General Internal Medicine, School of Medicine, University of Colorado, Aurora, Colorado
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado
| | - Rebecca Boxer
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Elizabeth Bayliss
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Department of Family Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Ted E. Palen
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
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Deng LR, Matlock DD, Bekelman DB. Preferred Role in Health Care Decision Making Over Time in Patients With Heart Failure: My Decision or My Doctor's Decision? J Card Fail 2022; 28:1362-1366. [PMID: 35470060 DOI: 10.1016/j.cardfail.2022.03.357] [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: 01/18/2022] [Revised: 03/19/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Understanding patients' preferred role in decision making can improve patient-centered care. This study aimed to determine change and the predictors of change in preferred decision-making roles over time in patients with heart failure. METHODS AND RESULTS During the CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) trial, patients' preferred roles in decision making were measured using the Control Preferences Scale (range 1-5; higher = less active; n = 312) at 4 timepoints over 1 year. The effect of the CASA intervention on preferred decision-making roles was tested using generalized linear mixed models. Whether preferences changed over time in the whole population was determined using linear regression. Demographic and health-related factors were examined as predictors of change using multiple linear regression. At baseline, most participants preferred active (score 1-2, 37.2%) or collaborative (score 3, 44.9%) roles. The CASA intervention did not influence preferred decision-making roles (P > 0.1). Preferences significantly changed over 1 year (P < 0.01), becoming more active (82.1%, 84.2%, 89.0%, 90.1% active/collaborative at each timepoint). Among all models and covariates, there were no significant predictors of change (P > 0.1). CONCLUSIONS Patients' preferred roles in decision making change over time, but changes are not well predicted. Clinicians should frequently and directly communicate with patients about their preferred decision-making roles.
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Affiliation(s)
- Lubin R Deng
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; Department of Statistics, Columbia University, New York, New York.
| | - Daniel D Matlock
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado
| | - David B Bekelman
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
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11
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Ha DM, Deng LR, Lange AV, Swigris JJ, Bekelman DB. Reliability, Validity, and Responsiveness of the DEG, a Three-Item Dyspnea Measure. J Gen Intern Med 2022; 37:2541-2547. [PMID: 34981344 PMCID: PMC9360273 DOI: 10.1007/s11606-021-07307-1] [Citation(s) in RCA: 2] [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: 08/08/2021] [Accepted: 11/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dyspnea is a common and debilitating symptom that affects many different patient populations. Dyspnea measures should assess multiple domains. OBJECTIVE To evaluate the reliability, validity, and responsiveness of an ultra-brief, multi-dimensional dyspnea measure. DESIGN We adapted the DEG from the PEG, a valid 3-item pain measure, to assess average dyspnea intensity (D), interference with enjoyment of life (E), and dyspnea burden with general activity (G). PARTICIPANTS We used data from a multi-site randomized clinical trial among outpatients with heart failure. MAIN MEASURES We evaluated reliability (Cronbach's alpha), concurrent validity with the Memorial-Symptom-Assessment-Scale (MSAS) shortness-of-breath distress-orbothersome item and 7-item Generalized-Anxiety-Disorder (GAD-7) scale, knowngroups validity with New-York-Heart-Association-Functional-Classification (NYHA) 1-2 or 3-4 and presence or absence of comorbid chronic obstructive pulmonary disease (COPD), responsiveness with the MSAS item as an anchor, and calculated a minimal clinically important difference (MCID) using distribution methods. KEY RESULTS Among 312 participants, the DEG was reliable (Cronbach's alpha 0.92). The mean (standard deviation) DEG score was 5.26 (2.36) (range 0-10) points. DEG scores correlated strongly with the MSAS shortness of breath distress-or-bothersome item (r=0.66) and moderately with GAD-7 categories (ρ=0.36). DEG scores were statistically significantly lower among patients with NYHA 1-2 compared to 3-4 [mean difference (standard error): 1.22 (0.27) points, p<0.01], and those without compared to with comorbid COPD [0.87 (0.27) points, p<0.01]. The DEG was highly sensitive to change, with MCID of 0.59-1.34 points, or 11-25% change. CONCLUSIONS The novel, ultra-brief DEG measure is reliable, valid, and highly responsive. Future studies should evaluate the DEG's sensitivity to interventions, use anchor-based methods to triangulate MCID estimates, and determine its prognostic usefulness among patients with chronic cardiopulmonary and other diseases.
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Affiliation(s)
- Duc M Ha
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling Street, Aurora, CO, 80045, USA. .,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA. .,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Lubin R Deng
- Denver-Seattle Center of Innovation, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeffrey J Swigris
- Interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
| | - David B Bekelman
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling Street, Aurora, CO, 80045, USA.,Denver-Seattle Center of Innovation, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.,Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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12
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Haverfield MC, Garcia A, Giannitrapani KF, Walling A, Rigdon J, Bekelman DB, Lo N, Lehmann LS, Jacobs J, Festa N, Lorenz KA. Goals of Care Documentation: Insights from A Pilot Implementation Study. J Pain Symptom Manage 2022; 63:485-494. [PMID: 34952172 DOI: 10.1016/j.jpainsymman.2021.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/11/2021] [Accepted: 12/16/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The Life Sustaining Treatment Decision Initiative is a national effort by the Veterans Health Administration to ensure goals of care documentation occurs among all patients at high risk of life-threatening events. OBJECTIVES Examine likelihood to receive goals of care documentation and explore associations between documentation and perceived patient care experience at the individual and site level. METHODS Retrospective, quality improvement analysis of initiative pilot data from four geographically diverse Veterans Affairs (VA) sites (Fall 2014-Winter 2016) before national roll-out. Goals of care documentation according to gender, marital status, urban/rural status, race/ethnicity, age, serious health condition, and Care Assessment Needs scores. Association between goals of care documentation and perceived patient care experience analyzed based on Bereaved Family Survey outcomes of overall care, communication, and support. RESULTS Veterans were more likely to have goals of care documentation if widowed, urban residents, and of white race. Patients older than 65-years and those with a higher Care Assessment Needs score were twice as likely as a frail patient to have goals of care documented. One pilot site demonstrated a positive association between documentation and perceived support. Pilot site was a statistically significant predictor of the occurrence of goals of care documentation and Bereaved Family Survey scores. CONCLUSION Older and seriously ill patients were most likely to have goals of care documented. Association between a documented goals of care conversation and perceived patient care experience were largely unsupported. Site-level largely contributed to understanding the likelihood of documentation and care experience.
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Affiliation(s)
- Marie C Haverfield
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA; Department of Communication Studies, San José State University, San Jose, California, USA.
| | - Ariadna Garcia
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA; School of Medicine, Stanford University, Stanford, California, USA
| | - Karleen F Giannitrapani
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA; School of Medicine, Stanford University, Stanford, California, USA
| | - Anne Walling
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Joseph Rigdon
- Wake Forest School of Medicine, Department of Biostatistics and Data Science, Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - David B Bekelman
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado, USA; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Natalie Lo
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA
| | - Lisa S Lehmann
- Veterans Affairs New England Healthcare System, Bedford, Massachusetts, USA
| | - Josephine Jacobs
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA
| | - Natalia Festa
- Yale New Haven Hospital, Department of Internal Medicine, Section of Geriatrics, New Haven, Connecticut, USA
| | - Karl A Lorenz
- VA Palo Alto, Center for Innovation to Implementation (Ci2i), Menlo Park, California, USA; School of Medicine, Stanford University, Stanford, California, USA
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13
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Ha DM, Prochazka AV, Bekelman DB, Stevens-Lapsley JE, Studts JL, Keith RL. Modifiable factors associated with health-related quality of life among lung cancer survivors following curative intent therapy. Lung Cancer 2022; 163:42-50. [PMID: 34896804 DOI: 10.1016/j.lungcan.2021.11.012] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/27/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The number of lung cancer survivors is increasing along with advances in screening, diagnosis, and treatment. Following curative intent therapy, many lung cancer survivors experience significant health-related quality of life (HRQL) impairments. We sought to identify potentially modifiable factors that contribute to the HRQL of these patients. MATERIALS AND METHODS In this cross-sectional observational study of disease-free, stage I-IIIA lung cancer survivors following curative intent therapy, we used a conceptual model to examine factors that included behavioral, objective functional and physiologic, self-rated function and symptom burden, specific comorbidities, and non-modifiable demographic and clinical lung cancer-related characteristics. We assessed HRQL using the valid and prognostic European Organization for Research and Treatment of Cancer Quality of Life (QoL) Core 30 global health/QoL subscale. We used univariable and multivariable linear regression modeling with backward elimination of potentially modifiable and non-modifiable factors, and interpreted clinically and statistically significant, consistent, and independent modifiable factors as meaningful. RESULTS Among 75 participants at a median of 12 months since treatment completion, the mean (standard deviation) C30 global health/QoL score was 62.7 (23.3) points (0-100 scale range). In multivariable analysis, with and without non-modifiable factors, we identified three clinically and statistically significant, consistent, and independent factors (unstandardized β range) associated with global health/QoL: 1) abnormal exercise-induced dyspnea (-9.23 to -10.0 points); 2) impaired self-rated role function (or inability to perform work or daily activities and pursuing leisure-time activities) (-12.6 to -16.4 points); and 3) abnormal insomnia (or trouble sleeping) (-12.6 to -16.4 points). CONCLUSION We identified meaningful modifiable factors associated with the HRQL of disease-free, stage I-IIIA lung cancer survivors following curative intent therapy. Interventions to improve the HRQL of these patients should aim to reduce exercise-induced dyspnea, improve role function - the ability to perform work and other daily including leisure-time activities, and control insomnia.
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Affiliation(s)
- Duc M Ha
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States; Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.
| | - Allan V Prochazka
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - David B Bekelman
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States; Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Denver-Seattle Center of Innovation, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
| | - Jennifer E Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Geriatric Research, Education, and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
| | - Jamie L Studts
- Cancer Prevention and Control, University of Colorado Cancer Center, Aurora, CO, United States; Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Robert L Keith
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Portz JD, Graney BA, Bekelman DB. " Made Me Realize That Life Is Worth Living": A Qualitative Study of Patient Perceptions of a Primary Palliative Care Intervention. J Palliat Med 2022; 25:28-38. [PMID: 34264752 PMCID: PMC8721497 DOI: 10.1089/jpm.2021.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Primary palliative care is needed to meet the complex needs of patients with serious illness and their families. However, patient perceptions of primary palliative care are not well understood and can inform subsequent primary palliative care interventions and implementation. Objective: Elicit the patient perspective on a primary palliative care intervention, Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA), from patient perspectives. Design: Qualitative study using patient interviews and two methods of triangulation. Setting/Subjects: Between July 2014 and September 2015, we interviewed 45 patients who participated in the intervention in a Veterans Affairs (VA) (primary site), academic, and urban safety-net health system in the United States. Main Measures: Participants were asked about what was most and least helpful, how the intervention affected participants' lives, and what should be changed about the intervention. Data were analyzed using a general inductive approach. To enhance validity of the results, we triangulated the findings from patient interviews, reviews of care coordinator documentation, and interprofessional palliative care providers. Results: The six themes identified that primary care intervention: (1) Cared for My Psychosocial Needs, (2) Encouraged Self-Management, (3) Medication Recommendations Worked, (4) Facilitated Goal Attainment, (5) Team was Beneficial, and (6) Good Visit Timing. Conclusions: Participants experienced benefits from the primary palliative care intervention and attributed these benefits to individualized assessment and support, facilitation of skill building and self-management, and oversight from an interprofessional care team. Future primary palliative care interventions may benefit from targeting these specific patient-valued processes.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Address correspondence to: Jennifer Dickman Portz, PhD, MSW, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Mailstop B180, 12631 East 17th Avenue, Aurora, CO 80045, USA
| | - Bridget A. Graney
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - David B. Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado, USA
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15
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Kavalieratos D, Harinstein ME, Rose B, Lowers J, Hoydich ZP, Bekelman DB, Allen LA, Rollman BL, Ernecoff NC, Moreines LT, Bakitas MA, Arnold RM. Primary palliative care for heart failure provided within ambulatory cardiology: A randomized pilot trial. Heart Lung 2022; 56:125-132. [PMID: 35863099 PMCID: PMC9941979 DOI: 10.1016/j.hrtlng.2022.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/13/2022] [Accepted: 07/06/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Heart failure is characterized by physical and emotional symptoms and decreased quality of life (QoL). Palliative care can reduce burdens of serious illness but often is limited to inpatient or academic settings. OBJECTIVES To develop and test the Primary Education for Nurses in Palliative care-HF (PENPal-HF) intervention, training outpatient cardiology nurses to address symptom burden, patient priorities for care and QoL, and advance care planning as part of quarterly HF visits. METHODS We conducted a pilot randomized clinical trial for adults with NYHA Stage III or IV HF and ≥ 2 hospitalizations in the past 12 months, recruited from a community-based cardiology clinic. Participants were randomized 2:1, PENPal-HF plus usual care versus usual care alone. Primary outcomes were feasibility and acceptability. RESULTS We randomized 30 adults with Stage III HF - 20 to PENPal-HF and 10 to usual care. Most in the intervention group (71%) and in the control group (62%) completed the study through the final outcome assessment in week 56; 5 participants died. Of 20 participants in the intervention, 14 (70%) remained in the study through the end of intervention visits; 11 (55%) completed all visits. Most intervention participants (93.75%) agreed or strongly agreed that they were satisfied with their care, and 87.5% agreed or strongly agreed that all people with HF should receive the intervention. Most intervention group participants (93.75%) reported a perceived improvement in physical symptoms, mood, and/or QoL. CONCLUSIONS This pilot study suggests that nurse-led primary palliative care in outpatient cardiology settings is promising. Research is warranted to determine efficacy and effectiveness.
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Affiliation(s)
| | | | - Beth Rose
- University of Pittsburgh Medical Center.
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16
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Sheffler JL, Schmiege SJ, Sussman J, Bekelman DB. A longitudinal analysis of the relationships between depression, fatigue, and pain in patients with heart failure. Aging Ment Health 2021; 25:2272-2278. [PMID: 33287562 PMCID: PMC8796211 DOI: 10.1080/13607863.2020.1855626] [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: 05/17/2020] [Accepted: 11/21/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Depression, pain, and fatigue are common and bothersome symptoms in heart failure, a serious illness in older adults. Understanding longitudinal pathways among depression, pain, and fatigue in heart failure could inform treatment and improve quality of life. METHODS We completed secondary, longitudinal data analyses of a sample of older adults with heart failure (baseline N = 317). Bootstrapped mediation was used to examine two longitudinal models of pain and depression, with fatigue at 6-months as the mediator. The outcome variables were 12-month pain and depression. RESULTS Depressive symptoms were associated with new onset of pain symptoms; however, this association was mediated by fatigue. Pain was not associated with new depression or fatigue symptoms in this sample. DISCUSSION In patients with heart-failure, worsening pain symptoms appear to be directly related to levels of depression and fatigue. These findings demonstrate that depression and fatigue may be key to reducing pain symptoms in this population.
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Affiliation(s)
- Julia L Sheffler
- Center for Translational Behavioral Science, Florida State University, Tallahassee, FL, USA
| | - Sarah J Schmiege
- Anschutz Medical Campus, University of Colorado, Denver, CO, USA
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17
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Dickman Portz J, Powers JD, Casillas A, Baldwin M, Bekelman DB, Palen TE, Bull S, Kutner JS, Bayliss E. Characteristics of Patients and Proxy Caregivers Using Patient Portals in the Setting of Serious Illness and End of Life. J Palliat Med 2021; 24:1697-1704. [PMID: 34061675 PMCID: PMC9022132 DOI: 10.1089/jpm.2020.0667] [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] [Accepted: 03/29/2021] [Indexed: 11/12/2022] Open
Abstract
Background: There are few studies examining the usage and utility of patient portals among seriously ill and end-of-life populations and their caregivers. Objective: The aim of this study was to describe portal user characteristics among patients and their caregivers (proxy login) at two time points: (1) the 12 months following an electronic medical record flag for serious illness and (2) during the last 12 months of life. Methods: A retrospective cohort analysis of Kaiser Permanente Colorado (KPCO) patients with serious illness, as defined by Kaiser Permanente's prognostic algorithm, and their proxy caregivers was performed for the two time periods. Use was characterized as (1) the discrete number of days the portal was used and (2) the number of days that portal features were accessed. Differences in use by user characteristics were assessed. Results: Patients flagged for serious illness (N = 6129) were 70.4 ± 14.2 years of age, and used the portal on average 50.4 days. Patients (N = 6517) in the last year of life were 76.7 ± 13.7 years of age and used the portal on average 43 days. Caregiver proxy use of the portal was low in both cohorts. Patients who were older, female, non-White, and healthier were less likely to use the portal. Conclusions: In comparison with overall KPCO portal use and recent patient portal studies examining use patterns, patient portal use was high among patients flagged with serious illness and nearing the end of life. However, because use was associated with age, gender, and race, addressing barriers to portal adoption among underserved populations and caregiver proxies is key to better leveraging patient portal systems for palliative and end-of-life care.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado Anschutz Medical, Aurora, Colorado, USA
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - John David Powers
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Megan Baldwin
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - David B. Bekelman
- Division of General Internal Medicine, University of Colorado Anschutz Medical, Aurora, Colorado, USA
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Ted E. Palen
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Jean S. Kutner
- Division of General Internal Medicine, University of Colorado Anschutz Medical, Aurora, Colorado, USA
| | - Elizabeth Bayliss
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
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18
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Deng LR, Masters KS, Schmiege SJ, Hess E, Bekelman DB. Two Factor Structures Possible for the FACIT-Sp in Patients With Heart Failure. J Pain Symptom Manage 2021; 62:1034-1040. [PMID: 34019976 PMCID: PMC8556182 DOI: 10.1016/j.jpainsymman.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 03/29/2021] [Accepted: 05/09/2021] [Indexed: 11/25/2022]
Abstract
CONTEXT The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp) is a 12-item measure of spiritual well-being in chronic illness originally developed in patients with cancer. The overall scale, a two-factor model (meaning/peace, faith), and a three-factor model (meaning, peace, faith) have been proposed for the FACIT-Sp, and consensus on the best factor structure has not been reached. In addition, the factor structure of the FACIT-Sp has not been considered in patients with heart failure. OBJECTIVES To examine the factor structure of the FACIT-Sp in heart failure patients. METHODS A confirmatory factor analysis framework was used to test three competing models on 217 patients with heart failure using data from the CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) trial. The overall scale (single factor), two-factor, and three-factor models were tested using baseline data, then confirmed with 12-month data. Model modifications were made based on empirical inspection of baseline data and replicated using 12-month data. Cronbach's alpha and correlations with measures of quality of life and psychological health were examined. RESULTS All three models had strong factor loadings on all items except the negatively worded items. The two-factor and three-factor models fit reasonably well after modifications, but the single factor did not fit well (1/2/3-factor: RMSEA 0.14/0.09/0.06, CFI 0.85/0.93/0.97, SRMR 0.09/0.05/0.04). Internal consistency was sufficient for all factors. CONCLUSION The two-factor and three-factor models were supported in heart failure patients. The three-factor model demonstrated better statistical fit but was not more interpretable. KEY MESSAGE This study investigated the factor structure of the FACIT-Sp in patients with heart failure. The two-factor and three-factor models were supported, but the single factor model was not. Negatively worded items did not perform well.
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Affiliation(s)
- Lubin R Deng
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System (L.R.D., E.H., D.B.B.), Aurora, Colorado, USA.
| | - Kevin S Masters
- Department of Psychology, University of Colorado Denver (K.S.M.), Denver, Colorado, USA
| | - Sarah J Schmiege
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus (S.J.S.), Aurora, Colorado, USA
| | - Edward Hess
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System (L.R.D., E.H., D.B.B.), Aurora, Colorado, USA
| | - David B Bekelman
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System (L.R.D., E.H., D.B.B.), Aurora, Colorado, USA; Division of General Internal Medicine, University of Colorado School of Medicine (D.B.B.), Aurora, Colorado, USA
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19
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Ahluwalia SC, Bandini JI, Kogan AC, Bekelman DB, Olsen B, Phillips J, Sudore RL. Impact of group visits for older patients with heart failure on advance care planning outcomes: Preliminary data. J Am Geriatr Soc 2021; 69:2908-2915. [PMID: 34077563 PMCID: PMC8497395 DOI: 10.1111/jgs.17283] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [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: 02/23/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Advance care planning (ACP) is critically important for heart failure patients, yet important challenges exist. Group visits can be a helpful way to engage patients and caregivers in identifying values and preferences for future care in a resource-efficient way. We sought to evaluate the impact of group visits for ACP among older adults with heart failure and their caregivers on ACP-related outcomes. METHODS We conducted a mixed-methods pilot study evaluating the impact of an ACP group visit for older adults with heart failure and their caregivers on ACP-related outcomes including readiness and self-efficacy. The evidence-based PREPARE for Your Care video-based intervention was used to guide the group visits. Twenty patients and 10 caregivers attended one of the five 90-min group visits led by a trained facilitator. Group visit participants completed pre-, post-, and 1-month follow-up surveys using validated 5-point ACP readiness and self-efficacy scales. Qualitative feedback obtained within 3 days of a group visit was analyzed using a directed content analysis. RESULTS Patient participants had a median age of 78 years. Approximately half were female while caregiver participants were mostly female. Participants were predominantly white. Patient readiness scores improved significantly pre-to-post (+0.53; p = 0.002) but was not sustained at 1-month follow-up. Patient and caregiver self-efficacy showed some improvement pre-to-post but was also not sustained at follow-up. Interviews revealed positive impacts of group visits across the three themes: encouraging reviewing or revisiting prior ACP activities, motivating patients to take direct steps towards ACP, and serving as a "wake-up" call to action. CONCLUSIONS Disease-focused group visits may have a short-term effect on ACP outcomes but ongoing touchpoints are likely necessary to sustain ACP over time. The results highlight a need for follow-up ACP conversations after a single group visit. Timing for follow-ups and the ideal person to follow-up ACP conversations needs to be explored.
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Affiliation(s)
- Sangeeta C. Ahluwalia
- RAND Corporation, Santa Monica, CA
- UCLA Fielding School of Public Health, Los Angeles, CA
| | | | - Alexis Coulourides Kogan
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
| | - David B. Bekelman
- Department of Medicine, Eastern Colorado VA HCS and Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus
| | - Bonnie Olsen
- Keck School of Medicine of USC, University of Southern California, Dept. of Family Medicine and Geriatrics, Alhambra, CA
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20
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Ma JE, Haverfield M, Lorenz KA, Bekelman DB, Brown-Johnson C, Lo N, Foglia MB, Lowery JS, Walling AM, Giannitrapani KF. Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach. Palliat Med 2021; 35:1542-1552. [PMID: 34080488 DOI: 10.1177/02692163211020473] [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] [Indexed: 12/16/2022]
Abstract
BACKGROUND The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations. AIM Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative. DESIGN A qualitative thematic analysis of semi-structured interviews. SETTING/PARTICIPANTS Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers. RESULTS Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers. CONCLUSIONS Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.
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Affiliation(s)
- Jessica E Ma
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health System, Durham, NC, USA
| | - Marie Haverfield
- Department of Communication Studies, San José State University, San José, CA, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, CO, USA.,Center of Innovation for Veteran-Centered and Value Driven Care and Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Natalie Lo
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Mary Beth Foglia
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, USA.,National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA
| | - Jill S Lowery
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Anne M Walling
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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21
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Deng LR, Masters KS, Schmiege SJ, Hess E, Bekelman DB. Factor Structure of Functional Assessment of Chronic Illness Therapy: Spiritual Well-Being Scale in Patients with Heart Failure Depends on Method Used. J Palliat Med 2021; 24:807-808. [PMID: 34061665 DOI: 10.1089/jpm.2021.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lubin R Deng
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Kevin S Masters
- Department of Psychology, University of Colorado Denver, Denver, Colorado, USA
| | - Sarah J Schmiege
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edward Hess
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - David B Bekelman
- Denver/Seattle Center of Innovation, Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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22
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Schenker Y, Ellington L, Bell L, Kross EK, Rosenberg AR, Kutner JS, Bickel KE, Ritchie C, Kavalieratos D, Bekelman DB, Mooney KB, Fischer SM. The National Postdoctoral Palliative Care Research Training Collaborative: History, Activities, Challenges, and Future Goals. J Palliat Med 2021; 24:545-553. [PMID: 32955969 PMCID: PMC8182655 DOI: 10.1089/jpm.2020.0411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Palliative care-related postdoctoral training opportunities are critical to increase the quantity and quality of palliative care research. Objective: To describe the history, activities, challenges, and future goals of the National Postdoctoral Palliative Care Research Training Collaborative. Design: National web-based survey of participating program leaders. Measurements: Information about participating programs, trainees, challenges faced, and future goals. Results: Nine participating programs at academic institutions across the United States focus on diverse aspects of palliative care research. The majority of 73 current and former fellows are female (75%) and white (84%). In total, 38% of fellows (n = 28) have MD backgrounds, of whom less than half (n = 12) completed hospice and palliative medicine fellowships. An additional 38% of fellows (n = 28) have nursing PhD backgrounds and 23% (n = 17) have other diverse types of PhD backgrounds. Key challenges relate to recruiting diverse trainees, fostering a shared identity, effectively advocating for trainees, and securing funding. Future goals include expanding efforts to engage clinician and nonclinician scientists, fostering the pipeline of palliative care researchers through expanded mentorship of predoctoral and clinical trainees, increasing the number of postdoctoral palliative care training programs, and expanding funding support for career development grants. Conclusion: The National Postdoctoral Palliative Care Research Training Collaborative fills an important role in creating a community for palliative care research trainees and developing strategies to address shared challenges.
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Affiliation(s)
- Yael Schenker
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Lindsay Bell
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Abby R. Rosenberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Palliative Care and Resilience Laboratory, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jean S. Kutner
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kathleen E. Bickel
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Medicine, Veterans Affairs Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Christine Ritchie
- Center for Palliative Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - David B. Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Medicine, Veterans Affairs Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | | | - Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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23
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Brown-Johnson C, Haverfield MC, Giannitrapani KF, Lo N, Lowery JS, Foglia MB, Walling AM, Bekelman DB, Shreve ST, Lehmann LS, Lorenz KA. Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative. J Pain Symptom Manage 2021; 61:262-269. [PMID: 32781166 DOI: 10.1016/j.jpainsymman.2020.07.040] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 11/29/2022]
Abstract
CONTEXT The Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017. OBJECTIVES Our goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls. METHODS We conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation. RESULTS Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships. CONCLUSION Learning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.
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Affiliation(s)
- Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.
| | - Marie C Haverfield
- Department of Communication Studies, San Jose State University, San Jose, California, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Natalie Lo
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Jill S Lowery
- National Center for Ethics in Health Care, Department of Veterans Affairs, Washington, DC, USA; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Mary Beth Foglia
- National Center for Ethics in Health Care, Department of Veterans Affairs, Washington, DC, USA; University of Washington School of Medicine, Seattle, Washington, USA
| | - Anne M Walling
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, California, USA; Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
| | - David B Bekelman
- Center of Innovation for Veteran-Centered and Value Driven Care, Rocky Mountain Regional VA Medical Center, Colorado, USA; University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado, USA
| | - Scott T Shreve
- Palliative and Hospice Care Program, Department of Veteran Affairs, Washington, DC, USA
| | - Lisa Soleymani Lehmann
- VA New England Healthcare System, Bedford, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
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24
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Ha DM, Prochazka AV, Bekelman DB, Stevens-Lapsley JE, Chan ED, Keith RL. Association of Leisure-Time Physical Activity With Health-Related Quality of Life Among US Lung Cancer Survivors. JNCI Cancer Spectr 2021; 5:pkaa118. [PMID: 35075444 PMCID: PMC7853156 DOI: 10.1093/jncics/pkaa118] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/27/2020] [Accepted: 11/16/2020] [Indexed: 02/02/2024] Open
Abstract
Background Physical activity and exercise improve function, symptom control, and health-related quality of life (QoL) for many cancer survivors; however, the evidence is limited and inconsistent in lung cancer. We examined the relationship between leisure-time physical activity (LTPA) and health-related QoL in a national sample of US lung cancer survivors. Methods We conducted a cross-sectional study using the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. We defined LTPA as a self-report of engaging in any physical activity or exercise such as running, calisthenics, golf, gardening, or walking for exercise in the past 30 days, health-related QoL as the number of days of having poor physical or mental health in the past 30 days, and general health status. We analyzed using multivariable logistic regressions with 95% confidence intervals (CIs). Results Among 614 lung cancer survivors, 316 (51.5%) reported engaging in LTPA. The counts (and proportions) of participants who engaged in LTPA vs no LTPA were, respectively, 135 (42.7%) vs 63 (21.1%) for 0 days of poor physical health, 222 (70.3%) vs 174 (58.4%) for 0 days of poor mental health, and 158 (50.0%) vs 77 (25.8%) for good to excellent general health. In multivariable analyses, participating in LTPA was associated with odds ratios of 2.64 (95% CI = 1.76 to 3.96) and 1.43 (95% CI = 0.97 to 2.10) for 0 days of poor physical and mental health, respectively, and 2.61 (95% CI = 1.74 to 3.91) for good to excellent general health. Conclusions Participating in LTPA was associated with improved health-related QoL. Interventions to promote LTPA and/or exercise-based rehabilitation may improve QoL among lung cancer survivors.
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Affiliation(s)
- Duc M Ha
- Section of Pulmonary and Critical Care, Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Allan V Prochazka
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Jennifer E Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Geriatric Research, Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Edward D Chan
- Section of Pulmonary and Critical Care, Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Medicine and Academic Affairs, National Jewish Health, Denver, CO, USA
| | - Robert L Keith
- Section of Pulmonary and Critical Care, Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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25
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Portz JD, Powers JD, Baldwin M, Bekelman DB, Casillas A, Kutner JS, Bayliss E. Patient Portal Use Near the End-of-Life. J Gen Intern Med 2021:10.1007/s11606-020-06333-9. [PMID: 33506403 DOI: 10.1007/s11606-020-06333-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/18/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
| | - J D Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M Baldwin
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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26
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Portz JD, Ford KL, Doyon K, Bekelman DB, Boxer RS, Kutner JS, Czaja S, Bull S. Using Grounded Theory to Inform the Human-Centered Design of Digital Health in Geriatric Palliative Care. J Pain Symptom Manage 2020; 60:1181-1192.e1. [PMID: 32615298 PMCID: PMC7323666 DOI: 10.1016/j.jpainsymman.2020.06.027] [Citation(s) in RCA: 10] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 01/11/2023]
Abstract
CONTEXT Digital health offers innovative mechanisms to engage in palliative care, yet digital systems are typically designed for individual users, rather than integrating the patient's caregiving "social convoy" (i.e., family members, friends, neighbors, formal caregiving supports) to maximize benefit. As older adults with serious illness increasingly rely on the support of others, there is a need to foster effective integration of the social convoy in digitally supported palliative care. OBJECTIVES Conduct a qualitative study examining patient, social convoy, and health care provider perspectives on digital health for palliative care to inform the design of future digital solutions for older adults with serious illness and their social convoy. METHODS Grounded theory approach using semi-structured interviews (N = 81) with interprofessional health care providers, older adults with serious illness, and their social convoy participants at home, clinic, or Zoom. Interviews were conducted using question guides relevant to the participant group and audio-recorded for verbatim transcription. Two coders lead the inductive analysis using open and axial coding. RESULTS Thematic results aligned with the human-centered design framework, which is a participatory approach to the design process that incorporates multiple user stakeholders to develop health solutions. The human-centered design process and corresponding theme included the following: 1) Empathy: Patient, Caregiver, and Provider Experience reports participants' experience with managing serious illness, caregiving, social support, and technology use. 2) Define: Reactions to Evidence-Based Care Concepts and Barriers illustrates participants' perspectives on the domains of palliative care ranging from symptom management to psychosocial-spiritual care. 3) Ideation: Desired Features reports participant recommendations for designing digital health tools for palliative care domains. CONCLUSION Digital health provides an opportunity to expand the reach of geriatric palliative care interventions. This paper documents human-centered preferences of geriatric palliative care digital health to ensure technologies are relevant and meaningful to health care providers, patients, and the caregiving social convoy.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA; mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Kelsey Lynett Ford
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Katherine Doyon
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA; Department of Medicine, Eastern Colorado Health Care System, Aurora, Colorado, USA; Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Rebecca S Boxer
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sara Czaja
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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27
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Portz JD, Ford KL, Elsbernd K, Knoepke CE, Flint K, Bekelman DB, Boxer RS, Bull S. "I Like the Idea of It…But Probably Wouldn't Use It" - Health Care Provider Perspectives on Heart Failure mHealth: Qualitative Study. JMIR Cardio 2020; 4:e18101. [PMID: 32885785 PMCID: PMC7501581 DOI: 10.2196/18101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/10/2020] [Accepted: 07/13/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Many mobile health (mHealth) technologies exist for patients with heart failure (HF). However, HF mhealth lacks evidence of efficacy, caregiver involvement, and clinically useful real-time data. OBJECTIVE We aim to capture health care providers' perceived value of HF mHealth, particularly for pairing patient-caregiver-generated data with clinical intervention to inform the design of future HF mHealth. METHODS This study is a subanalysis of a larger qualitative study based on interviewing patients with HF, their caregivers, and health care providers. This analysis included interviews with health care providers (N=20), focusing on their perceived usefulness of HF mHealth tools and interventions. RESULTS A total of 5 themes emerged: (1) bio-psychosocial-spiritual monitoring, (2) use of sensors, (3) interoperability, (4) data sharing, and (5) usefulness of patient-reported outcomes in practice. Providers remain interested in mHealth technologies for HF patients and their caregivers. However, providers report being unconvinced of the clinical usefulness of robust real-time patient-reported outcomes. CONCLUSIONS The use of assessments, sensors, and real-time data collection could provide value in patient care. Future research must continually explore how to maximize the utility of mHealth for HF patients, their caregivers, and health care providers.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States.,mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kelsey Lynett Ford
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kira Elsbernd
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Christopher E Knoepke
- Division of Cardiology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States.,Data Science to Patient Value (D2V) Initiative, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States.,Adult & Child Consortium for Outcomes Research & Delivery Science, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States
| | - Kelsey Flint
- Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Aurora, CO, United States
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, United States.,Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Aurora, CO, United States
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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28
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Flint KM, Fairclough DL, Spertus JA, Bekelman DB. Does heart failure-specific health status identify patients with bothersome symptoms, depression, anxiety, and/or poorer spiritual well-being? Eur Heart J Qual Care Clin Outcomes 2020; 5:233-241. [PMID: 30649237 DOI: 10.1093/ehjqcco/qcy061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 12/03/2018] [Accepted: 12/29/2018] [Indexed: 01/06/2023]
Abstract
AIMS Patients with heart failure often have under-recognized symptoms, depression, anxiety, and poorer spiritual well-being ('QoL domains'). Ideally all patients should have heart failure-specific health status and quality of life (QoL) domains routinely evaluated; however, lack of time and resources are limiting in most clinical settings. Therefore, we aimed to evaluate whether heart failure-specific health status was associated with QoL domains and to identify a score warranting further evaluation of QoL domain deficits. METHODS AND RESULTS Participants (N = 314) enrolled in the Collaborative Care to Alleviate Symptoms and Adjust to Illness trial completed measures of heart failure-specific health status [Kansas City Cardiomyopathy Questionnaire, KCCQ (score 0-100, 0 = worst health status)], additional symptoms (Memorial Symptom Assessment Scale), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and spiritual well-being (Facit-Sp) at baseline. Mean ± standard deviation (SD) KCCQ score was 46.9 ± 19.3, mean age was 65.5 ± 11.4, and 79% were male. Prevalence of QoL domain deficits ranged from 11% (nausea) to 47% (depression). Sensitivity/specificity of KCCQ for each QoL domain ranged from 20-40%/80-96% for KCCQ ≤ 25, 61-84%/48-62% for KCCQ ≤ 50, 84-97%/26-40% for KCCQ ≤ 60, and 96-100%/8-13% for KCCQ ≤ 75. Patients with KCCQ ≤ 60 had mean ± SD 4.5 ± 2.5 QoL domain deficits (maximum 12), vs. 1.6 ± 1.6 for KCCQ > 60 (P < 0.001). Similar results were seen for KCCQ ≤25 (6.6 ± 2.4 vs. 3.3 ± 2.4), KCCQ ≤ 50 (4.8 ± 2.6 vs. 2.5 ± 2) and KCCQ ≤ 75 (4.0 ± 2.6 vs. 1.0 ± 1.2) (all P < 00001). CONCLUSION KCCQ ≤ 60 had good sensitivity for each QoL domain deficit and for patients with at least one QoL domain deficit. Screening for QoL domain deficits should target patients with lower KCCQ scores based on a clinic's KCCQ score distribution and clinical resources for addressing QoL domain deficits.
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Affiliation(s)
- Kelsey M Flint
- Rocky Mountain Regional VA Medical Center, Cardiology, Department of Medicine, 1700 North Wheeling Street, Aurora, CO, USA.,Colorado Cardiovascular Outcomes Research Consortium, 13199 E Montview Blvd, Suite 300, Mail Stop F443, Denver, CO, USA
| | - Diane L Fairclough
- Department of Biostatics and Informatics, Colorado School of Public Health, 13199 E Montview Blvd, Suite 339, Aurora, CO, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, 4401 Wornall Rd, Kansas City, MO, USA
| | - David B Bekelman
- Colorado Cardiovascular Outcomes Research Consortium, 13199 E Montview Blvd, Suite 300, Mail Stop F443, Denver, CO, USA.,Rocky Mountain Regional VA Medical Center, Palliative Care, Department of Medicine, 1700 North Wheeling Street, Aurora, CO, USA.,Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado, 12631 E 17th Ave, Anschutz Medical Campus, Aurora, CO, USA
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Portz JD, Lum HD, Bull S, Boxer RS, Bekelman DB, Ford KL, Gleason K, Casillas A, Bayliss EA. Perceptions of Patient Portal Use for Advance Directive Documentation among Older Adults with Multiple Chronic Conditions. J Soc Work End Life Palliat Care 2020; 16:238-249. [PMID: 32482160 PMCID: PMC9205613 DOI: 10.1080/15524256.2020.1771806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patient portals can play an innovative role in facilitating advanced care planning (ACP) and documenting advance directives (ADs) among older adults with multiple chronic conditions. The objective of this qualitative sub-study was to (1) understand older adults' use of an ACP patient portal section and (2) obtain user-design input on AD documentation features. Although some older adults may be reluctant, participants reported likely to use a portal for ADs with proper portal design and support.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Hillary D. Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- VA Eastern Colorado Health Care System, Denver, Colorado
| | - Sheana Bull
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rebecca S. Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - David B. Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- VA Eastern Colorado Health Care System, Denver, Colorado
| | - Kelsey L. Ford
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Department of Family Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
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30
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Hadler RA, Curtis BR, Ikejiani DZ, Bekelman DB, Harinstein M, Bakitas MA, Hess R, Arnold RM, Kavalieratos D. "I'd Have to Basically Be on My Deathbed": Heart Failure Patients' Perceptions of and Preferences for Palliative Care. J Palliat Med 2020; 23:915-921. [PMID: 31916910 DOI: 10.1089/jpm.2019.0451] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: To identify patient perceptions of how and when palliative care (PC) could complement usual heart failure (HF) management. Background: Despite guidelines calling for the integration of PC into the management of HF, PC services remain underutilized by this population. Patient preferences regarding delivery of and triggers for PC are unknown. Setting/subjects: Individuals with New York Heart Association Class II-IV disease were recruited from inpatient and outpatient settings at an academic quaternary care hospital. Measurements: Participants completed semistructured interviews discussing perceptions, knowledge, and preferences regarding PC. They also addressed barriers and facilitators to PC delivery. Two investigators independently analyzed data using template analysis. Results: We interviewed 27 adults with HF (mean age 63, 85% white, 63% male, 30% Class II, 48% Class III, and 22% Class IV). Participants frequently conflated PC with hospice; once corrected, they expressed variable preferences for primary versus specialist services. Proponents of primary PC cited continuity in care, HF-specific expertise, convenience, and cost, whereas advocates for specialist care highlighted expertise in symptom management and caregiver support, reduced time constraints, and a comprehensive approach to care. Triggers for specialist PC focused on late-stage manifestations of disease such as loss of independence and absence of disease-directed therapies. Conclusions: Patients with HF demonstrated variable conceptions of PC and its relevance to their disease management. Although preferences for delivery model were based on a variety of logistical and relational factors, triggers for initiation remained focused on late-stage disease, suggesting that patients with HF may misconceive PC is an option of last resort.
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Affiliation(s)
- Rachel A Hadler
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Brett R Curtis
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dara Z Ikejiani
- Division of Oncology, Department of Medicine, Johns Hopkins School of Medicine, Sibley Memorial Hospital, Washington, DC, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health, Aurora, Colorado, USA
| | - Matthew Harinstein
- Heart and Vascular Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marie A Bakitas
- Center for Palliative and Supportive Care, School of Nursing and Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rachel Hess
- Division of Health System Innovation and Research, Department of Health Sciences, University of Utah Health Hospitals and Clinics, Salt Lake City, Utah, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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31
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Bekelman DB, Fink RM, Sannes T, Kline DM, Borrayo EA, Turvey C, Fischer SM. Puente para cuidar (bridge to caring): A palliative care patient navigator and counseling intervention to improve distress in Latino/as with advanced cancer. Psychooncology 2019; 29:688-695. [DOI: 10.1002/pon.5313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/01/2019] [Accepted: 12/08/2019] [Indexed: 12/17/2022]
Affiliation(s)
- David B. Bekelman
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
- Department of MedicineEastern Colorado Health Care System, VA Aurora Colorado
| | - Regina M. Fink
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
| | - Timothy Sannes
- Division of Psychosocial Oncology and Palliative CareDana Farber Cancer Institute Boston Massachusetts
| | - Danielle M. Kline
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
| | - Evelinn A. Borrayo
- Department of Community and Behavioral Health, Colorado School of Public HealthUniversity of Colorado Denver Colorado
| | - Carolyn Turvey
- Carver College of MedicineUniversity of Iowa Iowa City Iowa
| | - Stacy M. Fischer
- Department of MedicineUniversity of Colorado School of Medicine Aurora Colorado
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Affiliation(s)
- Jennifer D Portz
- 1 Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus , Aurora, Colorado.,2 School of Social Work, College of Health and Human Sciences, Colorado State University , Fort Collins, Colorado
| | | | - David B Bekelman
- 1 Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus , Aurora, Colorado.,4 Department of Veterans Affairs, Eastern Colorado Healthcare System , Denver, Colorado
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Dickman Portz J, Ford K, Bekelman DB, Boxer RS, Kutner JS, Czaja S, Elsbernd K, Bull S. "We're Taking Something So Human and Trying to Digitize": Provider Recommendations for mHealth in Palliative Care. J Palliat Med 2019; 23:240-247. [PMID: 31526220 DOI: 10.1089/jpm.2019.0216] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 01/17/2023] Open
Abstract
Background: Mobile health (mHealth) is a promising tool for improving health outcomes. However, the benefits of using mHealth in palliative care are under studied. Objective: As a first step to designing meaningful palliative care-specific mobile applications, this research explored provider perspectives regarding the utility of mHealth in palliative care. Design: A qualitative phenomenological study with semistructured interviews. Setting/Subjects: Providers from multiple disciplines working in palliative care settings at an academic medical center. Results: Thematic analysis resulted in five provider recommendations regarding the utility and design of palliative care-specific mHealth, including (i) thoughtfulness to language, context, and delivery when assessing palliative care needs; (ii) include tools for prognosis and advance care planning; (iii) tailor health and quality-of-life goals; (iv) emphasize supports for family and caregivers; and (v) consider technology abilities of older adults. Conclusions: Palliative care providers are enthusiastic about the use of mHealth to improve care coordination, facilitate communication, enhance symptom monitoring, and improve patient-family support. However, providers have reservations about mobile functionality and depersonalized assessment and care. Providers stress the utility of mHealth to facilitate palliative care rather than replace important multidisciplinary services.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado.,mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kelsey Ford
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado.,Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado
| | - Rebecca S Boxer
- Insitute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Jean S Kutner
- Division of General Internal Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado
| | - Sara Czaja
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York
| | - Kira Elsbernd
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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34
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Graney BA, Au DH, Barón AE, Cheng A, Combs SA, Glorioso TJ, Paden G, Parsons EC, Rabin BA, Ritzwoller DP, Stonecipher JJ, Turvey C, Welsh CH, Bekelman DB. Advancing Symptom Alleviation with Palliative Treatment (ADAPT) trial to improve quality of life: a study protocol for a randomized clinical trial. Trials 2019; 20:355. [PMID: 31196156 PMCID: PMC6567600 DOI: 10.1186/s13063-019-3417-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/08/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND People living with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD) suffer impaired quality of life due to burdensome symptoms and depression. The Advancing Symptom Alleviation with Palliative Treatment (ADAPT) trial aims to determine the effect of a multidisciplinary, team-based intervention on quality of life in people with these common diseases. METHODS/DESIGN The ADAPT trial is a two-site, patient-level randomized clinical trial that examines the effectiveness of the ADAPT intervention compared to usual care on patient-reported quality of life at 6 months in veterans with CHF, COPD or ILD with poor quality of life and increased risk for hospitalization or death. The ADAPT intervention involves a multidisciplinary team-a registered nurse, social worker, palliative care specialist, and primary care provider (with access to a pulmonologist and cardiologist)-who meet weekly to make recommendations and write orders for consideration by participants' individual primary care providers. The nurse and social worker interact with participants over six visits to identify and manage a primary bothersome symptom and complete a structured psychosocial intervention and advance care planning. The primary outcome is change in patient-reported quality of life at 6 months as measured by the Functional Assessment of Chronic Illness Therapy-General questionnaire. Secondary outcomes at 6 months include change in symptom distress, depression, anxiety, disease-specific quality of life hospitalizations, and advance care planning communication and documentation. Intervention implementation will be assessed using a mixed-methods approach including a qualitative assessment of participants' and intervention personnel experiences and a quantitative assessment of care delivery, resources, and cost. DISCUSSION The ADAPT trial studies an innovative intervention designed to improve quality of life for veterans with common, burdensome illnesses by targeting key underlying factors-symptoms and depression-that impair quality of life but persist despite disease-specific therapies. Leveraging the skills of affiliate health providers with physician supervision will extend the reach of palliative care and improve quality of life for those with advanced disease within routine outpatient care. The hybrid effectiveness/implementation design of the ADAPT trial will shorten the time to broader dissemination if effective and create avenues for future research. TRIAL REGISTRATION ClinicalTrials.gov, NCT02713347 . Registered March 19, 2016.
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Affiliation(s)
- Bridget A Graney
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA. .,University of Colorado Anschutz Medical Campus, Aurora, USA. .,National Jewish Health, Anschutz Medical Campus, 12700 East 19th Avenue, Research 2, 9th Floor, Box C272, Aurora, CO, 80045, USA.
| | - David H Au
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, WA, USA
| | - Anna E Barón
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew Cheng
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, WA, USA.,Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Sara A Combs
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Thomas J Glorioso
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
| | - Grady Paden
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, WA, USA.,Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Elizabeth C Parsons
- Department of Veterans Affairs, Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Borsika A Rabin
- Department of Family Medicine and Public Health, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | | | - Carolyn Turvey
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA.,Center for Access and Delivery Research and Evaluation, Department of Veterans Affairs, Iowa City Health Care System, Iowa City, IA, USA
| | - Carolyn H Welsh
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
| | - David B Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO, USA
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Portz JD, Fruhauf C, Bull S, Boxer RS, Bekelman DB, Casillas A, Gleason K, Bayliss EA. "Call a Teenager… That's What I Do!" - Grandchildren Help Older Adults Use New Technologies: Qualitative Study. JMIR Aging 2019; 2:e13713. [PMID: 31518274 PMCID: PMC6715044 DOI: 10.2196/13713] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/29/2019] [Accepted: 04/13/2019] [Indexed: 11/26/2022] Open
Abstract
Background Although family technical support seems intuitive, there is very little research exploring this topic. Objective The objective of this study was to conduct a subanalysis of data collected from a large-scale qualitative project regarding older adults’ experiences in using health information technology. Specifically, the subanalysis explored older adults’ experiences with technology support from family members to inform strategies for promoting older adults’ engagement with new health technologies. Although the primary analysis of the original study was theoretically driven, this paper reports results from an inductive, open-coding analysis. Methods This is a subanalysis of a major code identified unexpectedly from a qualitative study investigating older adults’ use experience of a widespread health technology, the patient portal. A total of 24 older patients (≥65 years) with multiple chronic conditions (Charlson Comorbidity Index >2) participated in focus groups conducted at the patients’ primary clinic. While conducting the primary theoretically driven analysis, coders utilized an open-coding approach to ensure important ideas not reflected in the theoretical code book were captured. Open coding resulted in 1 code: family support. This subanalysis further categorized family support by who provided tech support, how tech support was offered, and the opinions of older participants about receiving family tech support. Results The participants were not specifically asked about family support, yet themes around family assistance and encouragement for technology emerged from every focus group. Participants repeatedly mentioned that they called their grandchildren and adult children if they needed help with technology. Participants also reported that family members experienced difficulty when teaching technology use. Family members struggled to explain simple technology tasks and were frustrated by the slow teaching process. Conclusions The results suggest that older adults ask their family members, particularly grandchildren, to support them in the use of new technologies. However, family may experience difficulties in providing this support. Older adults will be increasingly expected to use health technologies, and family members may help with tech support. Providers and health systems should consider potential family support and engagement strategies to foster adoption and use among older patients.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado, Aurora, CO, United States.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Christine Fruhauf
- Department of Human Development and Family Studies, College of Health and Human Sciences, Colorado State University, Fort Collins, CO, United States
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - David B Bekelman
- Division of General Internal Medicine, University of Colorado, Aurora, CO, United States.,Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Denver, CO, United States
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
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Affiliation(s)
- David B Bekelman
- Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Denver
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora
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Portz JD, Bayliss EA, Bull S, Boxer RS, Bekelman DB, Gleason K, Czaja S. Using the Technology Acceptance Model to Explore User Experience, Intent to Use, and Use Behavior of a Patient Portal Among Older Adults With Multiple Chronic Conditions: Descriptive Qualitative Study. J Med Internet Res 2019; 21:e11604. [PMID: 30958272 PMCID: PMC6475817 DOI: 10.2196/11604] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/21/2018] [Accepted: 01/23/2019] [Indexed: 01/18/2023] Open
Abstract
Background Patient portals offer modern digital tools for older adults with multiple chronic conditions (MCC) to engage in their health management. However, there are barriers to portal adoption among older adults. Understanding portal user interface and user experience (UI and UX) preferences of older adults with MCC may improve the accessibility, acceptability, and adoption of patient portals. Objective The aim of this study was to use the Technology Acceptance Model (TAM) as a framework for qualitatively describing the UI and UX, intent to use, and use behaviors among older patients with MCC. Methods We carried out a qualitative descriptive study of Kaiser Permanente Colorado’s established patient portal, My Health Manager. Older patients (N=24; mean 78.41 (SD 5.4) years) with MCC participated in focus groups. Stratified random sampling was used to maximize age and experience with the portal among participants. The semistructured focus groups used a combination of discussion and think-aloud strategies. A total of 2 coders led the theoretically driven analysis based on the TAM to determine themes related to use behavior, portal usefulness and ease of use, and intent to use. Results Portal users commonly used email, pharmacy, and lab results sections of the portal. Although, generally, the portal was seen to be easy to use, simple, and quick, challenges related to log-ins, UI design (color and font), and specific features were identified. Such challenges inhibited participants’ intent to use the portal entirely or specific features. Participants indicated that the portal improved patient-provider communication, saved time and money, and provided relevant health information. Participants intended to use features that were beneficial to their health management and easy to use. Conclusions Older adults are interested in using patient portals and are already taking advantage of the features available to them. We have the opportunity to better engage older adults in portal use but need to pay close attention to key considerations promoting usefulness and ease of use.
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Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, United States.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States.,Department of Family Medicine, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Sheana Bull
- mHealth Impact Lab, Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | - Rebecca S Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - David B Bekelman
- Division of General Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, United States.,Department of Medicine, Eastern Colorado Health Care System, Department of Veterans Affairs, Denver, CO, United States
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States
| | - Sara Czaja
- Division of Geriatrics, Weill Cornell Medicine, New York, NY, United States.,Center for Research and Education on Aging and Technology Enhancement, University of Miami, Miami, FL, United States
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Kluger BM, Shattuck J, Berk J, Sebring K, Jones W, Brunetti F, Fairmont I, Bowles DW, Sillau S, Bekelman DB. Defining Palliative Care Needs in Parkinson's Disease. Mov Disord Clin Pract 2019; 6:125-131. [PMID: 30838311 PMCID: PMC6384178 DOI: 10.1002/mdc3.12702] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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: 07/05/2018] [Revised: 09/25/2018] [Accepted: 10/21/2018] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Palliative care addresses the suffering of patients and families affected by progressive illness through the management of medical symptoms, psychosocial issues, and spiritual concerns. Although there is an emerging interest in applying palliative care to Parkinson's disease (PD), potential palliative care needs have not been systematically investigated in PD patients. Our primary objective was to determine the prevalence of clinically significant symptomatic, psychosocial, and spiritual issues in PD and understand their impact on health-related quality of life (HRQOL). Secondary objectives included comparing the level of palliative care needs of PD patients to advanced cancer patients and assessing preferences for advance care planning. METHODS Ninety PD patients and 47 patients with advanced cancer were surveyed regarding potential palliative care needs, including symptom burden, mood, anticipatory grief, and spiritual well-being. PD patients completed additional scales regarding HRQOL, motor symptoms, cognitive impairment, and preferences regarding advance care planning. RESULTS Potential palliative care needs, including high symptom burden and grief, were common in PD patients and contributed to HRQOL even when controlling for depression and motor severity. In all domains investigated, PD patients had similar or higher levels of palliative care needs as patients with advanced cancer. PD patients expressed a desire to complete advance directives early in the disease course and with a physician. CONCLUSIONS Palliative care needs contribute to HRQOL in PD and are of similar severity as cancer patients. This study supports and helps focus efforts to integrate palliative care principles in PD care across the spectrum of the disease.
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Affiliation(s)
- Benzi M. Kluger
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Jo Shattuck
- Center for Brain, Biology, and BehaviorUniversity of NebraskaLincolnNebraskaUSA
| | - Julie Berk
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Kelly Sebring
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Wallace Jones
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Fabian Brunetti
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Isabel Fairmont
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Daniel W. Bowles
- Division of Medical OncologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Stefan Sillau
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - David B. Bekelman
- Division of General Internal MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
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Bekelman DB, Allen LA, McBryde CF, Hattler B, Fairclough DL, Havranek EP, Turvey C, Meek PM. Effect of a Collaborative Care Intervention vs Usual Care on Health Status of Patients With Chronic Heart Failure: The CASA Randomized Clinical Trial. JAMA Intern Med 2018; 178:511-519. [PMID: 29482218 PMCID: PMC5876807 DOI: 10.1001/jamainternmed.2017.8667] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE Many patients with chronic heart failure experience reduced health status despite receiving conventional therapy. OBJECTIVE To determine whether a symptom and psychosocial collaborative care intervention improves heart failure-specific health status, depression, and symptom burden in patients with heart failure. DESIGN, SETTING, AND PARTICIPANTS A single-blind, 2-arm, multisite randomized clinical trial was conducted at Veterans Affairs, academic, and safety-net health systems in Colorado among outpatients with symptomatic heart failure and reduced health status recruited between August 2012 and April 2015. Data from all participants were included regardless of level of participation, using an intent-to-treat approach. INTERVENTIONS Patients were randomized 1:1 to receive the Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) intervention or usual care. The CASA intervention included collaborative symptom care provided by a nurse and psychosocial care provided by a social worker, both of whom worked with the patients' primary care clinicians and were supervised by a study primary care clinician, cardiologist, and palliative care physician. MAIN OUTCOMES AND MEASURES The primary outcome was patient-reported heart failure-specific health status, measured by difference in change scores on the Kansas City Cardiomyopathy Questionnaire (range, 0-100) at 6 months. Secondary outcomes included depression (measured by the 9-item Patient Health Questionnaire), anxiety (measured by the 7-item Generalized Anxiety Disorder Questionnaire), overall symptom distress (measured by the General Symptom Distress Scale), specific symptoms (pain, fatigue, and shortness of breath), number of hospitalizations, and mortality. RESULTS Of 314 patients randomized (157 to intervention arm and 157 to control arm), there were 67 women and 247 men, mean (SD) age was 65.5 (11.4) years, and 178 (56.7%) had reduced ejection fraction. At 6 months, the mean Kansas City Cardiomyopathy Questionnaire score improved 5.5 points in the intervention arm and 2.9 points in the control arm (difference, 2.6; 95% CI, -1.3 to 6.6; P = .19). Among secondary outcomes, depressive symptoms and fatigue improved at 6 months with CASA (effect size of -0.29 [95% CI, -0.53 to -0.04] for depressive symptoms and -0.30 [95% CI, -0.55 to -0.06] for fatigue; P = .02 for both). There were no significant changes in overall symptom distress, pain, shortness of breath, or number of hospitalizations. Mortality at 12 months was similar in both arms (10 patients died receiving CASA, and 13 patients died receiving usual care; P = .52). CONCLUSIONS AND RELEVANCE This multisite randomized clinical trial of the CASA intervention did not demonstrate improved heart failure-specific health status. Secondary outcomes of depression and fatigue, both difficult symptoms to treat in heart failure, improved. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01739686.
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Affiliation(s)
- David B Bekelman
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Denver.,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Connor F McBryde
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Denver.,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Brack Hattler
- Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Denver.,Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Diane L Fairclough
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado
| | - Edward P Havranek
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora.,Department of Medicine, Denver Health, Denver, Colorado
| | | | - Paula M Meek
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora
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Hooker SA, Ross K, Masters KS, Park CL, Hale AE, Allen LA, Bekelman DB. Denver Spirited Heart: Mixed-Methods Pilot Study of a Psychospiritual Intervention for Heart Failure Patients. J Cardiovasc Nurs 2018; 32:226-235. [PMID: 27076391 PMCID: PMC5061581 DOI: 10.1097/jcn.0000000000000337] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Increased spiritual well-being is related to quality of life (QOL) in patients with heart failure (HF). However, consistent and deliberate integration of spirituality into HF patient care has received limited attention. OBJECTIVE The aim of this study was to evaluate the feasibility, acceptability, and preliminary evidence regarding the efficacy of a resource-sparing psychospiritual intervention to improve QOL in HF patients. METHODS A 12-week mail-based intervention addressing spirituality, stress, coping, and adjusting to illness was developed and tested using a mixed-methods, 1-group pretest-posttest pilot study design. A convenience sample of patients with HF completed prestudy and poststudy questionnaires, including the Kansas City Cardiomyopathy Questionnaire, Patient Health Questionnaire, Meaning in Life Questionnaire, and Functional Assessment of Chronic Illness Therapy-Spiritual. Research staff conducted semistructured interviews with program completers. Interviews were coded and analyzed using conventional content analysis. RESULTS Participants (N = 33; 82% male; mean age, 61 years) completed 87% of baseline data collection, an average of 9 intervention modules, and 55% of poststudy questionnaires. Participants rated all the modules as at least moderately helpful, and qualitative themes suggested that patients found the intervention acceptable and beneficial. Most participants believed spirituality should continue to be included, although they disagreed on the extent to which religion should remain. Participants who completed the intervention reported evidence suggesting increased QOL (Kansas City Cardiomyopathy Questionnaire; effect size [ES], 0.53), decreased depressive symptoms (Patient Health Questionnaire-9; ES, 0.62), and less searching for meaning (Meaning in Life Questionnaire; ES, 0.52). CONCLUSIONS Results indicate that a module-based program integrating spirituality and psychosocial coping strategies was feasible and acceptable and may improve QOL. This preliminary study suggests that clinicians be open to issues of spirituality as they may relate to QOL in patients with HF. Future research will test a revised intervention.
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Affiliation(s)
- Stephanie A Hooker
- Stephanie A. Hooker, MS, MPH PhD Candidate, Department of Psychology, University of Colorado Denver and Veterans Affairs Eastern Colorado Healthcare System, Denver, Colorado. Kaile Ross, MA PhD Candidate, Department of Psychology, University of Colorado Denver. Kevin S. Masters, PhD Professor and Program Director, Department of Psychology, University of Colorado Denver. Crystal L. Park, PhD Professor, Department of Psychology, University of Connecticut, Storrs. Amy E. Hale, PhD Postdoctoral Fellow, University of Connecticut Health Center, Farmington. Larry A. Allen, MD, MHS Associate Professor of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora. David B. Bekelman, MD, MPH Associate Professor of Medicine and Nursing, Veterans Affairs Eastern Colorado Healthcare System and University of Colorado School of Medicine, Aurora
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Bekelman DB, Johnson-Koenke R, Bowles DW, Fischer SM. Improving Early Palliative Care with a Scalable, Stepped Peer Navigator and Social Work Intervention: A Single-Arm Clinical Trial. J Palliat Med 2018; 21:1011-1016. [PMID: 29461908 DOI: 10.1089/jpm.2017.0424] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with cancer could benefit from early primary (i.e., basic) palliative care. Scalable models of care delivery are needed. OBJECTIVE Examine the feasibility of a stepped peer navigator and social work intervention developed to improve palliative care outcomes. DESIGN Single-arm prospective clinical trial. The peer navigator educated patients to advocate for pain and symptom management with their healthcare providers, motivated patients to pursue advance care planning, and discussed the role of hospice. The social worker saw patients with persistent psychosocial distress. SETTING/SUBJECTS Patients with advanced cancer at a VA Medical Center not currently in palliative care or hospice whose oncologist would not be surprised if the patient died in the subsequent year. MEASUREMENTS Participation and retention rates, patient-reported symptoms and quality of life, advance directive documentation, patient satisfaction survey, and semistructured interviews. RESULTS The participation rate was 38% (17/45), and 35% (7/17) completed final survey measures. Patients had stage IV (81%) and primarily genitourinary (47%) and lung (24%) malignancies. Median Eastern Cooperative Oncology Group performance status was 0. Patient-reported surveys indicated low distress (mean scores: Functional Assessment of Cancer Therapy-General, 75.3 [standard deviation {SD} 17.6]; Edmonton Symptom Assessment Scale symptom scores ranged from 1.6 to 3.8; Patient Health Questionnaire-9, 5.7 [SD 5.2]; and Generalized Anxiety Disorder-7, 2.8 [SD 4.1]). Of those who had not completed advance directives at baseline (n = 11, 65%), five completed them by the end of study (5/11, 45%). Patients who completed satisfaction surveys (n = 7) and interviews (n = 4) provided mixed reviews of the intervention. CONCLUSIONS At a single site, a stepped peer navigator and social work palliative care study had several challenges to feasibility, including low patient-reported distress and loss to follow-up.
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Affiliation(s)
- David B Bekelman
- 1 Department of Medicine, Veterans Affairs Eastern Colorado Health Care System , Denver, Colorado.,2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | - Rachel Johnson-Koenke
- 1 Department of Medicine, Veterans Affairs Eastern Colorado Health Care System , Denver, Colorado
| | - Daniel W Bowles
- 1 Department of Medicine, Veterans Affairs Eastern Colorado Health Care System , Denver, Colorado.,2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | - Stacy M Fischer
- 2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
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Kavalieratos D, Gelfman LP, Tycon LE, Riegel B, Bekelman DB, Ikejiani DZ, Goldstein N, Kimmel SE, Bakitas MA, Arnold RM. Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities. J Am Coll Cardiol 2017; 70:1919-1930. [PMID: 28982506 PMCID: PMC5731659 DOI: 10.1016/j.jacc.2017.08.036] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [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: 06/14/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 12/25/2022]
Abstract
Patients with heart failure (HF) and their families experience stress and suffering from a variety of sources over the course of the HF experience. Palliative care is an interdisciplinary service and an overall approach to care that improves quality of life and alleviates suffering for those living with serious illness, regardless of prognosis. In this review, we synthesize the evidence from randomized clinical trials of palliative care interventions in HF. While the evidence base for palliative care in HF is promising, it is still in its infancy and requires additional high-quality, methodologically sound studies to clearly elucidate the role of palliative care for patients and families living with the burdens of HF. Yet, an increase in attention to primary palliative care (e.g., basic physical and emotional symptom management, advance care planning), provided by primary care and cardiology clinicians, may be a vehicle to address unmet palliative needs earlier and throughout the illness course.
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Affiliation(s)
- Dio Kavalieratos
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Geriatric Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Laura E Tycon
- University of Pittsburgh Medical Center Palliative and Supportive Institute, Pittsburgh, Pennsylvania
| | - Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David B Bekelman
- Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
| | - Dara Z Ikejiani
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephen E Kimmel
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert M Arnold
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
BACKGROUND Heart failure is a progressive condition characterized by frequent hospitalizations for exacerbated symptoms. Informal family caregivers may help patients improve self-care, which may in turn reduce hospitalizations. However, little is known about how mutuality, defined as the quality of the patient-caregiver relationship, and caregiver burden affect self-care. OBJECTIVE This study examines the associations among mutuality, patient self-care confidence (beliefs in abilities to engage in self-care behaviors) and maintenance (behaviors such as medication adherence, activity, and low salt intake), caregiver confidence in and maintenance of patient care, and caregiver perceived burden. METHODS This study used cross-sectional baseline data from a multi-site randomized clinical trial of a symptom and psychosocial care intervention. Patient-caregiver dyads ( N=99) completed self-report surveys of mutuality and self-care confidence and maintenance, and caregivers completed a measure of caregiver burden. Path analysis, with actor (effects within a person) partner (effects across the dyad) interdependence model paths and regression models were used to examine the associations among mutuality, caregiver burden, and self-care. RESULTS The majority of patients ( M age=66, 21% female) and caregivers ( M age=57, 81% female) were spouses (60%). The path model demonstrated significant actor effects; patients and caregivers with better mutuality were more confident in patient self-care ( p<.05). Partner effects were not significant. Regression models indicated that caregivers with greater mutuality reported less perceived burden ( p<.01). CONCLUSIONS Mutuality in patient-caregiver dyads is associated with patient self-care and caregiver burden and may be an important intervention target to improve self-care and reduce hospitalizations.
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Affiliation(s)
- Stephanie A Hooker
- 1 Department of Psychology, University of Colorado Denver, USA.,2 Department of Family Medicine and Community Health, University of Minnesota, USA
| | - Sarah J Schmiege
- 3 Department of Biostatistics and Informatics, Colorado School of Public Health at the Anschutz Medical Campus, University of Colorado Denver, USA
| | - Ranak B Trivedi
- 4 Center for Innovation to Implementation, VA Palo Alto Health Care System, Department of Psychiatry and Behavioral Sciences, Stanford University, USA
| | - Nicole R Amoyal
- 5 Division of General Internal Medicine, University of Colorado School of Medicine, USA
| | - David B Bekelman
- 5 Division of General Internal Medicine, University of Colorado School of Medicine, USA.,6 Department of Veterans Affairs, Eastern Colorado Health Care System, USA
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Bekelman DB, Johnson-Koenke R, Ahluwalia SC, Walling AM, Peterson J, Sudore RL. Development and Feasibility of a Structured Goals of Care Communication Guide. J Palliat Med 2017; 20:1004-1012. [PMID: 28422561 DOI: 10.1089/jpm.2016.0383] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 10/19/2022] Open
Abstract
BACKGROUND Discussing goals of care and advance care planning is beneficial, yet how to best integrate goals of care communication into clinical care remains unclear. OBJECTIVE To develop and determine the feasibility of a structured goals of care communication guide for nurses and social workers. DESIGN/SETTING/SUBJECTS Developmental study with providers in an academic and Veterans Affairs (VA) health system (n = 42) and subsequent pilot testing with patients with chronic obstructive pulmonary disease or heart failure (n = 15) and informal caregivers (n = 4) in a VA health system. During pilot testing, the communication guide was administered, followed by semistructured, open-ended questions about the content and process of communication. Changes to the guide were made iteratively, and subsequent piloting occurred until no additional changes emerged. MEASUREMENTS Provider and patient feedback to the communication guide. RESULTS Iterative input resulted in the goals of care communication guide. The guide included questions to elicit patient understanding of and attitudes toward the future of illness, clarify values and goals, identify end-of-life preferences, and agree on a follow-up plan. Revisions to guide content and phrasing continued during development and pilot testing. In pilot testing, patients validated the importance of the topic; none said the goals of care discussion should not be conducted. Patients and informal caregivers liked the final guide length (∼30 minutes), felt it flowed well, and was clear. CONCLUSIONS In this developmental and pilot study, a structured goals of care communication guide was iteratively designed, implemented by nurses and social workers, and was feasible based on administration time and acceptability by patients and providers.
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Affiliation(s)
- David B Bekelman
- 1 Veterans Affairs Eastern Colorado Health Care System , Denver, Colorado.,2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | | | - Sangeeta C Ahluwalia
- 3 RAND Corporation , Santa Monica, California.,4 Department of Health Policy and Management, UCLA Fielding School of Public Health , Los Angeles, California
| | - Anne M Walling
- 3 RAND Corporation , Santa Monica, California.,5 Veterans Affairs Greater Los Angeles Healthcare System , Los Angeles, California.,6 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California at Los Angeles , Los Angeles, California
| | - Jamie Peterson
- 1 Veterans Affairs Eastern Colorado Health Care System , Denver, Colorado
| | - Rebecca L Sudore
- 7 Division of Geriatrics, Department of Medicine, University of California , San Francisco, San Francisco, California.,8 San Francisco Veterans Affairs Medical Center , San Francisco, California
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Bekelman DB, Allen LA, Peterson J, Hattler B, Havranek EP, Fairclough DL, McBryde CF, Meek PM. Rationale and study design of a patient-centered intervention to improve health status in chronic heart failure: The Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA) randomized trial. Contemp Clin Trials 2016; 51:1-7. [DOI: 10.1016/j.cct.2016.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/06/2016] [Accepted: 09/11/2016] [Indexed: 02/02/2023]
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Lum HD, Carey EP, Fairclough D, Plomondon ME, Hutt E, Rumsfeld JS, Bekelman DB. Burdensome Physical and Depressive Symptoms Predict Heart Failure-Specific Health Status Over One Year. J Pain Symptom Manage 2016; 51:963-70. [PMID: 26921492 PMCID: PMC5711728 DOI: 10.1016/j.jpainsymman.2015.12.328] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 07/26/2015] [Revised: 12/06/2015] [Accepted: 12/24/2015] [Indexed: 11/29/2022]
Abstract
CONTEXT Heart failure (HF)-specific health status (symptom burden, functional status, and health-related quality of life) is an important patient-reported outcome that is associated with palliative care needs, hospitalizations, and death. OBJECTIVES To identify potentially modifiable patient-reported factors that predict HF-specific health status over one year. METHODS This was a prospective cohort study using data from the Patient-Centered Disease Management trial. Participants were identified using population-based sampling of all patients with an HF diagnosis at four VA Medical Centers. Patients were enrolled with reduced HF-specific health status (i.e., significant HF symptoms, limited functional status, and poor quality of life, defined by a Kansas City Cardiomyopathy Questionnaire [KCCQ] score <60). Patient-reported factors at baseline were chest pain, other noncardiac pain, dry mouth, numbness/tingling, constipation, nausea, cough, dizziness, depressive symptoms (Patient Health Questionnaire-9), and spiritual well-being (validated, single-item measure). Patients reported HF-specific health status (KCCQ) at 3, 6, and 12 months. RESULTS Of 384 U.S. veterans, 42% screened positive for depression and 76% described burdensome physical symptoms at baseline. In bivariate analyses, all patient-reported factors were correlated with KCCQ score over one year. Multivariable mixed-effect modeling showed that baseline chest pain, numbness/tingling, depressive symptoms, and higher comorbidity count predicted HF-specific health status over the following year. CONCLUSION Burdensome physical and depressive symptoms independently predicted subsequent HF-specific health status in patients with symptomatic HF. Whether addressing these aspects of the patient experience can improve health status and well-being in symptomatic HF should be studied further.
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Affiliation(s)
- Hillary D Lum
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; Department of Veterans Affairs, Eastern Colorado Health Care System, Research (151), Denver, Colorado, USA.
| | - Evan P Carey
- Department of Veterans Affairs, Eastern Colorado Health Care System, Research (151), Denver, Colorado, USA
| | - Diane Fairclough
- University of Colorado School of Public Health, Aurora, Colorado, USA
| | | | - Evelyn Hutt
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; Department of Veterans Affairs, Eastern Colorado Health Care System, Research (151), Denver, Colorado, USA
| | - John S Rumsfeld
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; Cardiology (111B), Denver, Colorado, USA
| | - David B Bekelman
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; Department of Veterans Affairs, Eastern Colorado Health Care System, Research (151), Denver, Colorado, USA
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Bekelman DB, Rabin BA, Nowels CT, Sahay A, Heidenreich PA, Fischer SM, Main DS. Barriers and Facilitators to Scaling Up Outpatient Palliative Care. J Palliat Med 2016; 19:456-9. [PMID: 26974489 DOI: 10.1089/jpm.2015.0280] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The Institute of Medicine recommends people with serious advanced illness have access to skilled palliative care. However, the predominant delivery model of nonhospice palliative care is inpatient, consultative care focused on the end of life, with a small specialist palliative care workforce. OBJECTIVE The study objective was to understand organizational factors that could influence the adoption and scale-up of outpatient palliative care in chronic advanced illness, using the example of heart failure. METHODS This was a cross-sectional qualitative study. Participants were 17 health care providers and local, regional, and national health system leaders from the Veterans Health Administration (VHA) who were considering whether and how to adopt and sustain outpatient palliative care. Individual interviews using semistructured questions assessed domains of the Consolidated Framework for Implementation Science. RESULTS Most providers and leaders perceived outpatient palliative care as high priority in the VHA given its patient-centeredness and potential to decrease health care use and costs associated with conditions like heart failure. They also supported a collaborative care team model of outpatient palliative care delivery where a palliative care specialist collaborates with medical nurses and social workers. They reported lack of performance measures/incentives for patient-centered care processes and outcomes as a potential barrier to implementation. Features of outpatient palliative care viewed as important for successful adoption and scale-up included coordination and communication with other providers, ease of integration into existing programs, and evidence of improving quality of care while not substantially increasing overall health care costs. CONCLUSION Incentives such as performance measures and collaboration with local VHA providers and leaders could improve adoption and scale-up of outpatient palliative care.
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Affiliation(s)
- David B Bekelman
- 1 Department of Veterans Affairs, Eastern Colorado Health Care System , Denver, Colorado.,2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | - Borsika A Rabin
- 3 Department of Family Medicine and Colorado Health Outcomes Program, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | - Carolyn T Nowels
- 2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | - Anju Sahay
- 4 VA Palo Alto Health Care System , Palo Alto, California
| | | | - Stacy M Fischer
- 2 Department of Medicine, University of Colorado School of Medicine , Anschutz Medical Campus, Aurora, Colorado
| | - Deborah S Main
- 5 Department of Health and Behavioral Sciences, University of Colorado , Denver, Colorado
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Hoth KF, Wamboldt FS, Ford DW, Sandhaus RA, Strange C, Bekelman DB, Holm KE. The social environment and illness uncertainty in chronic obstructive pulmonary disease. Int J Behav Med 2015; 22:223-32. [PMID: 25008041 DOI: 10.1007/s12529-014-9423-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Illness uncertainty is associated with worse outcomes in patients with chronic health conditions. Research on social factors associated with uncertainty has focused on the beneficial role of social support. The goal of this study was to develop a more nuanced understanding of the social factors that are associated with uncertainty. METHODS Four hundred sixty-two individuals with alpha-1 antitrypsin deficiency (AATD)-associated chronic obstructive pulmonary disease (COPD) completed a mailed questionnaire. Measures of the social environment included general family functioning, perceived criticism from family members, whether the participant had family members with AATD or COPD, and participation in support groups. Uncertainty was measured using the Mishel Uncertainty in Illness Scale including subscales for ambiguity (uncertainty about physical cues and symptoms) and complexity (uncertainty about treatment and the medical system). Hierarchical regression was used to identify social correlates of ambiguity and complexity while adjusting for demographic and medical characteristics and psychological distress. RESULTS Perceived criticism was associated with more complexity (b = 0.21, SE = 0.09, p = 0.015) and ambiguity (b = 0.40, SE = 0.12, p = 0.001). Having a family member with AATD or COPD was associated with more ambiguity (b = 3.28, SE = 1.00, p = 0.001). Participation in support groups was associated with less ambiguity. Individuals who attended three or more support groups in the prior year reported less ambiguity than individuals who had not attended any (b = -3.31, SE = 1.29, p = 0.010). CONCLUSIONS The social environment is complex and encompasses more than social support. Multiple aspects of the social environment are associated with uncertainty, including perceived criticism, having a family member with a similar illness, and participation in support groups.
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Affiliation(s)
- Karin F Hoth
- Department of Psychiatry, University of Iowa Carver College of Medicine, 200 Hawkins Drive, W278GH, Iowa City, IA, 52242, USA,
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Lum HD, Jones J, Lahoff D, Allen LA, Bekelman DB, Kutner JS, Matlock DD. Unique challenges of hospice for patients with heart failure: A qualitative study of hospice clinicians. Am Heart J 2015; 170:524-30.e3. [PMID: 26385036 PMCID: PMC4575769 DOI: 10.1016/j.ahj.2015.06.019] [Citation(s) in RCA: 9] [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: 04/09/2015] [Accepted: 06/30/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with heart failure have end-of-life care needs that may benefit from hospice care. The goal of this descriptive study was to understand hospice clinicians' perspectives on the unique aspects of caring for patients with heart failure to inform approaches to improving end-of-life care. METHODS This qualitative study explored experiences, observations, and perspectives of hospice clinicians regarding hospice care for patients with heart failure. Thirteen hospice clinicians from a variety of professional disciplines and clinical roles, diverse geographic regions, and varying lengths of time working in hospice participated in semistructured interviews. Through team-based, iterative qualitative analysis, we identified 3 major themes. RESULTS Hospice clinicians identified 3 themes regarding care for patients with heart failure. First, care for patients with heart failure involves clinical complexity and a tailored approach to cardiac medications and advanced cardiac technologies. Second, hospice clinicians describe the difficulty patients with heart failure have in trusting hospice care due to patient optimism, prognostic uncertainty, and reliance on prehospice health care providers. Third, hospice clinicians described opportunities to improve heart failure-specific hospice care, highlighting the desire for collaboration with referring cardiologists. CONCLUSIONS From a hospice clinician perspective, caring for patients with heart failure is unique compared with other hospice populations. This study suggests potential opportunities for hospice clinicians and referring providers who seek to collaborate to improve care for patients with heart failure during the transition to hospice care.
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Affiliation(s)
- Hillary D Lum
- University of Colorado School of Medicine, Aurora, CO; Veterans Affairs Eastern Colorado Health Care System, Denver, CO.
| | | | - Dana Lahoff
- University of Colorado School of Medicine, Aurora, CO
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
| | - David B Bekelman
- University of Colorado School of Medicine, Aurora, CO; Veterans Affairs Eastern Colorado Health Care System, Denver, CO; Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
| | - Jean S Kutner
- University of Colorado School of Medicine, Aurora, CO
| | - Daniel D Matlock
- University of Colorado School of Medicine, Aurora, CO; Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
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Bekelman DB, Plomondon ME, Carey EP, Sullivan MD, Nelson KM, Hattler B, McBryde CF, Lehmann KG, Gianola K, Heidenreich PA, Rumsfeld JS. Primary Results of the Patient-Centered Disease Management (PCDM) for Heart Failure Study: A Randomized Clinical Trial. JAMA Intern Med 2015; 175:725-32. [PMID: 25822284 DOI: 10.1001/jamainternmed.2015.0315] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Heart failure (HF) has a major effect on patients' health status, including their symptom burden, functional status, and health-related quality of life. OBJECTIVE To determine the effectiveness of a collaborative care patient-centered disease management (PCDM) intervention to improve the health status of patients with HF. DESIGN, SETTING, AND PARTICIPANTS The Patient-Centered Disease Management (PCDM) trial was a multisite randomized clinical trial comparing a collaborative care PCDM intervention with usual care in patients with HF. A population-based sample of 392 patients with an HF diagnosis from 4 Veterans Affairs centers who had a Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score of less than 60 (heavy symptom burden and impaired functional status and quality of life) were enrolled between May 2009 and June 2011. INTERVENTIONS The PCDM intervention included collaborative care by a multidisciplinary care team consisting of a nurse coordinator, cardiologist, psychiatrist, and primary care physician; home telemonitoring and patient self-management support; and screening and treatment for comorbid depression. MAIN OUTCOMES AND MEASURES The primary outcome was change in the KCCQ overall summary score at 1 year (a 5-point change is clinically significant). Mortality, hospitalization, and depressive symptoms (Patient Health Questionnaire 9) were secondary outcomes. RESULTS There were no significant differences in baseline characteristics between patients randomized to the PCDM intervention (n=187) vs usual care (n=197); baseline mean KCCQ overall summary scores were 37.9 vs 36.9 (P=.48). There was significant improvement in the KCCQ overall summary scores in both groups after 1 year (mean change, 13.5 points in each group), with no significant difference between groups (P=.97). The intervention was not associated with greater improvement in the KCCQ overall summary scores when the effect over time was estimated using 3-month, 6-month, and 12-month data (P=.74). Among secondary outcomes, there were significantly fewer deaths at 1 year in the intervention arm (8 of 187 [4.3%]) than in the usual care arm (19 of 197 [9.6%]) (P = .04). Among those who screened positive for depression, there was a greater improvement in the Patient Health Questionnaire 9 scores after 1 year in the intervention arm than in the usual care arm (2.1 points lower, P=.01). There was no significant difference in 1-year hospitalization rates between the intervention arm and the usual care arm (29.4% vs 29.9%, P=.87). CONCLUSIONS AND RELEVANCE This multisite randomized trial of a multifaceted HF PCDM intervention did not demonstrate improved patient health status compared with usual care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00461513.
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Affiliation(s)
- David B Bekelman
- Research, Geriatrics, Ambulatory Care, and Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver2Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora3Denver-Seattle Center of Innovatio
| | - Mary E Plomondon
- Research, Geriatrics, Ambulatory Care, and Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver3Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, Colorado
| | - Evan P Carey
- Research, Geriatrics, Ambulatory Care, and Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver3Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, Colorado
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Karin M Nelson
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Denver, Colorado5Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Brack Hattler
- Research, Geriatrics, Ambulatory Care, and Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver2Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora
| | - Connor F McBryde
- Research, Geriatrics, Ambulatory Care, and Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver2Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora
| | - Kenneth G Lehmann
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington6Department of Medicine, University of Washington, Seattle
| | | | - Paul A Heidenreich
- Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - John S Rumsfeld
- Research, Geriatrics, Ambulatory Care, and Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver2Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora3Denver-Seattle Center of Innovatio
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