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Code Status Transitions in Patients with High-Risk Acute Myeloid Leukemia. Blood Adv 2022; 6:4208-4215. [PMID: 35537113 PMCID: PMC9327548 DOI: 10.1182/bloodadvances.2022007009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/07/2022] [Indexed: 11/20/2022] Open
Abstract
Patients with AML often undergo code status transitions near the end of life; median time from last code status change to death was 2 days. Patients participated in only 60.5% of final code status transitions, highlighting a need for earlier conversations to improve involvement.
Patients with high-risk acute myeloid leukemia (AML) often experience intensive medical care at the end of life (EOL), including high rates of hospitalizations and intensive care unit (ICU) admissions. Despite this, studies examining code status transitions are lacking. We conducted a mixed-methods study of 200 patients with high-risk AML enrolled in supportive care studies at Massachusetts General Hospital between 2014 and 2021. We defined high-risk AML as relapsed/refractory or diagnosis at age ≥60. We used a consensus-driven medical record review to characterize code status transitions. At diagnosis, 86.0% (172/200) of patients were “full code” (38.5% presumed, 47.5% confirmed) and 8.5% had restrictions on life-sustaining therapies. Overall, 57.0% of patients experienced a transition during the study period. The median time from the last transition to death was 2 days (range, 0-350). Most final transitions (71.1%) were to comfort measures near EOL; only 60.5% of patients participated in these last transitions. We identified 3 conversation types leading to transitions: informative conversations focusing on futility after clinical deterioration (51.0%), anticipatory conversations at the time of acute deterioration (32.2%), and preemptive conversations (15.6%) before deterioration. Younger age (B = 0.04; P = .002) and informative conversations (B = −2.79; P < .001) were associated with shorter time from last transition to death. Over two-thirds of patients were “presumed full code” at diagnosis of high-risk AML, and most experienced code status transitions focused on the futility of continuing life-sustaining therapies near EOL. These results suggest that goals-of-care discussions occur late in the illness course for patients with AML and warrant interventions to increase earlier discussions regarding EOL preferences.
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Meyers DJ, Rivera-Hernandez M, Kim D, Keohane LM, Mor V, Trivedi AN. Comparing the care experiences of Medicare Advantage beneficiaries with and without Alzheimer's disease and related dementias. J Am Geriatr Soc 2022; 70:2344-2353. [PMID: 35484976 DOI: 10.1111/jgs.17817] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/04/2022] [Accepted: 03/30/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The Medicare Advantage (MA) program is rapidly growing. Limited evidence exists about the care experiences of MA beneficiaries with Alzheimer's Disease and Related Dementia (ADRD). Our objective was to compare care experiences for MA beneficiaries with and without ADRD. METHODS We examined MA beneficiaries who completed the Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) and used inpatient, nursing home, or home health services in the past 3 years. We classified beneficiaries with ADRD using the presence of diagnosis codes in hospitals, nursing homes, and home health records. Our key measures included overall ratings of care and health plan, and indices of receiving timely care, care coordination, receiving needed care, and customer service. We compared differences between beneficiaries with and without ADRD using regression analysis adjusting for demographic, health, and plan characteristics, and stratifying by proxy response status. RESULTS Among beneficiaries sampled by CAHPS, 22.2% with ADRD completed the survey compared to 38.5% without ADRD. Among proxy responses, beneficiaries with ADRD were 4.2 (95% CI: 0.1-8.4) percentage points less likely to report a high score for receiving needed care, and 3.5 percentage points (95% CI: 0.2-6.9) less likely to report a high score for customer service. Among non-proxy responses, those with ADRD were 9.0 (95% CI: 5.5-12.5) percentage points less likely to report a high score for needed care, and 8.5 (95% CI: 5.4-11.5) percentage points less likely to report a high score for customer service. CONCLUSIONS ADRD respondents to the CAHPS were more likely to be excluded from CAHPS performance measures because they did not meet eligibility requirements and rates of non-response were higher. Among responders with or without a proxy, MA enrollees with an ADRD diagnosis reported worse care experiences in receiving needed care and in customer service than those without an ADRD diagnosis.
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Affiliation(s)
- David J Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Daeho Kim
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Laura M Keohane
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Amal N Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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Johnston B, Stevens E. Exploring the Dilemma of Ethical Issues Using the Lens of Seedhouse Can Help Oncology Nurses to Gain a Different Perspective on Caring for Older Adults with Cancer. Semin Oncol Nurs 2021; 37:151231. [PMID: 34753643 DOI: 10.1016/j.soncn.2021.151231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To explore ethical issues associated with older adults with cancer and the people who matter to them. DATA SOURCES A scoping review of the literature was conducted to inform the article using CINAHL, Medline, and Google Scholar databases using broad terms, older adults, geriatrics, cancer, and ethics. CONCLUSION Older adults with cancer experience ageism, which stems from a range of uncertainties on best practice in care and treatment. By employing an ethical lens, decision-making by oncology nurses can be aided by creating and promoting autonomy through impeccable communication. Best interests for individual older adults with cancer can also be served by oncology nurses working in a way that serves needs first and acts in the best interests of the person and their family. IMPLICATIONS FOR NURSING PRACTICE The article is of relevance to practicing oncology globally nurses because the framework can be easily used in clinical practice.
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Affiliation(s)
- Bridget Johnston
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland, UK; NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK.
| | - Elaine Stevens
- University of the West of Scotland, Paisley, Scotland, UK
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Roydhouse JK, Cohen ML, Eshoj HR, Corsini N, Yucel E, Rutherford C, Wac K, Berrocal A, Lanzi A, Nowinski C, Roberts N, Kassianos AP, Sebille V, King MT, Mercieca-Bebber R. The use of proxies and proxy-reported measures: a report of the international society for quality of life research (ISOQOL) proxy task force. Qual Life Res 2021; 31:317-327. [PMID: 34254262 DOI: 10.1007/s11136-021-02937-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 12/15/2022]
Abstract
AIMS Proxy reports are often used when patients are unable to self-report. It is unclear how proxy measures are currently in use in adult health care and research settings. We aimed to describe how proxy reports are used in these settings, including the use of measures developed specifically for proxy reporting in adult health populations. METHODS We systematically searched Medline, PsycINFO, PsycTESTS, CINAHL and EMBASE from database inception to February 2018. Search terms included a combination of terms for quality of life and health outcomes, proxy-reporters, and health condition terms. The data extracted included clinical context, the name of the proxy measure(s) used and other descriptive data. We determined whether the measures were developed specifically for proxy use or were existing measures adapted for proxy use. RESULTS The database search identified 17,677 possible articles, from which 14,098 abstracts were reviewed. Of these, 11,763 were excluded and 2335 articles were reviewed in full, with 880 included for data extraction. The most common clinical settings were dementia (30%), geriatrics (15%) and cancer (13%). A majority of articles (51%) were paired studies with proxy and patient responses for the same person on the same measure. Most paired studies (77%) were concordance studies comparing patient and proxy responses on these measures. DISCUSSION Most published research using proxies has focused on proxy-patient concordance. Relatively few measures used in research with proxies were specifically developed for proxy use. Future work is needed to examine the performance of measures specifically developed for proxies. SYSTEMATIC REVIEW REGISTRATION PROSPERO No. CRD42018103179.
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Affiliation(s)
- Jessica K Roydhouse
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, TAS, 7000, Australia.
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Matthew L Cohen
- Department of Communication Sciences and Disorders, University of Delaware, Newark, DE, USA
| | - Henrik R Eshoj
- Department of Hematology, Quality of Life Research Center, Odense University Hospital, Odense, Denmark
| | - Nadia Corsini
- Rosemary Bryant AO Research Centre, University of South Australia, Adelaide, SA, Australia
| | - Emre Yucel
- Amgen, Global Health Economics, Thousand Oaks, CA, USA
- Bristol Myers Squibb, New York, NY, USA
| | - Claudia Rutherford
- Cancer Nursing Research Unit (CNRU), Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
| | - Katarzyna Wac
- Quality of Life Technologies Lab, University of Geneva, Geneva, Switzerland
- Quality of Life Technologies Lab, University of Copenhagen, Copenhagen, Denmark
| | - Allan Berrocal
- Quality of Life Technologies Lab, University of Geneva, Geneva, Switzerland
| | - Alyssa Lanzi
- Department of Communication Sciences and Disorders, University of Delaware, Newark, DE, USA
| | - Cindy Nowinski
- Departments of Medical Social Sciences and Neurology, Northwestern University Feinberg School of Medicine, Evanston, IL, USA
| | - Natasha Roberts
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane, QLD, Australia
| | - Angelos P Kassianos
- Department of Applied Health Research, University College London, London, UK
| | - Veronique Sebille
- SPHERE, University of Nantes, University of Tours, INSERM, Nantes, France
- Department of Methodology and Biostatistics, Nantes University Hospital, Nantes, France
| | - Madeleine T King
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
| | - Rebecca Mercieca-Bebber
- Faculty of Medicine, Sydney Medical School, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
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