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Shilling DM, Manz CR, Strand JJ, Patel MI. Let Us Have the Conversation: Serious Illness Communication in Oncology: Definitions, Barriers, and Successful Approaches. Am Soc Clin Oncol Educ Book 2024; 44:e431352. [PMID: 38788187 DOI: 10.1200/edbk_431352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Serious illness communications are crucial elements of care delivery for patients with cancer. High-quality serious illness communications are composed of open, honest discussions between patients, caregivers, and clinicians regarding patient's communication preferences, expected illness trajectory, prognosis, and risks and benefits of any recommended care. High-quality communication ideally starts at the time of a patients' cancer diagnosis, allows space for and response to patient emotions, elicits patients' values and care preferences, and is iterative and longitudinal. When integrated into cancer care, such communication can result in improved patient experiences with their care, care that matches patients' goals, and reduced care intensity at the end of life. Despite national recommendations for routine integration of these communication into cancer care, a minority of patients with cancer receive such communication. In this chapter, we describe elements of high-quality serious illness communication, patient-, clinician-, institution-, and payer-level barriers, and successful strategies that can routinely integrate such communication into cancer care delivery.
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Affiliation(s)
- Danielle M Shilling
- Division of Community Internal Medicine, Geriatrics & Palliative Care, Mayo Clinic, Rochester, MN
| | - Christopher R Manz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jacob J Strand
- Division of Community Internal Medicine, Geriatrics & Palliative Care, Mayo Clinic, Rochester, MN
| | - Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
- VA Palo Alto Health Care System, Palo Alto, CA
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Abdallah M, Jensen-Battaglia M, Patil A, Digiovanni G, Sanapala C, Watson E, LoCastro M, Wang Y, Mortaz-Hedjri S, Magnuson A, Ramsdale E, McHugh C, Loh KP. Prognostic awareness and willingness to explore prognosis in older adults with cancer. J Geriatr Oncol 2024; 15:101810. [PMID: 38823374 DOI: 10.1016/j.jgo.2024.101810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 05/01/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION Prognostic awareness varies widely among older adults with cancer. Accurate prognostic awareness helps to ensure delivery of care that is aligned with the patient's goals. Understanding factors associated with poor prognostic awareness in older adults with cancer may help identify which patients may need interventions to improve prognostic awareness. In this study, we assessed factors associated with poor prognostic awareness in older adults with cancer. MATERIALS AND METHODS We conducted a cross-sectional analysis of older patients with cancer referred to a geriatric oncology clinic at the University of Rochester. We provided paper questionnaires for patients to complete prior to their clinic assessment. Questionnaires asked patients to estimate their overall life expectancy and the life expectancy of a person of the same age with normal health. Prognostic awareness was considered poor if patients estimated living at least as long as a person of the same age with normal health. We assessed independent demographic and clinical variables (age, sex, race, income, religion, living situation, education, marital status, and cancer type and stage), aging-related factors (comorbidities, cognition, depression, social support, nutritional status, and physical function), and willingness to discuss prognosis. Factors significant at p ≤ 0.15 on bivariate analyses were included in the multivariable logistic regression model. RESULTS We included 257 patients; the mean age was 80 years (standard deviation [SD] 6.8, range 55-97), 37% were female, 71% were White, and 44% were married. Nearly two-thirds of patients (62%) had poor prognostic awareness: 7% estimated they would live longer than and 55% estimated they would live as long as a person of the same age with normal health. Half (49%) were willing to discuss prognosis, 29% were not, and 22% did not answer. On multivariable analysis, factors associated with poor prognostic awareness were older age [one-year increase; adjusted odds ratio (AOR) 1.07, 95% confidence interval (CI) 1.02-1.12], race other than White (AOR 2.35, 95% CI 1.09-5.06), unwillingness to discuss prognosis (AOR 3.33, 95% CI 1.54-7.18), and stage I-III cancer (vs. stage IV, AOR 3.83, 95% CI 1.8-8.17). DISCUSSION In a cohort of older patients with cancer, approximately two-thirds had poor prognostic awareness. Older age, race other than White, stage I-III cancer, and unwillingness to discuss prognosis were associated with higher odds of poor prognostic awareness. Interventions aiming to improve patients' prognostic awareness may need to gauge patients' willingness to discuss prognosis.
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Affiliation(s)
- Maya Abdallah
- Section of Hematology & Medical Oncology, Boston University Chobanian & Avedisian School of Medicine, Boston, USA.
| | | | - Amita Patil
- Center of Infectious Disease and Nursing Innovation, Johns Hopkins University, School of Nursing, Baltimore, MD, USA.
| | - Grace Digiovanni
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, USA.
| | - Chandrika Sanapala
- Burrell College of Osteopathic Medicine, New Mexico State University, Las Cruces, USA.
| | - Erin Watson
- Department of Psychology, Princeton University, Princeton, USA.
| | - Marissa LoCastro
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.
| | - Ying Wang
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA.
| | - Soroush Mortaz-Hedjri
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA; Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, USA.
| | - Allison Magnuson
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, USA.
| | - Erika Ramsdale
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, USA.
| | - Colin McHugh
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, USA.
| | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, USA.
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Daniels S, Franqui-Rios ND, Mothi SS, Gaitskill E, Cantrell K, Kaye EC. Access to legacy-oriented interventions at end of life for pediatric oncology patients: A decedent cohort review. Pediatr Blood Cancer 2024:e31066. [PMID: 38757484 DOI: 10.1002/pbc.31066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/13/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Legacy-oriented interventions have the potential to offer pediatric oncology patients and families comfort at end of life and during bereavement. Certified child life specialists often provide these services, and presently little is known about whether disparities exist in the provision of legacy-oriented interventions. METHODS In this retrospective decedent cohort study, we examined demographic and clinical characteristics from a sample of 678 pediatric oncology patients who died between 2015 and 2019. Bivariate analysis assessed differences between patients who received any versus no legacy-oriented intervention. Uni- and multivariable logistic regression models assessed associations of baseline characteristics and likelihood of receiving legacy-oriented intervention. Further multivariable analysis explored joint effects of significant variables identified in the univariable analysis. RESULTS Fifty-two percent of patients received a legacy-oriented intervention. Older adolescents (≥13 years) were less likely (odds ratio [OR]: 1.73, p = .007) to receive legacy-oriented interventions than younger ones. Patients with home/hospice deaths were also less likely (OR: 19.98, p < .001) to receive interventions compared to patients who passed away at SJCRH locations. Hispanic patients (OR: 1.53, p = .038) and those in palliative care (OR: 10.51, p < .001) were more likely to receive interventions. No significant race association was noted. CONCLUSION All children and adolescents with cancer deserve quality care at end of life, including access to legacy-oriented interventions, yet nearly half of patients in this cohort did not receive these services. By identifying demographic and clinical characteristics associated with decreased odds of receiving legacy-oriented interventions, healthcare professionals can modify end-of-life care processes to improve access. Introducing legacy-oriented interventions early and increasing exposure in community spaces may enhance access to legacy-oriented interventions for pediatric oncology patients.
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Affiliation(s)
- Sarah Daniels
- Child Life Program, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Nelson D Franqui-Rios
- School of Medicine, Ponce Health Sciences University, Ponce, Puerto Rico, Puerto Rico
| | - Suraj S Mothi
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Elizabeth Gaitskill
- Child Life Program, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Kathryn Cantrell
- Department of Human Development, Family Studies, and Counseling, Texas Woman's University, Denton, Texas, USA
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Rodriguez GM, Popat R, Rosas LG, Patel MI. Racial and Ethnic Disparities in Intensity of Care at the End of Life for Patients With Lung Cancer: A 13-Year Population-Based Study. J Clin Oncol 2024; 42:1646-1654. [PMID: 38478794 PMCID: PMC11095875 DOI: 10.1200/jco.23.01045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 05/09/2024] Open
Abstract
PURPOSE Lung cancer is the leading cause of cancer death in the United States. Disparities in lung cancer mortality among racial and ethnic minorities are well documented. Less is known as to whether racial and ethnic minority patients with lung cancer experience higher rates of intensity of care at the end of life (EOL) compared with non-Hispanic White (NHW) patients. METHODS We conducted a population-based analysis of patients 18 years and older with a lung cancer diagnosis who died between 2005 and 2018 using the California Cancer Registry linked to patient discharge data abstracts. Our primary outcome was intensity of care in the last 14 days before death (defined as any hospital admission or emergency department [ED] visit, intensive care unit [ICU] admission, intubation, cardiopulmonary resuscitation [CPR], hemodialysis, and death in an acute care setting). We used multivariable logistic regression models to evaluate associations between race and ethnicity and intensity of EOL care. RESULTS Among 207,429 patients with lung cancer who died from 2005 to 2018, the median age was 74 years (range, 18-107) and 106,821 (51%) were male, 146,872 (70.8%) were NHW, 1,045 (0.5%) were American Indian, 21,697 (10.5%) were Asian Pacific Islander (API), 15,490 (7.5%) were Black, and 22,325 (10.8%) were Hispanic. Compared with NHW patients, in the last 14 days before death, API, Black, and Hispanic patients had greater odds of a hospital admission, an ICU admission, intubation, CPR, and hemodialysis and greater odds of a hospital or ED death. CONCLUSION Compared with NHW patients, API, Black, and Hispanic patients who died with lung cancer experienced higher intensity of EOL care. Future studies should develop approaches to eliminate such racial and ethnic disparities in care delivery at the EOL.
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Affiliation(s)
- Gladys M. Rodriguez
- Department of Medicine, Northwestern University Feinberg School of Medicine and the Comprehensive Cancer Center, Chicago, IL
| | - Rita Popat
- Stanford University School of Medicine, Stanford, CA
- Department of Epidemiology and Population Health, Stanford, CA
| | - Lisa G. Rosas
- Stanford University School of Medicine, Stanford, CA
- Department of Epidemiology and Population Health, Stanford, CA
| | - Manali I. Patel
- Stanford University School of Medicine, Stanford, CA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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Fischer SM, Min SJ, Kline DM, Lester K, Gozansky W, Schifeling C, Himberger J, Lopez J, Fink RM. Patient Navigator Intervention to Improve Palliative Care Outcomes for Hispanic Patients With Serious Noncancer Illness: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:384-393. [PMID: 38345793 PMCID: PMC10862271 DOI: 10.1001/jamainternmed.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024]
Abstract
Importance Disparities persist across the trajectory of serious illness, including at the end of life. Patient navigation has been shown to reduce disparities and improve outcomes for underserved populations. Objective To determine the effectiveness of a lay patient navigator intervention, Apoyo con Cariño, in improving palliative care outcomes among Hispanic patients. Design, Setting, and Participants This was a multicenter randomized clinical trial that took place across academic, nonprofit, safety-net, and community health care systems in urban, rural, and mountain/frontier regions of Colorado from January 2017 to January 2021. Self-identifying Hispanic adults with serious noncancer medical illness and limited prognosis were recruited. Data were collected and analyzed from July 2022 to July 2023. Interventions Participants randomized to the intervention group received 5 home visits from a bilingual, bicultural lay patient navigator; participants randomized to control received care as usual. Both groups received culturally tailored educational materials. Investigators/outcome accessors remained blinded to participant assignment. Main Outcomes and Measures Change in score from baseline to 3 months on the Functional Assessment of Chronic Illness Therapy (FACIT) General quality of life (QOL) scale (primary outcome), Advance Care Planning (ACP) Engagement Survey, Brief Pain Inventory, Edmonton Symptom Assessment Scale, and FACIT Spiritual Well-Being subscale; at 6 months, advance directive (AD) documentation; and at 46 months or death, hospice utilization and length of stay, as well as aggressiveness of care at end of life. Results Of 209 patients enrolled (mean [SD] age, 63.6 [14.3] years; 108 [51.7%] male), 105 patients were randomized to control and 104 patients to the intervention. There were no statistically significant differences in the change in mean (SD) QOL score between the intervention and control groups (5.0 [16.5] vs 4.3 [15.5]; P = .75). Participants in the intervention group, compared with the control group, had statistically significant greater increases in mean (SD) ACP engagement (0.8 [1.3] vs 0.1 [1.4]; P < .001) and were more likely to have a documented AD (62 of 104 [59.6%] vs 28 of 105 [26.9%]; P < .001). There were no statistically significant differences in mean (SD) change in pain intensity score (0-10) between patients in the intervention group compared with control (-0.4 [2.6] vs -0.5 [2.8]; P = .79), nor pain interference (-0.2 [3.7] vs -0.4 [3.7]; P = .71). Patients receiving the intervention were more likely to be referred to hospice compared with patients receiving control (19 of 43 patients [44.2%] vs 7 of 33 patients [21.2%]; P = .04) and less likely to receive aggressive care at end of life (27 of 42 patients [64.3%] vs 28 of 33 patients [84.8%]; P = .046). Conclusion and Relevance In this randomized clinical trial, a culturally tailored patient navigator intervention did not improve QOL for patients. However, the intervention did increase ACP engagement, AD documentation, and hospice utilization in Hispanic persons with serious medical illness. Trial Registration ClinicalTrials.gov Identifier: NCT03181750.
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Affiliation(s)
- Stacy M. Fischer
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | | | | | | | | | | | | | - Joseph Lopez
- University of Colorado Health North, Fort Collins
| | - Regina M. Fink
- University of Colorado School of Medicine, Aurora
- University of Colorado College of Nursing, Aurora
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Izumi S(S, Garcia E, Kualaau A, Sloan DE, DeSanto-Madeya S, Candrian C, Anderson E, Sanders J. Advance care planning as perceived by marginalized populations: Willing to engage and facing obstacles. PLoS One 2024; 19:e0301426. [PMID: 38557983 PMCID: PMC10984538 DOI: 10.1371/journal.pone.0301426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/17/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Health disparities exist in end-of-life (EOL) care. Individuals and communities that are marginalized due to their race, ethnicity, income, geographic location, language, or cultural background experience systemic barriers to access and receive lower quality EOL care. Advance care planning (ACP) prepares patients and their caregivers for EOL decision-making for the purpose of promoting high-quality EOL care. Low engagement in ACP among marginalized populations is thought to have contributed to disparity in EOL care. To advance health equity and deliver care that aligns with the goals and values of each individual, there is a need to improve ACP for marginalized populations. AIM To describe how patients from marginalized populations experience and perceive ACP. METHODS We used an interpretive phenomenological approach with semi-structured qualitative interviews. Participants were recruited from four primary care clinics and one nursing home in a US Pacific Northwest city. Thirty patients from marginalized populations with serious illness participated in individual interviews between January and December 2021. Participants were asked to describe their experiences and perceptions about ACP during the interviews. RESULTS The mean age of 30 participants was 69.5; 19 (63%) were women; 12 (40%) identified as Asian/Pacific Islanders, 10 (33%) as Black; and 9 (30%) were non-native English speakers. Our three key findings were: 1) patients from marginalized populations are willing to engage in ACP; 2) there were multiple obstacles to engaging in ACP; and 3) meaningful ACP conversations could happen when clinicians listen. Although participants from marginalized populations were willing to engage in ACP, a fragmented and restrictive healthcare system and clinicians' biased behaviors or lack of interest in knowing their patients were obstacles. Participants who felt their clinicians took time and listened were encouraged to engage in ACP. CONCLUSION Patients from marginalized populations are willing to engage in ACP conversations despite a common belief otherwise. However, obstacles to meaningful ACP conversations with healthcare providers exist. Clinicians need to be aware of these obstacles and listen to build trust and engage marginalized patients in mutually meaningful ACP conversations.
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Affiliation(s)
- Shigeko (Seiko) Izumi
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Ellen Garcia
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Andrew Kualaau
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Danetta E. Sloan
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Susan DeSanto-Madeya
- College of Nursing, University of Rhode Island, Providence, Rhode Island, United States of America
| | - Carey Candrian
- School of Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - Elizabeth Anderson
- Pacific Institute for Research and Evaluation, Louisville, Kentucky, United States of America
| | - Justin Sanders
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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Park HS, DeGroote NP, Lange A, Kavalieratos D, Brock KE. The Scope of Practice of an Embedded Pediatric Palliative Oncology Clinic. J Pain Symptom Manage 2024; 67:250-259.e5. [PMID: 38065424 DOI: 10.1016/j.jpainsymman.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/22/2023]
Abstract
CONTEXT Pediatric palliative care (PPC) improves end-of-life (EOL) outcomes for children with cancer. Though PPC visits are the 'intervention' in studies focused on EOL care, the content of PPC visits within pediatric oncology is poorly understood. OBJECTIVES This study aimed to understand the scope of PPC practice during visits for children with cancer and their families. METHODS This was a retrospective cohort study of patients 0-27 years with cancer seen in PPC clinic within an academic pediatric oncology center between 2017 and 2022. During each PPC visit, documenting providers chose the domains discussed or managed (goals of care, symptom management, and care coordination with respective subdomains). Data was abstracted from the electronic health record, PPC clinic database, and Cancer Registry. The differences in frequency and addressed domains were analyzed by demographics, visit type, diagnosis group, and proximity to EOL. RESULTS Across 351 patients, 1919 outpatient PPC visits occurred. Median domains were higher in visits <90 days vs. 91+ days from EOL (12.0 vs. 10.0; p < 0.0001); pain and hospice collaboration were particularly discussed closer to EOL. Psychological symptoms like anxiety (30.7% vs. 21.1%; p < 0.001) were addressed more in follow-ups than initial visits. Compared to brain tumor or leukemia/lymphoma visits, solid tumor visits addressed more symptom management subdomains, especially pain (79.9%; p < 0.0001). CONCLUSION The scope of PPC practice is broad and varied. Each visit encompasses many subdomains, the most common being care coordination with oncology teams and helping patients/families cope with the disease. More domains were addressed in solid tumor visits and near EOL.
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Affiliation(s)
- Hee Su Park
- Emory University School of Medicine (H.S.P), Atlanta, Georgia, USA
| | - Nicholas P DeGroote
- Aflac Cancer & Blood Disorders Center (N.P.D, A.L., K.E.B.), Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Anna Lange
- Aflac Cancer & Blood Disorders Center (N.P.D, A.L., K.E.B.), Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine (D.K.), Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Katharine E Brock
- Aflac Cancer & Blood Disorders Center (N.P.D, A.L., K.E.B.), Children's Healthcare of Atlanta, Atlanta, Georgia, USA; Divisions of Pediatric Hematology/Oncology and Palliative Care (K.E.B.), Department of Pediatrics, Emory University, Atlanta, Georgia, USA.
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Patel MI, Kapphahn K, Wood E, Coker T, Salava D, Riley A, Krajcinovic I. Effect of a Community Health Worker-Led Intervention Among Low-Income and Minoritized Patients With Cancer: A Randomized Clinical Trial. J Clin Oncol 2024; 42:518-528. [PMID: 37625110 DOI: 10.1200/jco.23.00309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/27/2023] Open
Abstract
PURPOSE To determine whether a community health worker (CHW)-led intervention could improve health-related quality of life (HRQoL; primary outcome) more than usual care among low-income and racial and ethnic minoritized populations newly diagnosed with cancer. METHODS This randomized clinical trial was conducted from November 1, 2018, until August 31, 2021, in outpatient cancer clinics in Atlantic City, NJ, and Chicago, IL. Hourly low-wage worker members of an employer union health fund age 18 years or older with newly diagnosed solid tumor and hematologic malignancies were randomly assigned 1:1 to usual care (control group) or usual care augmented with a trained CHW for 12 months (intervention group). The CHW assisted participants with advance care planning (ACP), proactively screened symptoms, and referred participants to community-based resources for identified health-related social needs. Usual care comprised nurse case management and benefits redesign (waived copayments and free transportation for any cancer care received at preferred oncology clinics in each city). The primary outcome was HRQoL. Secondary outcomes included patient activation, satisfaction with decision, ACP documentation, health care use, total health care costs, and overall survival. RESULTS A total of 160 participants were enrolled. Intervention group participants had a greater increase in mean HRQoL scores at 4-month and 12-month follow-up as compared with baseline than control group participants (expected mean difference, 11.25 [95% CI, 7.28 to 15.22]; 11.29 [95% CI, 6.96 to 15.62], respectively). CONCLUSION In this randomized trial, a CHW-led intervention significantly improved HRQoL for low-income and racial and ethnic minoritized patients with cancer more than usual care alone.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Kris Kapphahn
- Qualitative Sciences Unit, Stanford University School of Medicine, Stanford, CA
| | - Emily Wood
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
| | - Tumaini Coker
- Seattle Childrens Health, University of Washington, Seattle, WA
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Lee N, Perry LM, Hoerger M, Thomas C, Malhotra S. Advance Care Planning Practice Patterns Before and During a Pandemic. J Palliat Med 2024; 27:246-250. [PMID: 37856144 PMCID: PMC10825290 DOI: 10.1089/jpm.2023.0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction: The COVID-19 pandemic resulted in introspection of the United States health care infrastructure, especially with advance care planning (ACP). Methods: This is a retrospective chart review assessing the frequency of ACP discussions and formal documents reflecting ACP wishes in an outpatient palliative medicine (PM) practice. The study site was at University Medical Center New Orleans from pre-COVID-19 surge (November 2019-February 2020) to months during and post-COVID-19 surge (March-April 2020). Results: Results showed an increase in ACP discussions during the post-COVID-19 months. Patients seen during the surge and post-COVID-19 months were more likely to discuss medical power of attorney (odds ratio [OR] = 1.78, p = 0.045) and preferred code status (OR = 2.82, p < 0.001). Conclusion: Our study showed that more ACP discussions were conducted post-COVID-19 versus pre-COVID-19. However, formal documents reflecting these wishes were lacking. These results can help guide ACP use in crisis periods and improve understanding of ACP discussions in an outpatient PM clinic.
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Affiliation(s)
- Natasha Lee
- Department of Internal Medicine, Supportive and Palliative Care, Christiana Care, Newark, Delaware, USA
| | - Laura M. Perry
- Department of Medical Social Sciences, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana, USA
| | - Christina Thomas
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Sonia Malhotra
- Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Shen MJ, Prigerson HG, Maciejewski PK, Daly B, Adelman R, McConnell Trevino KM. A communication intervention to improve prognostic understanding and engagement in advance care planning among diverse advanced cancer patient-caregiver dyads: A pilot study. Palliat Support Care 2024; 22:10-18. [PMID: 37526150 PMCID: PMC10901460 DOI: 10.1017/s1478951523000901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVES Accurate prognostic understanding among patients with advanced cancer and their caregivers is associated with greater engagement in advance care planning (ACP) and receipt of goal-concordant care. Poor prognostic understanding is more prevalent among racial and ethnic minority patients. The purpose of this study was to examine the feasibility, acceptability, and impact of a patient-caregiver communication-based intervention to improve prognostic understanding, engagement in ACP, and completion of advance directives among a racially and ethnically diverse, urban sample of patients and their caregivers. METHODS Patients with advanced cancer and their caregivers (n = 22 dyads) completed assessments of prognostic understanding, engagement in ACP, and completion of advance directives at baseline and post-intervention, Talking About Cancer (TAC). TAC is a 7-session intervention delivered remotely by licensed social workers that includes distress management and communication skills, review of prognosis, and information on ACP. RESULTS TAC met a priori benchmarks for feasibility, acceptability, and fidelity. Prognostic understanding and engagement in ACP did not change over time. However, patients showed increases in completion of advance directives. SIGNIFICANCE OF RESULTS TAC was feasible, acceptable, and delivered with high fidelity. Involvement of caregivers in TAC may provide added layers of support to patients facing advanced cancer diagnoses, especially among racial and ethnic minorities. Trends indicated greater completion of advance directives but not in prognostic understanding or engagement in ACP. Future research is needed to optimize the intervention to improve acceptability, tailor to diverse patient populations, and examine the efficacy of TAC in a randomized controlled trial.
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Affiliation(s)
- Megan J Shen
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Paul K Maciejewski
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA
| | - Bobby Daly
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald Adelman
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kelly M McConnell Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Golmohammadi M, Ebadi A, Ashrafizadeh H, Rassouli M, Barasteh S. Factors related to advance directives completion among cancer patients: a systematic review. BMC Palliat Care 2024; 23:3. [PMID: 38166983 PMCID: PMC10762918 DOI: 10.1186/s12904-023-01327-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients. METHODS A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior. RESULTS Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics". CONCLUSION The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.
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Affiliation(s)
- Mobina Golmohammadi
- Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hadis Ashrafizadeh
- Student Research Committee, Faculty of Nursing, Dezful University of Medical Sciences, Dezful, Iran
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Salman Barasteh
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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Davila C, Chan SH, Gosline A, Arenas Z, Kavanagh J, Feltz B, McCarthy E, Pitts T, Ritchie C. Online Forums as a Tool for Broader Inclusion of Voices on Health Care Communication Experiences and Serious Illness Care: Mixed Methods Study. J Med Internet Res 2023; 25:e48550. [PMID: 38055311 PMCID: PMC10733833 DOI: 10.2196/48550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/10/2023] [Accepted: 09/28/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Existing health care research, including serious illness research, often underrepresents individuals from historically marginalized communities. Capturing the nuanced perspectives of individuals around their health care communication experiences is difficult. New research strategies are needed that increase engagement of individuals from diverse backgrounds. OBJECTIVE The aim of this study was to develop a mixed methods approach with qualitative online forums to better understand health communication experiences of individuals, including people from groups historically marginalized such as Black and Latino individuals; older adults; and people with low income, disability, or serious illness. METHODS We used a multiphase mixed methods, community-informed research approach to design study instruments and engage participants. We engaged a diverse group of collaborators with lived experience of navigating the health care system who provided feedback on instruments, added concepts for testing, and offered guidance on creating a safe experience for participants (phase 1). We conducted a national quantitative survey between April and May 2021 across intrapersonal, interpersonal, and systems-level domains, with particular focus on interpersonal communication between patients and clinicians (phase 2). We conducted two asynchronous, qualitative online forums, a technique used in market research, between June and August 2021, which allowed us to contextualize the learnings and test concepts and messages (phase 3). Using online forums allowed us to probe more deeply into results and hypotheses from the survey to better understand the "whys" and "whats" that surfaced and to test public messages to encourage action around health. RESULTS We engaged 46 community partners, including patients and clinicians from a Federally Qualified Health Center, to inform study instrument design. In the quantitative survey, 1854 adults responded, including 50.5% women, 25.2% individuals over 65 years old, and 51.9% individuals with low income. Nearly two-thirds identified as non-Hispanic white (65.7%), 10.4% identified as non-Hispanic Black, and 15.5% identified as Hispanic/Latino. An additional 580 individuals participated in online forums, including 60.7% women, 17.4% individuals over 65 years old, and 49.0% individuals with low income. Among the participants, 70.3% identified as non-Hispanic white, 16.0% as non-Hispanic Black, and 9.5% as Hispanic/Latino. We received rich, diverse input from our online forum participants, and they highlighted satisfaction and increased knowledge with engagement in the forums. CONCLUSIONS We achieved modest overrepresentation of people who were over 65 years old, identified as non-Hispanic Black, and had low income in our online forums. The size of the online forums (N=580) reflected the voices of 93 Black and 55 Hispanic/Latino participants. Individuals who identify as Hispanic/Latino remained underrepresented, likely because the online forums were offered only in English. Overall, our findings demonstrate the feasibility of using the online forum qualitative approach in a mixed methods study to contextualize, clarify, and expound on quantitative findings when designing public health and clinical communications interventions.
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Affiliation(s)
- Carine Davila
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Stephanie H Chan
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States
| | - Anna Gosline
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States
| | | | - Jane Kavanagh
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Ariadne Labs, Boston, MA, United States
| | - Brian Feltz
- Flowetik, Boston, MA, United States
- 3D Research Partners LLC, Harvard, MA, United States
| | - Elizabeth McCarthy
- Flowetik, Boston, MA, United States
- Elizabeth M McCarthy Consulting, Boston, MA, United States
| | - Tyrone Pitts
- The Coalition to Transform Advanced Care, Washington, DC, United States
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Center for Aging in Serious Illness, Mongan Institute, Boston, MA, United States
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13
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Allen JM, Awunti M, Guo Y, Bian J, Rogers SC, Scarton L, DeRemer DL, Wilkie DJ. Unraveling Racial Disparities in Supportive Care Medication Use among End-of-Life Pancreatic Cancer Patients: Focus on Pain Management and Psychiatric Therapies. Cancer Epidemiol Biomarkers Prev 2023; 32:1675-1682. [PMID: 37788369 PMCID: PMC10690138 DOI: 10.1158/1055-9965.epi-23-0251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/06/2023] [Accepted: 09/11/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Supportive care medication use differences may contribute to racial disparities observed in health-related quality of life in patients with pancreatic cancer. METHODS In this observation study using the Surveillance, Epidemiology, and End Results-Medicare linked database, we sought to examine supportive care medication use disparities in patients with pancreatic cancer from 2005 to 2017 by race and ethnicity. RESULTS Among 74,309 patients included in the final analysis, racial and ethnic disparities in the use of supportive care medications were identified. After adjustment for confounding factors and compared with non-Hispanic Whites, minorities had significantly less use of opioids [Black: adjusted OR (aOR), 0.84; 95% confidence interval (CI), 0.79-0.88; Asian: aOR, 0.84; 95% CI, 0.79-0.90), and skeletomuscular relaxants (Black: aOR, 0.90; 95% CI, 0.82-0.99; Hispanic: aOR, 0.82; 95% CI, 0.74-0.91; Asian: aOR, 0.59; 95% CI, 0.51-0.68), and increased use of non-opioid analgesics (Hispanic: aOR, 1.16; 95% CI, 1.01-1.14; Asian: aOR, 1.37; 95% CI, 1.26-1.49). Racial and ethnic minorities had less use of antidepressants (Black: aOR, 0.56; 95% CI, 0.53-0.59; Hispanic: aOR, 0.77; 95% CI, 0.73-0.82; Asian: aOR, 0.47; 95% CI, 0.44-0.51), anxiolytics (Black: aOR, 0.78; 95% CI, 0.74-0.82; Hispanic: aOR, 0.66; 95% CI, 0.62-0.71; Asian: aOR, 0.52; 95% CI, 0.48-0.57), and antipsychotics (Hispanic: aOR, 0.90; 95% CI, 0.82-0.99; Asian: aOR, 0.84; 95% CI, 0.74-0.95). CONCLUSIONS Racial and ethnic disparities in the use of supportive care medications among patients with pancreatic cancer were observed, with the differences unexplained by sociodemographic factors. IMPACT Future studies should identify strategies to promote equitable use of supportive care medications among racial minorities and explore factors that may influence their use in these populations.
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Affiliation(s)
- John M. Allen
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Orlando, Florida
| | - MegCholack Awunti
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Orlando, Florida
| | - Yi Guo
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Jiang Bian
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Sherise C. Rogers
- Division of Hematology & Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Lisa Scarton
- Department of Family, Community, and Health Systems Science, University of Florida College of Nursing, Gainesville, Florida
| | - David L. DeRemer
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida
| | - Diana J. Wilkie
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida
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Robison J, Shugrue N, Dillon E, Migneault D, Charles D, Wakefield D, Richards B. Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents. JAMA HEALTH FORUM 2023; 4:e234240. [PMID: 38064239 PMCID: PMC10709774 DOI: 10.1001/jamahealthforum.2023.4240] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/03/2023] [Indexed: 12/18/2023] Open
Abstract
Importance Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population. Objective To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. Design, Setting, and Participants This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020. Exposure Race and ethnicity. Main Outcomes and Measures Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death. Results Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85). Conclusions and Relevance Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.
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Affiliation(s)
- Julie Robison
- UConn Health, Center on Aging, Farmington, Connecticut
| | | | - Ellis Dillon
- UConn Health, Center on Aging, Farmington, Connecticut
| | | | | | | | - Bradley Richards
- Connecticut Department of Social Services, Hartford, Connecticut
- Yale School of Medicine, New Haven, Connecticut
- Yale School of Management, New Haven, Connecticut
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15
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Wu A, Giannitrapani KF, Garcia A, Bozkurt S, Boothroyd D, Adams AS, Kim KM, Zhang S, McCaa MD, Morris AM, Shreve S, Lorenz KA. Disparities in Preoperative Goals of Care Documentation in Veterans. JAMA Netw Open 2023; 6:e2348235. [PMID: 38113045 PMCID: PMC10731481 DOI: 10.1001/jamanetworkopen.2023.48235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023] Open
Abstract
Importance Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk. Objective To assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans. Design, Setting, and Participants This retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022. Exposures Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors. Main Outcomes and Measures Preoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression. Results In this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P <.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P <.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P <.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P <.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001). Conclusions and Relevance In this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.
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Affiliation(s)
- Adela Wu
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Karleen F. Giannitrapani
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
- Department of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Ariadna Garcia
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
- Quantitative Sciences Unit, School of Medicine, Stanford University, Stanford, California
| | - Selen Bozkurt
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
- Evaluation Sciences Unit, School of Medicine, Stanford University, Stanford, California
| | - Derek Boothroyd
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
- Quantitative Sciences Unit, School of Medicine, Stanford University, Stanford, California
| | - Alyce S. Adams
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Kyung Mi Kim
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
- Office of Research Patient Care Services, Stanford Health Care, Palo Alto, California
| | - Shiqi Zhang
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
- Quantitative Sciences Unit, School of Medicine, Stanford University, Stanford, California
| | - Matthew D. McCaa
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
| | - Arden M. Morris
- S-SPIRE Center, Department of Surgery, School of Medicine, Stanford University, Palo Alto, California
- Veterans Affairs Palo Alto Health Care System, US Department of Veterans Affairs, Palo Alto, California
| | - Scott Shreve
- Lebanon VA Medical Center, US Department of Veterans Affairs, Lebanon, Pennsylvania
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Karl A. Lorenz
- VA Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California
- Department of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
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16
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Khayal IS, O'Malley AJ, Barnato AE. Clinically informed machine learning elucidates the shape of hospice racial disparities within hospitals. NPJ Digit Med 2023; 6:190. [PMID: 37828119 PMCID: PMC10570342 DOI: 10.1038/s41746-023-00925-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/20/2023] [Indexed: 10/14/2023] Open
Abstract
Racial disparities in hospice care are well documented for patients with cancer, but the existence, direction, and extent of disparity findings are contradictory across the literature. Current methods to identify racial disparities aggregate data to produce single-value quality measures that exclude important patient quality elements and, consequently, lack information to identify actionable equity improvement insights. Our goal was to develop an explainable machine learning approach that elucidates healthcare disparities and provides more actionable quality improvement information. We infused clinical information with engineering systems modeling and data science to develop a time-by-utilization profile per patient group at each hospital using US Medicare hospice utilization data for a cohort of patients with advanced (poor-prognosis) cancer that died April-December 2016. We calculated the difference between group profiles for people of color and white people to identify racial disparity signatures. Using machine learning, we clustered racial disparity signatures across hospitals and compared these clusters to classic quality measures and hospital characteristics. With 45,125 patients across 362 hospitals, we identified 7 clusters; 4 clusters (n = 190 hospitals) showed more hospice utilization by people of color than white people, 2 clusters (n = 106) showed more hospice utilization by white people than people of color, and 1 cluster (n = 66) showed no difference. Within-hospital racial disparity behaviors cannot be predicted from quality measures, showing how the true shape of disparities can be distorted through the lens of quality measures. This approach elucidates the shape of hospice racial disparities algorithmically from the same data used to calculate quality measures.
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Affiliation(s)
- Inas S Khayal
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA.
- Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA.
- Department of Computer Science, Dartmouth College, Hanover, NH, 03755, USA.
- Cancer Population Sciences Program, Norris Cotton Cancer Center, Lebanon, NH, 03756, USA.
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA
- Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA
- Department of Computer Science, Dartmouth College, Hanover, NH, 03755, USA
- Department of Mathematics, Dartmouth College, Hanover, NH, 03755, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA
- Cancer Population Sciences Program, Norris Cotton Cancer Center, Lebanon, NH, 03756, USA
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
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Mindo-Panusis D, Sudore RL, Cenzer I, Smith AK, Kotwal AA. Disparities in advance care planning among older US immigrants. J Am Geriatr Soc 2023; 71:3244-3253. [PMID: 37431769 PMCID: PMC10592399 DOI: 10.1111/jgs.18498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/08/2023] [Accepted: 06/18/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Despite known racial disparities in advance care planning (ACP), little is known about ACP disparities experienced by US immigrants. METHODS We used data from the 2016 wave of the Health and Retirement Study. We defined ACP engagement as self-reported end-of-life (EOL) discussions, designation of a power of attorney (DPOA), documented living will, or "any" of the three behaviors. Immigration status was determined by respondent-reported birth outside the United States. Time in the United States was calculated by subtracting the year of arrival in the United States from the survey year of 2016. We used multivariable logistic regression to estimate the association between ACP engagement and immigration status and the relationship of acculturation to ACP engagement, adjusting for sociodemographics, religiosity, and life expectancy. RESULTS Of the total cohort (N = 9928), 10% were immigrants; 45% of immigrants identified as Hispanic. After adjustment, immigrants had significantly lower adjusted probability of any ACP engagement (immigrants: 74% vs. US-born: 83%, p < 0.001), EOL discussions (67% vs. 77%, p < 0.001), DPOA designation (50% vs. 59%, p = 0.001) and living will documentation (50% vs. 56%, p = 0.03). Among immigrants, each year in the United States was associated with a 4% increase in the odds of any ACP engagement (aOR 1.04, 95% CI 1.03-1.06), ranging from 36% engaged 10 years after immigration to 78% after 70 years. CONCLUSION ACP engagement was lower for US immigrants compared to US-born older adults, particularly for those that recently immigrated. Future studies should explore strategies to reduce disparities in ACP and the unique ACP needs among different immigrant populations.
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Affiliation(s)
- Dallas Mindo-Panusis
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
| | - Irena Cenzer
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
| | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
| | - Ashwin A. Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center
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18
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Siddiqi A, Monton O, Woods A, Masroor T, Fuller S, Owczarzak J, Yenokyan G, Cooper LA, Freund KM, Smith TJ, Kutner JS, Colborn KL, Joyner R, Elk R, Johnston FM. Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC): a study protocol for a hybrid type 1 randomized controlled trial. BMC Palliat Care 2023; 22:139. [PMID: 37718442 PMCID: PMC10506196 DOI: 10.1186/s12904-023-01250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/24/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND There are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention. METHODS We will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms. DISCUSSION We expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States. TRIAL REGISTRATION Registered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022.
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Affiliation(s)
- Amn Siddiqi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Olivia Monton
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
| | - Alison Woods
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Taleaa Masroor
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Shannon Fuller
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
| | - Jill Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
| | - Lisa A Cooper
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
- Johns Hopkins University School of Nursing, 525 N Wolfe Street, Baltimore, MD, 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, 2024 East Monument Street, Suite 2-515, Baltimore, MD, 21287, USA
| | - Karen M Freund
- Department of Medicine, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - Thomas J Smith
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, 12401 E 17th Ave, Aurora, CO, 80045, USA
| | - Kathryn L Colborn
- Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Robert Joyner
- Richard A. Henson Research Institute, TidalHealth Peninsula Regional, 100 East Carroll Street, Salisbury, MD, 21801, USA
| | - Ronit Elk
- Department of Medicine, University of Alabama at Birmingham, 933 19th Street S, Birmingham, AL, 35205, USA
| | - Fabian M Johnston
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University, 600 N Wolfe Street, Blalock 606, Baltimore, MD, 21287, USA.
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Torres Blasco N, Rosario L, Shen MJ. Latino advanced cancer patients' prognostic awareness and familial cultural influences on advance care planning engagement: a qualitative study. Palliat Care Soc Pract 2023; 17:26323524231193038. [PMID: 37662440 PMCID: PMC10472825 DOI: 10.1177/26323524231193038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/21/2023] [Indexed: 09/05/2023] Open
Abstract
Background Advanced cancer patients need an accurate understanding of their prognoses in order to engage in informed end-of-life care treatment decision-making. Latino cancer patients experience disparities around prognostic understanding, in part due to a lack of culturally competent communication around prognosis and advance care planning (ACP). Objective The objective of the present study of Latino patients with advanced, terminally ill cancer is to examine their understanding of prognosis, and how cultural factors may influence this understanding and engagement in ACP. Methods A mixed methods study was conducted, which consisted of surveys and semi-structured interviews. Descriptive statistics were used for sociodemographic information and self-reported prognostic understanding. Interviews around prognostic understanding and cultural influences on this understanding and engagement in ACP were recorded, transcribed, and then coded and analyzed using thematic content analysis. Findings Latino patients with advanced cancer (n = 20) completed a self-reported survey and participated in a semi-structured interview. Results indicate that among terminally ill patients, 50% of the patients inaccurately believed they had early-stage cancer, 85% did not believe their cancer was terminal, and 70% believed their cancer was curable. Moreover, interviews yielded two main themes: varying levels of awareness of the incurability of their cancer and diverse end-of-life care decision-making and treatment preferences based on prognostic understanding. Within these themes, patients expressed denial or acceptance of their prognosis through communication with the oncologist, the importance of family, and incorporating their pre-existing beliefs. Conclusion Findings indicate the importance of communication, family involvement, and incorporation of beliefs for promoting an accurate prognostic understanding among Latino patients. It is imperative to address disparities in Latino advanced cancer patients' prognostic understanding so they can engage in informed treatment decision-making around end-of-life care.
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Affiliation(s)
- Normarie Torres Blasco
- School of Behavioral and Brain Science Ponce Health Science University, 388 Zona Industrial Reparada 2, Ponce, 00732-7004, USA
| | - Lianel Rosario
- Ponce Health Science University, School of Behavioral and Brain Science, Ponce, Puerto Rico
| | - Megan J. Shen
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA, USA
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20
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Puerto G, Chiriboga G, DeSanto-Madeya S, Duodu V, Cruz-Oliver DM, Tjia J. Advance Care Planning for Spanish-Language Speakers: Patient, Family, and Interpreter Perspectives. J Appl Gerontol 2023; 42:1840-1849. [PMID: 36794526 PMCID: PMC10440849 DOI: 10.1177/07334648231156864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Language access barriers for individuals with limited-English proficiency are a challenge to advance care planning (ACP). Whether Spanish-language translations of ACP resources are broadly acceptable by US Spanish-language speakers from diverse countries is unclear. This ethnographic qualitative study ascertained challenges and facilitators to ACP with respect to Spanish-language translation of ACP resources. We conducted focus groups with a heterogeneous sample of 29 Spanish-speaking persons who had experience with ACP as a patient, family member, and/or medical interpreter. We conducted thematic analysis with axial coding. Themes include: (1). ACP translations are confusing; (2). ACP understanding is affected by country of origin; (3). ACP understanding is affected by local healthcare provider culture and practice; and (4). ACP needs to be normalized into local communities. ACP is both a cultural and clinical practice. Recommendations for increasing ACP uptake extend beyond language translation to acknowledging users' culture of origin and local healthcare culture.
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21
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Nouri S, Quinn M, Doyle BN, McKissack M, Johnson N, Wertz M, Tan C, Pantilat SZ, Lyles CR, Ritchie CS, Sudore RL. "We've Got to Bring Information to Where People Are Comfortable": Community-Based Advance Care Planning with the Black Community. J Gen Intern Med 2023; 38:2478-2485. [PMID: 36894819 PMCID: PMC9998020 DOI: 10.1007/s11606-023-08134-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND People identifying as Black/African American are less likely to engage in advance care planning (ACP) compared to their White peers, despite the association of ACP with improved patient and caregiver outcomes. OBJECTIVES Assess facilitators/barriers to ACP in the San Francisco (SF) Black community and co-design/implement/test community-based ACP pilot events. DESIGN Community-based participatory research, including qualitative research, intervention development, and implementation. PARTICIPANTS In partnership with the SF Palliative Care Workgroup (which includes health system, city, and community-based organizations), we formed an African American Advisory Committee (n = 13). We conducted 6 focus groups with Black older adults (age ≥ 55), caregivers, and community leaders (n = 29). The Advisory Committee then selected 5 community-based organizations through a widespread request for proposal. These community-based organizations designed and implemented community-based pilot events to support ACP engagement. MAIN MEASURES Two authors analyzed recorded focus group transcripts using thematic analysis. We assessed pre- vs post-event readiness to engage in ACP (validated ACP Engagement Survey; 1-4 scale, 4 = most ready) using Wilcoxon signed rank tests and assessed event acceptability with open-ended questions. KEY RESULTS Themes included the importance of ACP to the Black community (sub-themes: strengthens families; preserves dignity, particularly for sexual/gender minorities; is tied to financial planning) and facilitators for increasing ACP engagement (sub-themes: culturally relevant materials; events in trusted community spaces including Black-owned businesses). A total of 114 participants attended 5 events; 74% identified as Black, and 16% as sexual/gender minorities. Readiness to engage in ACP was similar pre- vs post-events; 98% would recommend the events to others. CONCLUSIONS Community-based ACP events designed and led by and for the Black community are highly acceptable. Novel insights underscored the importance of financial planning as part of ACP and the role of Black-owned businesses as trusted spaces for ACP-related discussions.
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Affiliation(s)
- Sarah Nouri
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Mara Quinn
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Natalya Johnson
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Molly Wertz
- Molly Wertz Consulting, San Francisco, CA, USA
| | - Charissa Tan
- John A. Burns School of Medicine, University of Hawai'I at Mānoa, Honolulu, HI, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Courtney R Lyles
- Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, USA
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Shen MJ, Cho S, De Los Santos C, Yarborough S, Maciejewski PK, Prigerson HG. Planning for Your Advance Care Needs (PLAN): A Communication Intervention to Improve Advance Care Planning among Latino Patients with Advanced Cancer. Cancers (Basel) 2023; 15:3623. [PMID: 37509284 PMCID: PMC10377387 DOI: 10.3390/cancers15143623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The goal of this study was to develop and optimize an intervention designed to address barriers to engagement in advance care planning (ACP) among Latino patients with advanced cancer. The resulting intervention, titled Planning Your Advance Care Needs (PLAN), is grounded in theoretical models of communication competence and sociocultural theory. MATERIALS AND METHODS An initial version of the PLAN manual was developed based on a prior intervention, Ca-HELP, that was designed to improve communication around pain among cancer patients. PLAN uses this framework to coach patients on how to plan for and communicate their end-of-life care needs through ACP. In the present study, feedback was obtained from key stakeholders (n = 11 patients, n = 11 caregivers, n = 10 experts) on this preliminary version of the PLAN manual. Participants provided ratings of acceptability and feedback around the intervention content, format, design, modality, and delivery through quantitative survey questions and semi-structured qualitative interviews. RESULTS Results indicated that the PLAN manual was perceived to be helpful and easy to understand. All stakeholder groups liked the inclusion of explicit communication scripts and guidance for having conversations about ACP with loved ones and doctors. Specific feedback was given to modify PLAN to ensure it was optimized and tailored for Latino patients. Some patients noted reviewing the manual motivated engagement in ACP. CONCLUSIONS Feedback from stakeholders resulted in an optimized, user-centered version of PLAN tailored to Latino patients. Future research will examine the acceptability, feasibility, and potential efficacy of this intervention to improve engagement in ACP.
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Affiliation(s)
- Megan J. Shen
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Susie Cho
- School of Nursing, University of Washington, Seattle, WA 98195, USA;
| | - Claudia De Los Santos
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Sarah Yarborough
- Division of Clinical Research, Fred Hutchinson Cancer Center, 1100 Fairview Ave. N., Mail Stop D5-290, Seattle, WA 98109, USA; (C.D.L.S.); (S.Y.)
| | - Paul K. Maciejewski
- Department of Radiology, Weill Cornell Medical College, New York, NY 10065, USA;
| | - Holly G. Prigerson
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA;
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23
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Tung HJ, Yeh MC. Use of Advance Directives in US Veterans and Non-Veterans: Findings from the Decedents of the Health and Retirement Study 1992-2014. Healthcare (Basel) 2023; 11:1824. [PMID: 37444658 DOI: 10.3390/healthcare11131824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Evidence shows that older patients with advance directives such as a living will, or durable power of attorney for healthcare, are more likely to receive care consistent with their preferences at the end of life. Less is known about the use of advance directives between veteran and non-veteran older Americans. Using data from the decedents of a longitudinal survey, we explore whether there is a difference in having an established advance directive between the veteran and non-veteran decedents. Data were taken from the Harmonized End of Life data sets, a linked collection of variables derived from the Health and Retirement Study (HRS) Exit Interview. Only male decedents were included in the current analysis (N = 4828). The dependent variable, having an established advance directive, was measured by asking the proxy, "whether the deceased respondent ever provided written instructions about the treatment or care he/she wanted to receive during the final days of his/her life" and "whether the deceased respondent had a Durable Power of Attorney for healthcare?" A "yes" to either of the two items was counted as having an advance directive. The independent variable, veteran status, was determined by asking participants, "Have you ever served in the active military of the United States?" at their first HRS core interview. Logistic regression was used to predict the likelihood of having an established advance directive. While there was no difference in having an advance directive between male veteran and non-veteran decedents during the earlier follow-up period (from 1992 to 2003), male veterans who died during the second half of the study period (from 2004 to 2014) were more likely to have an established advance directive than their non-veteran counterparts (OR = 1.24, p < 0.05). Other factors positively associated with having an established advance directive include dying at older ages, higher educational attainment, needing assistance in activities of daily living and being bedridden three months before death, while Black decedents and those who were married were less likely to have an advance directive in place. Our findings suggest male veterans were more likely to have an established advance directive, an indicator for better end-of-life care, than their non-veteran counterparts. This observed difference coincides with a time when the Veterans Health Administration (VHA) increased its investment in end-of-life care. More studies are needed to confirm if this higher utilization of advance directives and care planning among veterans can be attributed to the improved access and quality of end-of-life care in the VHA system.
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Affiliation(s)
- Ho-Jui Tung
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, P.O. Box 8015, Statesboro, GA 30460-8015, USA
| | - Ming-Chin Yeh
- Nutrition Program, Hunter College, City University of New York, New York, NY 10065, USA
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24
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Shen MJ, Prigerson HG, Maciejewski PK. Associations between Latino ethnicity and the use of emotional support and completion of advance directives. Palliat Support Care 2023; 21:385-391. [PMID: 37039467 PMCID: PMC10264148 DOI: 10.1017/s1478951523000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVES Latino patients have been shown to engage in advance care planning (ACP) at much lower rates than non-Latino White patients. Coping strategies, such as the use of emotional support, may differentially relate to engagement in ACP among Latino and non-Latino patients. The present study sought to examine the moderating effect of ethnicity on the relationship between the use of emotional support as a coping strategy and completion of advance directives. METHODS The present study employed a weighted sample (Nw = 185) of Latino and non-Latino White patient participants in Coping with Cancer III, an National Institutes of Health-sponsored, multisite, longitudinal, observational cohort study of patients with advanced cancer and their informal caregivers and oncology providers designed to evaluate Latino/non-Latino disparities in ACP and end-of-life cancer care. Main and interaction effects of Latino ethnicity and use of emotional support on patient use of advance directives were estimated as odds ratios. RESULTS Use of emotional support was associated with dramatically lower do-not-resuscitate (DNR) order completion to a greater extent among Latino as compared to non-Latino patients (interaction AOR = 0.33, p = 0.005). Interaction effects were not statistically significant for living will or health-care proxy form completion. SIGNIFICANCE OF RESULTS Use of emotional support is associated with lower odds of completing DNRs among Latino than among non-Latino patients. Seeking and/or receiving emotional support may deter Latino patients from completing DNR orders. Research is needed to address both emotional needs and practicalities to ensure high quality end-of-life care among Latino patients with cancer.
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Affiliation(s)
- Megan Johnson Shen
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Holly G Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Paul K Maciejewski
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
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25
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Reich AJ, Reich JA, Mathew P. Advance Care Planning, Shared Decision Making, and Serious Illness Conversations in Onconephrology. Semin Nephrol 2023; 42:151349. [PMID: 37121171 DOI: 10.1016/j.semnephrol.2023.151349] [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: 05/02/2023]
Abstract
Advance care planning, shared decision making, and serious illness conversations are communication processes designed to promote patient-centered care. In onconephrology, patients face a series of complex medical decisions regarding their care at the intersection of oncology and nephrology. Clinicians who aim to ensure that patient preferences and values are integrated into treatment planning must work within a similarly complex care team comprising multiple disciplines. In this review, we describe key decision points in a patient's care trajectory, as well as guidance on how and when to engage in advance care planning, shared decision making, and serious illness discussions. Further research on these processes in the complex context of onconephrology is needed.
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Affiliation(s)
- Amanda Jane Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA.
| | - John Adam Reich
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Paul Mathew
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA
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26
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Crooks J, Trotter S, Clarke G. How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review. BMC Palliat Care 2023; 22:43. [PMID: 37062841 PMCID: PMC10106323 DOI: 10.1186/s12904-023-01168-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/04/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals' care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this. METHODS Mixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000-04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients' care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough's Weight of Evidence. RESULTS N=35 papers were included in total; all had Medium/High Weight of Evidence. Fifteen papers (comparing two or more ethnic groups) addressed the primary outcome measure. Twelve of the fifteen papers reported White patients had statistically higher rates of formally documented ACP in their care records than patients from other ethnic groups. There were no significant differences in the presence of informal ACP between ethnic groups. Nineteen papers addressed the secondary outcome measure; thirteen discussed patient-based factors impacting ACP presence with four key themes: poor awareness and understanding of ACP; financial constraints; faith and religion; and family involvement. Eight papers discussed clinician-based factors with three key themes: poor clinician confidence around cultural values and ideals; exacerbation of institutional constraints; and pre-conceived ideas of patients' wishes. CONCLUSIONS This review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences. TRIAL REGISTRATION PROSPERO-CRD42022315252.
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Affiliation(s)
| | - Sophie Trotter
- Academic Unit of Palliative Care, University of Leeds, Leeds, UK
| | - Gemma Clarke
- Academic Unit of Palliative Care, University of Leeds, Leeds, UK
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27
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Manz CR, Zhang Y, Chen K, Long Q, Small DS, Evans CN, Chivers C, Regli SH, Hanson CW, Bekelman JE, Braun J, Rareshide CAL, O'Connor N, Kumar P, Schuchter LM, Shulman LN, Patel MS, Parikh RB. Long-term Effect of Machine Learning-Triggered Behavioral Nudges on Serious Illness Conversations and End-of-Life Outcomes Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncol 2023; 9:414-418. [PMID: 36633868 PMCID: PMC9857721 DOI: 10.1001/jamaoncol.2022.6303] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Serious illness conversations (SICs) between oncology clinicians and patients are associated with improved quality of life and may reduce aggressive end-of-life care. However, most patients with cancer die without a documented SIC. Objective To test the impact of behavioral nudges to clinicians to prompt SICs on the SIC rate and end-of-life outcomes among patients at high risk of death within 180 days (high-risk patients) as identified by a machine learning algorithm. Design, Setting, and Participants This prespecified 40-week analysis of a stepped-wedge randomized clinical trial conducted between June 17, 2019, and April 20, 2020 (including 16 weeks of intervention rollout and 24 weeks of follow-up), included 20 506 patients with cancer representing 41 021 encounters at 9 tertiary or community-based medical oncology clinics in a large academic health system. The current analyses were conducted from June 1, 2021, to May 31, 2022. Intervention High-risk patients were identified using a validated electronic health record machine learning algorithm to predict 6-month mortality. The intervention consisted of (1) weekly emails to clinicians comparing their SIC rates for all patients against peers' rates, (2) weekly lists of high-risk patients, and (3) opt-out text messages to prompt SICs before encounters with high-risk patients. Main Outcomes and Measures The primary outcome was SIC rates for all and high-risk patient encounters; secondary end-of-life outcomes among decedents included inpatient death, hospice enrollment and length of stay, and intensive care unit admission and systemic therapy close to death. Intention-to-treat analyses were adjusted for clinic and wedge fixed effects and clustered at the oncologist level. Results The study included 20 506 patients (mean [SD] age, 60.0 [14.0] years) and 41 021 patient encounters: 22 259 (54%) encounters with female patients, 28 907 (70.5%) with non-Hispanic White patients, and 5520 (13.5%) with high-risk patients; 1417 patients (6.9%) died by the end of follow-up. There were no meaningful differences in demographic characteristics in the control and intervention periods. Among high-risk patient encounters, the unadjusted SIC rates were 3.4% (59 of 1754 encounters) in the control period and 13.5% (510 of 3765 encounters) in the intervention period. In adjusted analyses, the intervention was associated with increased SICs for all patients (adjusted odds ratio, 2.09 [95% CI, 1.53-2.87]; P < .001) and decreased end-of-life systemic therapy (7.5% [72 of 957 patients] vs 10.4% [24 of 231 patients]; adjusted odds ratio, 0.25 [95% CI, 0.11-0.57]; P = .001) relative to controls, but there was no effect on hospice enrollment or length of stay, inpatient death, or end-of-life ICU use. Conclusions and Relevance In this randomized clinical trial, a machine learning-based behavioral intervention and behavioral nudges to clinicans led to an increase in SICs and reduction in end-of-life systemic therapy but no changes in other end-of-life outcomes among outpatients with cancer. These results suggest that machine learning and behavioral nudges can lead to long-lasting improvements in cancer care delivery. Trial Registration ClinicalTrials.gov Identifier: NCT03984773.
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Affiliation(s)
- Christopher R Manz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Yichen Zhang
- Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kan Chen
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Qi Long
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Dylan S Small
- Wharton School of the University of Pennsylvania, Philadelphia
| | - Chalanda N Evans
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | | | - Justin E Bekelman
- Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | | | - Charles A L Rareshide
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nina O'Connor
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Pallavi Kumar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Lynn M Schuchter
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Lawrence N Shulman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | | | - Ravi B Parikh
- Division of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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Tabuyo-Martin A, Torres-Morales A, Pitteloud MJ, Kshetry A, Oltmann C, Pearson JM, Khawand M, Schlumbrecht MP, Sanchez JC. Palliative Medicine Referral and End-of-Life Interventions Among Racial and Ethnic Minority Patients With Advanced or Recurrent Gynecologic Cancer. Cancer Control 2023; 30:10732748231157191. [PMID: 36762494 PMCID: PMC9943963 DOI: 10.1177/10732748231157191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Referral to palliative medicine (PM) has been shown to improve quality of life, reduce hospitalizations, and improve survival. Limited data exist about PM utilization among racial minorities with gynecologic malignancies. Our objective was to assess differences in palliative medicine referrals and end of life interventions (within the last 30 days of life) by race and ethnicity in a diverse population of gynecologic oncology patients. METHODS A retrospective cohort study of patients receiving gynecologic oncologic care at a tertiary referral center between 2017 - 2019 was conducted. Patients had either metastatic disease at the time of diagnosis or recurrence. Demographic and clinical data were abstracted. Exploratory analyses were done using chi-square and rank sum tests. Tests were two-sided with significance set at P < .05. RESULTS A total of 186 patients were included. Of those, 82 (44.1%) were referred to palliative medicine. Underrepresented minorities accounted for 47.3% of patients. English was identified as the primary language for 69.9% of the patients and Spanish in 24.2%. Over 90% of patients had insurance coverage. Ovarian cancer (37.6%) and uterine cancer (32.8%) were the most common sites of origin. Most patients (75%) had advanced stage at the time of diagnosis. Race and language spoken were not associated with referral to PM. Black patients were more likely to have been prescribed appetite stimulants compared to White patients (41% vs 24%, P = .038). Black patients also had a higher number of emergency department visits compared to White patients during the study timeframe. Chemotherapy in the last 30 days of life was also more likely to be given to Black patients compared to White (P = .019). CONCLUSIONS Race was associated with variation in interventions and healthcare utilization near end-of-life. Understanding the etiologies of these differences is crucial to inform interventions for care optimization as it relates specifically to the health of minority patients.
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Affiliation(s)
- Angel Tabuyo-Martin
- Division of Gynecologic Oncology,
Sylvester Comprehensive Cancer Center, Department of Obstetrics, Gynecology, and
Reproductive Sciences, University of Miami Miller School of
Medicine, Miami, FL, USA,Angel Tabuyo-Martin, Gynecology Oncology,
University of Miami, 1121 NW 14th St, Suite 345C, Miami, FL, USA.
| | - Angelica Torres-Morales
- Division of Geriatrics and
Palliative Medicine, Department of Medicine, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Marie J. Pitteloud
- Division of Geriatrics and
Palliative Medicine, Department of Medicine, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Alisha Kshetry
- Division of Geriatrics and
Palliative Medicine, Department of Medicine, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Carina Oltmann
- Division of Geriatrics and
Palliative Medicine, Department of Medicine, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Joseph Matthew Pearson
- Division of Gynecologic Oncology,
Sylvester Comprehensive Cancer Center, Department of Obstetrics, Gynecology, and
Reproductive Sciences, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Mariana Khawand
- Division of Geriatrics and
Palliative Medicine, Department of Medicine, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Matthew P. Schlumbrecht
- Division of Gynecologic Oncology,
Sylvester Comprehensive Cancer Center, Department of Obstetrics, Gynecology, and
Reproductive Sciences, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Julia C. Sanchez
- Division of Geriatrics and
Palliative Medicine, Department of Medicine, University of Miami Miller School of
Medicine, Miami, FL, USA
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Santos Carmo BD, de Camargos MG, Santos Neto MFD, Paiva BSR, Lucchetti G, Paiva CE. Relationship Between Religion/Spirituality and the Aggressiveness of Cancer Care: A Scoping Review. J Pain Symptom Manage 2023; 65:e425-e437. [PMID: 36758908 DOI: 10.1016/j.jpainsymman.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
CONTEXT Religiosity/spirituality/religious-spiritual coping (RS) are resources used by cancer patients with cancer to help cope with the disease and may influence the preference and receipt of end-of-life (EOL) treatment. OBJECTIVES To examine the relationship between RS and the EOL care preferred or received by cancer patients. METHODS This review protocol is registered on (International Prospective Register of Systematic Review, CRD42021251833) and follows the recommendations of the preferred reporting items for systematic reviews and meta-analyses checklist. Embase, Proquest, PubMed, Scopus, and Web of Science databases were consulted. Google Scholar was consulted for additional publications and gray literature. Quantitative studies including adults with any cancer type/stage were eligible. The paper selection was performed by two independent reviewers; the methodological quality was measured using the Newcastle Ottawa scale. RESULTS Seventeen studies were included in the review. In general, RS is related to the preference or receipt of aggressive EOL care and with less advance care planning. Spiritual care by the medical team is related to higher referral to hospice and less aggressive care; in contrast, high spiritual support from religious communities is associated with less hospice and more aggressive care. Religious denominations influenced health care preferences, as Catholics were less likely to sign a do-not-resuscitate order and Buddhists or Taoists received more aggressive interventions at the EOL. Most studies (70%) were of high quality according to the Newcastle Ottawa scale. CONCLUSION RS is associated with more aggressive EOL treatments, as well as with lower rates of ACP in cancer patients. On the other hand, spiritual care provided by the medical team seems to be associated with less aggressive EOL care.
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Affiliation(s)
- Bruna Dos Santos Carmo
- Palliative Care and Quality of Life Research Group (GPQual) (Bd.S.C., M.G.dC., M.Fd.S.N., B.S.R.P., C.E.P.), Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Mayara Goulart de Camargos
- Palliative Care and Quality of Life Research Group (GPQual) (Bd.S.C., M.G.dC., M.Fd.S.N., B.S.R.P., C.E.P.), Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Martins Fidelis Dos Santos Neto
- Palliative Care and Quality of Life Research Group (GPQual) (Bd.S.C., M.G.dC., M.Fd.S.N., B.S.R.P., C.E.P.), Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Bianca Sakamoto Ribeiro Paiva
- Palliative Care and Quality of Life Research Group (GPQual) (Bd.S.C., M.G.dC., M.Fd.S.N., B.S.R.P., C.E.P.), Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Giancarlo Lucchetti
- Federal University of Juiz de Fora (UFJF) (G.L.), Juiz de Fora, Minas Gerais, Brazil
| | - Carlos Eduardo Paiva
- Palliative Care and Quality of Life Research Group (GPQual) (Bd.S.C., M.G.dC., M.Fd.S.N., B.S.R.P., C.E.P.), Barretos Cancer Hospital, Barretos, São Paulo, Brazil.
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Harmon A, Jordan M, Platt A, Wilson J, Keith K, Chandrashekaran S, Schlichte L, Pendergast J, Ming D. Goal-Concordance in Children with Complex Chronic Conditions. J Pediatr 2023; 253:278-285.e4. [PMID: 36257348 DOI: 10.1016/j.jpeds.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 10/01/2022] [Accepted: 10/05/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To characterize delivery of goal-concordant end-of-life (EOL) care among children with complex chronic conditions and to determine factors associated with goal-concordance. STUDY DESIGN This was a retrospective review of goals of care discussions for 272 children with at least 1 complex chronic condition who died at a tertiary care hospital between January 1, 2014, and December 31, 2017. Goals of care and code status were assessed before and within the last 72 hours of life. Goals of care discussions were coded as full interventions; considering withdrawal of interventions (palliation); planned transition to palliation; or actively transitioning/transitioned to palliation. RESULTS In total, 158 children had documented goals of care discussions before and within the last 72 hours of life, 18 had goals of care discussions only >72 hours before death, 54 only in the last 72 hours of life, and 42 had no documented goals of care. For children with goals of care, EOL care was goal-concordant for 82.2%, discordant in 7%, and unclear in 10.8%. Black children had a greater than 8-fold greater odds of discordant care compared with White children (OR 8.34, P = .007). Comparison of goals of care and code status before and within the last 72 hours of life revealed trends toward nonescalation of care. Specifically, rates of active palliation increased from 11.7% to 63.0%, and code status shifted from 32.6% do not resuscitate to 65.2% (P < .001). CONCLUSIONS In this cohort, a majority of children had documented goals of care discussions and received goal-concordant EOL care. However, Black children had greater odds of receiving goal-discordant care. Goals of care and code status shifted toward palliation during the last 72 hours of life.
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Affiliation(s)
- Alexis Harmon
- Department of Pediatrics, McGaw Medical Center of Northwestern University, Chicago, IL
| | - Megan Jordan
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Alyssa Platt
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Jonathon Wilson
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Kevin Keith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | | | - Jane Pendergast
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - David Ming
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.
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Callahan K, Acharya Y, Hollenbeak CS. The affordable care act and do-not-resuscitate orders: Differences by race and ethnicity. Heart Lung 2023; 59:16-22. [PMID: 36669442 DOI: 10.1016/j.hrtlng.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/05/2023] [Accepted: 01/15/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Affordable Care Act (ACA) created new payment rules that provided reimbursement for physicians to engage in advance care planning (ACP) conversations with patients. This reimbursement policy has the potential to increase ACP participation, including among racial and ethnic minority groups that have had lower ACP participation. OBJECTIVES To examine whether the ACP payment rules were associated with an increase in use of do-not-resuscitate (DNR) orders, particularly among racial and ethnic minority groups, among patients diagnosed with heart failure (HF) in California. METHODS The California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data Set was used to identify a cohort of elderly patients with a principal diagnosis of HF. This study included 432,520 hospital admissions of patients over the age of 65 with a primary diagnosis of HF between 2012 and 2018. DNR status was identified using International Classification of Diseases, Clinical Modification Ninth and Tenth Revision, codes. RESULTS There was a small increase in the utilization of DNR orders overall after the ACA reimbursement policy, but the change was not significantly different for all racial and ethnic groups when compared to white non-Hispanic patients. CONCLUSIONS ACP payment rules provided in the ACA were associated with increased utilization of DNR, but the effect was not significantly different for racial and ethnic minorities hospitalized with HF in CA. Additional efforts are needed to increase ACP participation among racial and ethnic minorities.
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Affiliation(s)
- Katherine Callahan
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA 16802 USA.
| | - Yubraj Acharya
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA 16802 USA
| | - Christopher S Hollenbeak
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA 16802 USA
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LoCastro M, Sanapala C, Mendler JH, Norton S, Bernacki R, Carroll T, Klepin H, Watson E, Liesveld J, Huselton E, O'Dwyer K, Baran A, Flannery M, Kluger BM, Loh KP. Advance care planning in older patients with acute myeloid leukemia and myelodysplastic syndromes. J Geriatr Oncol 2023; 14:101374. [PMID: 36100548 PMCID: PMC9974785 DOI: 10.1016/j.jgo.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Older patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) have worse survival rates compared to younger patients, and experience more intense inpatient healthcare at the end of life (EOL) compared to patients with solid tumors. Advance care planning (ACP) has been shown to limit aggressive and burdensome care at EOL for patients with AML and MDS. The purpose of this study was to better understand ACP from the perspective of clinicians, older patients with AML and MDS, and their caregivers. MATERIALS AND METHODS We conducted semi-structured interviews with 45 study participants. Interviews were audio-recorded and transcribed. Open coding and focused content analysis were used to organize data and develop and contextualize categories and subcategories. RESULTS Guided by our specific aims, we developed four themes: (1) The language of ACP and medical order for life-sustaining treatment (MOLST) does not resonate with patients, (2) There is no uniform consensus on when ACP is currently happening, (3) Oncology clinician-perceived barriers to ACP (e.g., patient discomfort, patient lack of knowledge, and lack of time), and (4) Patients felt that they are balancing fear and hope when navigating their AML or MDS diagnosis. DISCUSSION The results of this study can be used to develop interventions to promote serious illness conversations for patients with AML and MDS and their caregivers to ensure that patient care aligns with patient values.
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Affiliation(s)
- Marissa LoCastro
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.
| | - Chandrika Sanapala
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jason H Mendler
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
| | - Sally Norton
- School of Nursing, University of Rochester, Rochester, NY, USA.
| | - Rachelle Bernacki
- Department of Palliative Care, Harvard Medical School, Boston, MA, USA.
| | - Thomas Carroll
- Division of General Medicine and Palliative Care, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Heidi Klepin
- Department of Hematology/Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | | | - Jane Liesveld
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
| | - Eric Huselton
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
| | - Kristen O'Dwyer
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
| | - Andrea Baran
- Department of Biostatistics and Computational Biology, University of Rochester, New York, USA.
| | - Marie Flannery
- School of Nursing, University of Rochester, Rochester, NY, USA.
| | - Benzi M Kluger
- Division of General Medicine and Palliative Care, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA; Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA.
| | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
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Rodriguez GM, Leach M, Osorio J, Villicana G, Koontz Z, Wood EH, Duron Y, O'Brien D, Rosas LG, Patel MI. Exploring cancer care needs for Latinx adults: a qualitative evaluation. Support Care Cancer 2023; 31:76. [PMID: 36544063 PMCID: PMC9771768 DOI: 10.1007/s00520-022-07518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Latinx adults with cancer, as compared with non-Latinx White adults, are diagnosed with more advanced stages and experience worse quality of life. Identifying barriers in cancer care among low-income Latinx adults is crucial to designing and implementing culturally appropriate interventions. The objective of this study was to explore the specific barriers encountered by Latinx adults after a cancer diagnosis and perspectives on the use of community health workers (CHWs) to address these barriers. METHODS We conducted semi-structured qualitative interviews with low-income Latinx adults with a past or current history of cancer and/or their caregivers in a community oncology clinic located in an agricultural community in California. Analysis was based in grounded theory and performed using the constant comparative method. RESULTS Sixteen interviews were conducted with patients alone (n = 11), a caregiver alone (n = 1), and patient-caregiver pairs (n = 4 patients; n = 4 caregivers). Four major themes emerged: (1) low cancer health literacy including cancer diagnosis and treatment, cancer fatalism, navigating next steps after diagnosis, advance directives, and precision medicine; (2) challenges in communicating and receiving supportive services due to language barriers; (3) stress and anxiety regarding financial hardships related to job loss, insurance barriers, and the COVID-19 pandemic; (4) the need for supportive, bilingual, and bicultural personnel to assist in overcoming these challenges. CONCLUSIONS Low-income Latinx adults with cancer and their caregivers experience health literacy, communication, and financial barriers that impede quality cancer care delivery. Embedding CHWs in the care team could be one way to address these barriers to culturally concordant, accessible care.
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Affiliation(s)
| | - Maria Leach
- Community Hospital, Montage Health, Monterey, CA, USA
| | | | | | | | - Emily H Wood
- Stanford University School of Medicine, Stanford, CA, USA
| | | | - Dale O'Brien
- Cancer Patients Alliance, Pacific Grove, CA, USA
| | - Lisa G Rosas
- Stanford University School of Medicine, Stanford, CA, USA
| | - Manali I Patel
- Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Jones S, Mulaikal TA. End of Life: What Is the Anesthesiologist's Role? Adv Anesth 2022; 40:1-14. [PMID: 36333041 DOI: 10.1016/j.aan.2022.07.007] [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: 11/07/2022]
Abstract
Anesthesiologists receive extensive training in the area of perioperative care and the specialized skills required to maintain life during surgery and complex procedures. Integrated into almost every facet of contemporary medicine, they interact with patients at multiple stages of their health care journeys. While traditionally thought of as the doctors best equipped to save lives, they may also be some of the best doctors to help navigate the chapters at the end of life. Successfully navigating end-of-life care, particularly in the COVID-19 era, is a complicated task. Competing ethical principles of autonomy and nonmaleficence may often be encountered as sophisticated medical technologies offer the promise of extending life longer than ever before seen. From encouraging patients to actively engage in advance care planning, normalizing the conversations around the end of life, employing our skills to relieve pain and suffering associated with dying, and using our empathy and communication skills to also care for the families of dying patients, there are many ways for the anesthesiologist to elevate the care provided at the end of life. The aim of this article is to review the existing literature on the role of the anesthesiologist in end-of-life care, as well as to encourage future development of our specialty in this area.
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Affiliation(s)
- Stephanie Jones
- Columbia University Irving Medical Center, Division of Critical Care Medicine, 622 W. 168th St, New York, NY 10032, USA
| | - Teresa A Mulaikal
- Division of Cardiothoracic and Critical Care, Columbia University Medical Center, 622 W. 168th St., PH 5 Stem 133, New York, NY 10032, USA.
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Lowers J, Dellon EP, Stephenson A, Arnold R, Althouse A, Jeong K, Dubin E, Soodalter J, Hovater C, Bakitas M, Goggin J, Hunt W, Ladores S, Curseen K, Winter G, Solomon G, Ailon J, Conrad D, Kavalieratos D. Integrating specialist palliative care to improve care and reduce suffering: cystic fibrosis (InSPIRe:CF) - study protocol for a multicentre randomised clinical trial. BMJ Open Respir Res 2022; 9:9/1/e001381. [PMID: 36126995 PMCID: PMC9490626 DOI: 10.1136/bmjresp-2022-001381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Cystic fibrosis (CF) is a life-limiting genetic disorder estimated to affect more than 160 000 individuals and their families worldwide. People living with CF commonly experience significant physical and emotional symptom burdens, disruptions to social roles and complex treatment decision making. While palliative care (PC) interventions have been shown to relieve many such burdens in other serious illnesses, no rigorous evidence exists for palliative care in CF. Thus, this study aims to compare the effect of specialist palliative care plus usual CF care vs usual CF care alone on patient quality of life. Methods and analysis This is a five-site, two-arm, partially masked, randomised superiority clinical trial. 264 adults with CF will be randomly assigned to usual CF care or usual CF care plus a longitudinal palliative care intervention delivered by a palliative care specialist. The trial’s primary outcome is patient quality of life (measured with the Functional Assessment of Chronic Illness Therapy-Palliative care instrument). Secondary outcomes include symptom burden, satisfaction with care and healthcare utilisation. Outcomes will be measured at 12 months (primary endpoint) and 15 months (secondary endpoint). In addition, we will conduct qualitative interviews with patient participants, caregivers, and palliative care and CF care team members to explore perceptions of the intervention’s impact and barriers and facilitators to dissemination. Ethics and dissemination Human subjects research ethics approval was obtained from all participating sites, and all study participants gave informed consent. We will publish the results of this trial in a peer-reviewed journal. Trial registration number ISRCTN53323164.
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Affiliation(s)
- Jane Lowers
- Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Elisabeth P Dellon
- Pediatrics, The University of North Carolina, School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Robert Arnold
- General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew Althouse
- General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kwonho Jeong
- General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ethan Dubin
- Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Jesse Soodalter
- Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Cade Hovater
- Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Marie Bakitas
- School of Nursing, The University of Alabama, Birmingham, Alabama, USA
| | - Jessica Goggin
- Medicine, University of California, La Jolla, California, USA
| | | | - Sigrid Ladores
- School of Nursing, The University of Alabama, Birmingham, Alabama, USA
| | - Kimberly Curseen
- Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | | | - George Solomon
- Medicine, The University of Alabama, Birmingham, AL, USA
| | - Jonathan Ailon
- Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Douglas Conrad
- Medicine, University of California, La Jolla, California, USA
| | - Dio Kavalieratos
- Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
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Torres-Blasco N, Costas-Muñiz R, Zamore C, Porter L, Claros M, Bernal G, Shen MJ, Breitbart W, Rosario L, Peña-Vargas C, Castro-Figueroa EM. Family as a Bridge to Improve Meaning in Latinx Individuals Coping with Cancer. Palliat Med Rep 2022; 3:186-193. [PMID: 36203712 PMCID: PMC9531875 DOI: 10.1089/pmr.2022.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Family and meaning-making resources are culturally congruent and help support Latinx coping with cancer. Objectives: To explore Latinx advanced cancer patients' perspectives on the role of family and meaning/purpose in adjustment to advanced cancer. Methods: A qualitative study was conducted. In-depth interviews were performed and transcripts were analyzed using the method from applied thematic analysis. Setting/Subject: Participants were patients with any advanced cancer diagnosis, recruited from Memorial Sloan Kettering Cancer Center (MSKCC), New York; Lincoln Medical Center (LMC), New York; and Ponce Health Science University (PHSU), Puerto Rico. Measurements: Sociodemographic and semistructured interview. Results: N = 24 in-depth interviews were completed by Latinx advanced cancer patients (Stage III and IV). When evaluating patients' perspectives on the role of family and meaning/purpose in adjustment to advanced cancer, the team generated three categories: (1) family support, (2) family communication, and (3) include support for the family. Many patients reported the importance of family as a source of meaning and social support in the process of cancer diagnosis and treatment. They also reported communication as central to process information and planning. Also, participants describe their desire to incorporate family members into therapy and for encouraging them to seek counseling. Conclusions: Results highlight the need to include syntonic cultural values such as family and meaning for Latinx individuals coping with advanced cancer in psychological interventions.
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Affiliation(s)
- Normarie Torres-Blasco
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Science, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Rosario Costas-Muñiz
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Immigrant Health & Cancer Disparities, New York, New York, USA
| | - Carolina Zamore
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Immigrant Health & Cancer Disparities, New York, New York, USA
| | - Laura Porter
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Maria Claros
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Immigrant Health & Cancer Disparities, New York, New York, USA
| | - Guillermo Bernal
- Caribbean Alliance of National Psychological Associations, San Juan, Puerto Rico
| | - Megan J. Shen
- Division of Geriatrics and Palliative Medicine, Department of Medicine, New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, Immigrant Health & Cancer Disparities, New York, New York, USA
| | - Lianel Rosario
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Science, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Cristina Peña-Vargas
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Science, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Eida M. Castro-Figueroa
- Department of Psychiatry and Human Behavior, School of Behavioral and Brain Science, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
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Chuang E, Yu S, Georgia A, Nymeyer J, Williams J. A Decade of Studying Drivers of Disparities in End-of-Life Care for Black Americans: Using the NIMHD Framework for Health Disparities Research to Map the Path Ahead. J Pain Symptom Manage 2022; 64:e43-e52. [PMID: 35381316 PMCID: PMC9189009 DOI: 10.1016/j.jpainsymman.2022.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/02/2022] [Accepted: 03/24/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this paper is to provide a review of the existing literature on racial disparities in quality of palliative and end-of-life care and to demonstrate gaps in the exploration of underlying mechanisms that produce these disparities. BACKGROUND Countless studies over several decades have revealed that our healthcare system in the United States consistently produces poorer quality end-of-life care for Black compared with White patients. Effective interventions to reduce these disparities are sparse and hindered by a limited understanding of the root causes of these disparities. METHODS We searched PubMed, CINAHL and PsychInfo for research manuscripts that tested hypotheses about causal mechanisms for disparities in end-of-life care for Black patients. These studies were categorized by domains outlined in the National Institute of Minority Health and Health Disparities (NIMHD) framework, which are biological, behavioral, physical/built environment, sociocultural and health care systems domains. Within these domains, studies were further categorized as focusing on the individual, interpersonal, community or societal level of influence. RESULTS The majority of the studies focused on the Healthcare System and Sociocultural domains. Within the Health Care System domain, studies were evenly distributed among the individual, interpersonal, and community level of influence, but less attention was paid to the societal level of influence. In the Sociocultural domain, most studies focused on the individual level of influence. Those focusing on the individual level of influence tended to be of poorer quality. CONCLUSIONS The sociocultural environment, physical/built environment, behavioral and biological domains remain understudied areas of potential causal mechanisms for racial disparities in end-of-life care. In the Healthcare System domain, social influences including healthcare policy and law are understudied. In the sociocultural domain, the majority of the studies still focused on the individual level of influence, missing key areas of research in interpersonal discrimination and local and societal structural discrimination. Studies that focus on individual factors should be better screened to ensure that they are of high quality and avoid stigmatizing Black communities.
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Affiliation(s)
- Elizabeth Chuang
- Department of Family and Social Medicine (E.C.), Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Sandra Yu
- Columbia Mailman School of Public Health (S.Y.), New York, NY, USA
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Starr LT, Ulrich C, Perez GA, Aryal S, Junker P, O’Connor NR, Meghani SH. Hospice Enrollment, Future Hospitalization, and Future Costs Among Racially and Ethnically Diverse Patients Who Received Palliative Care Consultation. Am J Hosp Palliat Care 2022; 39:619-632. [PMID: 34318700 PMCID: PMC8795236 DOI: 10.1177/10499091211034383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Palliative care consultation to discuss goals-of-care ("PCC") may mitigate end-of-life care disparities. OBJECTIVE To compare hospitalization and cost outcomes by race and ethnicity among PCC patients; identify predictors of hospice discharge and post-discharge hospitalization utilization and costs. METHODS This secondary analysis of a retrospective cohort study assessed hospice discharge, do-not-resuscitate status, 30-day readmissions, days hospitalized, ICU care, any hospitalization cost, and total costs for hospitalization with PCC and hospitalization(s) post-discharge among 1,306 Black/African American, Latinx, White, and Other race PCC patients at a United States academic hospital. RESULTS In adjusted analyses, hospice enrollment was less likely with Medicaid (AOR = 0.59, P = 0.02). Thirty-day readmission was less likely among age 75+ (AOR = 0.43, P = 0.02); more likely with Medicaid (AOR = 2.02, P = 0.004), 30-day prior admission (AOR = 2.42, P < 0.0001), and Black/African American race (AOR = 1.57, P = 0.02). Future days hospitalized was greater with Medicaid (Coefficient = 4.49, P = 0.001), 30-day prior admission (Coefficient = 2.08, P = 0.02), and Black/African American race (Coefficient = 2.16, P = 0.01). Any future hospitalization cost was less likely among patients ages 65-74 and 75+ (AOR = 0.54, P = 0.02; AOR = 0.53, P = 0.02); more likely with Medicaid (AOR = 1.67, P = 0.01), 30-day prior admission (AOR = 1.81, P = 0.0001), and Black/African American race (AOR = 1.40, P = 0.02). Total future hospitalization costs were lower for females (Coefficient = -3616.64, P = 0.03); greater with Medicaid (Coefficient = 7388.43, P = 0.01), 30-day prior admission (Coefficient = 3868.07, P = 0.04), and Black/African American race (Coefficient = 3856.90, P = 0.04). Do-not-resuscitate documentation (48%) differed by race. CONCLUSIONS Among PCC patients, Black/African American race and social determinants of health were risk factors for future hospitalization utilization and costs. Medicaid use predicted hospice discharge. Social support interventions are needed to reduce future hospitalization disparities.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Connie Ulrich
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - G. Adriana Perez
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Subhash Aryal
- BECCA (Biostatistics * Evaluation * Collaboration *
Consultation * Analysis) Lab, University of Pennsylvania School of Nursing,
Philadelphia, Pennsylvania
| | | | - Nina R. O’Connor
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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Torres Blasco N, Costas Muñiz R, Zamore C, Porter L, Claros M, Bernal G, Shen MJ, Breitbart W, Castro EM. Cultural adaptation of meaning-centered psychotherapy for latino families: a protocol. BMJ Open 2022; 12:e045487. [PMID: 35379609 PMCID: PMC8981324 DOI: 10.1136/bmjopen-2020-045487] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Literature suggests couple-based interventions that target quality of life and communication can lead to positive outcomes for patients with cancer and their partners. Nevertheless, to date, an intervention to address the needs of Latino families coping with advanced cancer has not been developed. Meta-analytic evidence suggests that culturally adapted evidenced-based intervention targeting a specific cultural group is four times more effective. Our goal is to culturally adapt a novel psychosocial intervention protocol entitled 'Caregivers-Patients Support to Latinx coping advanced-cancer' (CASA). We hypothesised that combine two evidence-based interventions and adapting them, we will sustain a sense of meaning and improving communication as patients approach the end of life among the patient-caregiver dyad. METHODS AND ANALYSIS To culturally adapt CASA, we will follow an innovative hybrid research framework that combines elements of an efficacy model and best practices from the ecological validity model, adaptation process model and intervention mapping. As a first step, we adapt a novel psychosocial intervention protocol entitled protocol entitled 'Caregivers-Patients Support to Latinx coping advanced-cancer' (CASA). The initial CASA protocol integrates two empirically based interventions, meaning-centred psychotherapy and couple communication skills training. This is an exploratory and prepilot study, and it is not necessary for a size calculation. However, based on recommendations for exploratory studies of this nature, a priori size of 114 is selected. We will receive CASA protocol feedback (phase 1b: refine) by conducting 114 questionnaires and 15 semistructured interviews with patients with advanced cancer and their caregivers. The primary outcomes of this study will be identifying the foundational information needed to further the develop the CASA (phase IIa: proof-of-concept and phase IIb: pilot study). ETHICS AND DISSEMINATION The Institutional Review Board of Ponce Research Institute approved the study protocol #1907017527A002. Results will be disseminated through peer-reviewed publications.
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Affiliation(s)
| | - Rosario Costas Muñiz
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carolina Zamore
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura Porter
- Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - Maria Claros
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Guillermo Bernal
- Professor of Psychology (Retired), Universidad de Puerto Rico, San Juan, Puerto Rico
| | | | - William Breitbart
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - E M Castro
- SBBS, Ponce Health Sciences University, Ponce, Puerto Rico
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Tucker Edmonds B, Schmidt A, Walker VP. Addressing bias and disparities in periviable counseling and care. Semin Perinatol 2022; 46:151524. [PMID: 34836664 DOI: 10.1016/j.semperi.2021.151524] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Addressing bias and disparities in counseling and care requires that we contend with dehumanizing attitudes, stereotypes, and beliefs that our society and profession holds towards people of color, broadly, and Black birthing people in particular. It also necessitates an accounting of the historically informed, racist ideologies that shape present-day implicit biases. These biases operate in a distinctly complex and damaging manner in the context of end-of-life care, which centers around questions related to human pain, suffering, and value. Therefore, this paper aims to trace biases and disparities that operate in periviable care, where end-of-life decisions are made at the very beginning of life. We start from a historical context to situate racist ideologies into present day stereotypes and tropes that dehumanize and disadvantage Black birthing people and Black neonates in perinatal care. Here, we review the literature, address historical incidents and consider their impact on our ability to deliver patient-centered periviable care.
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Affiliation(s)
- Brownsyne Tucker Edmonds
- Associate Professor of Obstetrics and Gynecology & Vice Chair for Faculty Development and Diversity, Department of Obstetrics and Gynecology; Assistant Dean for Diversity Affairs, Indiana University School of Medicine, Indianapolis, IN.
| | | | - Valencia P Walker
- Associate Chief Diversity & Health Equity Officer, Nationwide Children's Hospital; Associate Division Chief for Health Equity & Inclusion, Department of Pediatrics, Division of Neonatology, The Ohio State University College of Medicine
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Azizi B, Tilburgs B, van Hout HPJ, van der Heide I, Verheij RA, Achterberg WP, van der Steen JT, Joling KJ. Occurrence and Timing of Advance Care Planning in Persons With Dementia in General Practice: Analysis of Linked Electronic Health Records and Administrative Data. Front Public Health 2022; 10:653174. [PMID: 35392479 PMCID: PMC8980429 DOI: 10.3389/fpubh.2022.653174] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) is a process of communication in which patients and family caregivers discuss preferences for future care with the healthcare team. For persons with dementia, it is crucial to timely engage in ACP. Therefore, we study ACP in dementia using electronic health record data. This study aims to determine how often ACP conversations are recorded, analyze time from dementia diagnosis until the first recorded conversation and time from the first recorded conversation to death, and analyze which factors are associated with the timing of ACP. Methods Electronic records of 15,493 persons with dementia in Dutch general practice between 2008 and 2016 were linked to national administrative databases. ACP conversations and indicators of health deficits to determine frailty were obtained from electronic records coded with the International Classification of Primary Care. Socio-demographic characteristics were derived from the national population registry managed by Statistics Netherlands. Date of death was derived from the Personal Records Database (2008–2018). Results ACP was recorded as such as 22 (95% CI, 20–23) first conversations per 1,000 person-years of follow-up. The hazard ratio (HR) for the first conversation increased every year after dementia diagnosis, from 0.01 in the first year to 0.07 in the 7th and 8th year after diagnosis. Median time from a first conversation to death was 2.57 years (95% CI, 2.31–2.82). Migrant status [non-Western vs. Western (HR 0.31, 95% CI, 0.15–0.65)] was significantly associated with a longer time from dementia diagnosis to the first conversation. Being pre-frail (HR 2.06, 95% CI, 1.58–2.69) or frail (HR 1.40, 95% CI, 1.13–1.73) vs. non-frail was significantly associated with a shorter time from dementia diagnosis to the first ACP conversation. Conclusion ACP conversations in Dutch general practice were rare for persons with dementia, or was rarely recorded as such. In particular among persons with a non-Western migration background and those who are non-frail, it started long after diagnosis. We advise further research into public health and practical strategies to engage persons with dementia with a non-Western migration background and non-frail persons early in the disease trajectory in ACP.
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Affiliation(s)
- Bahar Azizi
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Bram Tilburgs
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Science, Nijmegen, Netherlands
| | - Hein P. J. van Hout
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Iris van der Heide
- Nivel, Netherlands Institute for Health Services Research, Utrecht, Netherlands
| | - Robert A. Verheij
- Nivel, Netherlands Institute for Health Services Research, Utrecht, Netherlands
- Tilburg School of Social and Behavioral Sciences (TRANZO), Tilburg University, Tilburg, Netherlands
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Jenny T. van der Steen
| | - Karlijn J. Joling
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Zametkin E, Williams E, Feingold-Link M, Jiang L, Martin E, Erqou S, Gravenstein S, Wice M, Wu WC, Rudolph JL. Racial Differences in Burdensome Transitions in Heart Failure Patients with Palliative Care: A Propensity-Matched Analysis. J Palliat Med 2022; 25:1122-1126. [PMID: 35275739 DOI: 10.1089/jpm.2021.0317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Examining racial disparities in the treatment of heart failure (HF) patients and the effects of palliative care (PC) consultation is important to developing culturally competent clinical behaviors. Objective: To compare burdensome transitions for Black and White Veterans hospitalized with HF after PC consultation. Participants: This retrospective study evaluated Veterans admitted for HF to Veterans Administration hospitals who received PC consultation from October 2010 through August 2017. Methods: We propensity-matched Black to White Veterans using demographic, comorbidity, clinical, hospital, and survival time data. Results: Propensity matching of our cohort (n = 5638) yielded 796 Black and White Veterans (total n = 1592) who were well-matched on observed variables (standard mean difference <0.15 for all variables). Matched Black Veterans had more burdensome transitions than White Veterans (n = 218, 27.4% vs. n = 174, 21.9%; p = 0.011) over the six-month follow-up period. Conclusions: This propensity-matched cohort found racial differences in burdensome transitions among admitted HF patients after PC consultation.
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Affiliation(s)
- Emily Zametkin
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Edelva Williams
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mara Feingold-Link
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long Term Services and Supports, Providence Veteran Affairs Medical Center, Providence, Rhode Island, USA
| | - Edward Martin
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Sebhat Erqou
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Center of Innovation in Long Term Services and Supports, Providence Veteran Affairs Medical Center, Providence, Rhode Island, USA
| | - Stefan Gravenstein
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mitchell Wice
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Center of Innovation in Long Term Services and Supports, Providence Veteran Affairs Medical Center, Providence, Rhode Island, USA
| | - Wen-Chih Wu
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Center of Innovation in Long Term Services and Supports, Providence Veteran Affairs Medical Center, Providence, Rhode Island, USA
| | - James L Rudolph
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Center of Innovation in Long Term Services and Supports, Providence Veteran Affairs Medical Center, Providence, Rhode Island, USA
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Choi SL, Shin SH, Allen RS. How widowhood status relates to engagement in advance care planning among older adults: does race/ethnicity matter? Aging Ment Health 2022; 26:604-613. [PMID: 33380176 DOI: 10.1080/13607863.2020.1867823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study investigated whether and to what extent widowhood status is related to engagement in advance care planning (ACP), and further whether race/ethnicity moderated the relation. METHODS We analyzed a total of 11,257 older Americans from the Health and Retirement Study using random-effect regression models after controlling for covariates and year-fixed effects. RESULTS We found that both being a widow/widower ever and having been widowed for a longer period of time were associated with a higher probability of engagement in ACP. Specifically, we found that a one-year increase in the number of years since spousal death was associated with 1.02 (p < 0.05, 95% CI = 1.00, 1.03) changes in the odds ratios of informal ACP; however, inclusion of a quadratic term indicated that this association reversed after the peak. Moreover, our findings suggested a moderating effect of race/ethnicity on the relations of the length of time since spousal loss with engagement in ACP. Specifically, the odds of widowed non-Hispanic Blacks discussing with someone the care or medical treatment (informal ACP) and having a living will (formal ACP) were 0.96 (p < 0.05, 95% CI = 0.93, 1.00) and 0.88 (p < 0.05, 95% CI = 0.79, 0.97) times that of non-widowed non-Hispanic Whites. Compared with their non-Hispanic White counterparts, widowed non-Hispanic Blacks were less likely to engage in ACP, and the negative relations were exacerbated when they became widows/widowers. CONCLUSION We elaborated on these findings and discussed their implications for understanding the moderating effect of race/ethnicity on the relation between late-life widowhood and engagement in ACP. In order to develop programs that enhance engagement in ACP and reduce racial/ethnic disparities, research must incorporate intersectionality theory with attention to motivations and decision-making style among diverse widows/widowers. The findings from this study could help inform policy makers when developing public health programs and health care reimbursement programs that enhance engagement in ACP among widows/widowers.
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Affiliation(s)
- Shinae L Choi
- Department of Consumer Sciences, The University of Alabama, Tuscaloosa, AL, USA
| | - Su Hyun Shin
- Department of Family and Consumer Studies, The University of Utah, Salt Lake City, UT, USA
| | - Rebecca S Allen
- Alabama Research Institute on Aging, The University of Alabama, Tuscaloosa, AL, USA.,Department of Psychology, The University of Alabama, Tuscaloosa, AL, USA
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Kabaria S, Gupta K, Bhurwal A, Patel AV, Rustgi VK. Predictors of do-not-resuscitate order utilization in decompensated cirrhosis hospitalized patients: A nationwide inpatient cohort study. Ann Hepatol 2021; 22:100284. [PMID: 33160032 DOI: 10.1016/j.aohep.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Decompensated cirrhosis carries high inpatient morbidity and mortality. Consequently, advance care planning is an integral aspect of medical care in this patient population. Our study aims to identify do-not-resuscitate (DNR) order utilization and demographic disparities in decompensated cirrhosis patients. PATIENTS OR MATERIALS AND METHODS Nationwide Inpatient Sample was used to extract the cohort of patients from January 1st, 2016 to December 31st, 2017, based on the most comprehensive and recent data. The first cohort included hospitalized patients with decompensated cirrhosis. The second cohort included patients with decompensated cirrhosis with at least one contraindication for liver transplantation. RESULTS A cohort of 585,859 decompensated cirrhosis patients was utilized. DNR orders were present in 14.2% of hospitalized patients. DNR utilization rate among patients with relative contraindication for liver transplantation was 15.0%. After adjusting for co-morbid conditions, disease severity, and inpatient mortality, African-American and Hispanic patient populations had significantly lower DNR utilization rates. There were regional, and hospital-level differences noted. Moreover, advanced age, advanced stage of decompensated cirrhosis, inpatient mortality, and relative contraindications for liver transplantation (metastatic neoplasms, dementia, alcohol misuse, severe cardiopulmonary disease, medical non-adherence) were independently associated with increased DNR utilization rates. CONCLUSIONS The rate of DNR utilization in patients with relative contraindications for liver transplantation was similar to patients without any relative contraindications. Moreover, there were significant demographic and hospital-level predictors of DNR utilization. This information can guide resource allocation in educating patients and their families regarding prognosis and outcome expectations.
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Affiliation(s)
- Savan Kabaria
- Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States.
| | - Kapil Gupta
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Anish V Patel
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
| | - Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States
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Miyashita J, Shimizu S, Fukuhara S, Yamamoto Y. Association between religious beliefs and discussions regarding advance care planning: A nationwide survey. Palliat Med 2021; 35:1856-1864. [PMID: 34355585 DOI: 10.1177/02692163211029508] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The relationship between advance care planning and religious beliefs, which are important for palliative care, is controversial in Western countries and has not been verified in Asian countries. AIM To investigate the association between advance care planning discussions and religious beliefs in Japan. DESIGN A nationwide survey conducted in 2016 using a quota sampling method to obtain a representative sample of Japan's general population. SETTING/PARTICIPANTS We analyzed responses from 3167 adults aged 20-84 years (mean age ± standard deviation, 50.9 ± 16.8 years). The outcome was measured by asking whether the respondents had ever discussed advance care planning, and the main exposure by whether they had any religious beliefs or affiliations, and if so, their degree of devoutness. We analyzed religious beliefs, affiliations, and devoutness in relation to the occurrence of discussions using multivariable logistic regression models adjusted for possible sociodemographic covariates. RESULTS Compared with respondents without, those with religious beliefs had significantly higher odds of having had discussions (adjusted odds ratio: 1.45, 95% confidence interval: 1.22-1.73). The devoutness of religious belief was proportional to the propensity of the occurrence of discussions (p for trend < 0.001). In addition, Buddhists and Christians had higher odds of having had discussions than did nonbelievers. CONCLUSION The results suggest that holding religious beliefs, especially in Japanese Buddhism and Christianity, facilitates advance care planning discussions among Japanese adults, and thus, may help health-care providers identify those prioritized for facilitating engagement in advance care planning, especially in palliative and spiritual care settings.
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Affiliation(s)
- Jun Miyashita
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Shirakawa, Fukushima, Japan.,Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
| | - Sayaka Shimizu
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan.,Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shunichi Fukuhara
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Shirakawa, Fukushima, Japan.,Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Yosuke Yamamoto
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan.,Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Ivey GD, Johnston FM. Barriers to Equitable Palliative Care Utilization Among Patients with Cancer. Surg Oncol Clin N Am 2021; 31:9-20. [PMID: 34776067 DOI: 10.1016/j.soc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Over the past half century, palliative care has grown to become a pillar of clinical oncology. Its practice revolves around relieving suffering and optimizing quality of life, not just dealing with end-of-life decisions. Despite evidence that palliative care has the potential to reduce health care utilization and improve advance care planning without affecting mortality, palliative care remains inequitably accessible and underutilized. Furthermore, it is still too often introduced late in the care of patients receiving surgical intervention. This article summarizes the numerous and complex barriers to equitable palliative care utilization among patients with cancer. Potential strategies for dismantling these barriers are also discussed.
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Affiliation(s)
- Gabriel D Ivey
- Department of Surgery, Division of Surgical Oncology, The Johns Hopkins University, 600 North Wolfe Street, Blalock 611, Baltimore, MD 21287, USA
| | - Fabian M Johnston
- Department of Surgery, Division of Surgical Oncology, The Johns Hopkins University, 600 North Wolfe Street, Blalock 606, Baltimore, MD 21287, USA.
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Bazargan M, Cobb S, Assari S. Completion of advance directives among African Americans and Whites adults. PATIENT EDUCATION AND COUNSELING 2021; 104:2763-2771. [PMID: 33840551 PMCID: PMC8481344 DOI: 10.1016/j.pec.2021.03.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The primary purpose of this study was to analyze the completion of advance directives among African American and White adults and examine related factors, including demographics, socio-economic status, health conditions, and experiences with health care providers. METHODS This study used data from the Survey of California Adults on Serious Illness and End-of-Life 2019. We compared correlates of completion of advance directives among a sample of 1635 African American and White adults. Multivariate analysis was conducted. RESULTS Whites were 50% more likely to complete an advance directive than African Americans. The major differences between African Americans and Whites were mainly explained by the level of mistrust and discrimination experienced by African Americans and partially explained by demographic characteristics. Our study showed that at both bivariate and multivariate levels, participation in religious activities was associated with higher odds of completion of an advance directive for both African Americans and Whites. CONCLUSION Interventional studies needed to address the impact of mistrust and perceived discrimination on advance directive completion. PRACTICAL IMPLICATIONS Culturally appropriate multifaceted, theoretical- and religious-based interventions are needed that include minority health care providers, church leaders, and legal counselors to educate, modify attitudes, provide skills and resources for communicating with health care providers and family members.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, College of Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA; Department of Family Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA; Department of Public Health, CDU, Los Angeles, CA, USA; Physician Assistant Program, CDU, Los Angeles, CA, USA.
| | - Sharon Cobb
- School of Nursing, CDU, Los Angeles, CA, USA
| | - Shervin Assari
- Department of Family Medicine, College of Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA; Department of Public Health, CDU, Los Angeles, CA, USA
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48
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Brenner K, Greer JA, Jackson V, Park E, Wright E, Jacobsen J, Topping C, Jagielo A, Elyze M, Sereno I, Temel JS, El-Jawahri A. Development of a Prognostic Awareness Impact Scale for Patients with Advanced Cancer. J Palliat Med 2021; 25:445-454. [PMID: 34637630 DOI: 10.1089/jpm.2021.0238] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: No reliable instruments exist to measure prognostic awareness and its psychological and behavioral impacts for patients with advanced cancer. Methods: We developed the Prognostic Awareness Impact Scale (PAIS) using a qualitative approach. During phase 1, we convened a working group with a transdisciplinary team of clinicians from oncology (n = 2), psychology (n = 2), psychiatry (n = 1), palliative care (n = 3), and survey development (n = 1) to identify key domains of PAIS. Using a consensus-driven process, the team generated an item bank for each domain. During phase 2, we conducted cognitive interviews with 39 patients with advanced cancer to assess the understandability of the PAIS. Results: The working group developed a conceptual framework for PAIS, identifying three domains: (1) cognitive understanding of prognosis (capacity to understand intellectually one's prognosis), (2) emotional coping (capacity to process prognostic uncertainty and terminal prognosis), and (3) adaptive response (capacity to use prognostic awareness to inform life decisions). Cognitive interviews revealed that patients had an accurate understanding of most PAIS items. Patients reported difficulty with binary response options for questions pertaining to emotional coping. They expressed difficulty answering numerous questions regarding their cognitive understanding of their prognosis. We revised the PAIS by (1) replacing binary response options with ordinal agreement scales; and (2) reducing the number of items focused on cognitive understanding of prognosis. Conclusion: We developed a conceptual framework to capture prognostic awareness and its psychological and behavioral impacts for patients with advanced cancer using the PAIS. Future work should focus on validating the PAIS by testing its psychometric properties.
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Affiliation(s)
- Keri Brenner
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Stanford University, Palo Alto, California, USA
| | - Joseph A Greer
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Vicki Jackson
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Elyse Park
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Emily Wright
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | - Jennifer S Temel
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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49
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Rural Hispanic/Latino cancer patients’ perspectives on facilitators, barriers, and suggestions for advance care planning: A qualitative study. Palliat Support Care 2021; 20:535-541. [DOI: 10.1017/s1478951521001498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective
Hispanic/Latinos living in rural areas have limited healthcare resources, including palliative and hospice care. Moreover, little is known about advance care planning (ACP) among Hispanic/Latino cancer patients in rural areas. This study explores facilitators and barriers for ACP. It elicits suggestions to promote ACP among rural Hispanic/Latino cancer patients in a US/Mexico border region.
Methods
Hispanic/Latino cancer patients (n = 30) were recruited from a nonprofit cancer organization. Data were collected via in-person interviews. Interviews were transcribed and translated from Spanish to English. Data were uploaded into NVivo 12 and analyzed using thematic analysis.
Results
A common theme for facilitators and barriers for ACP was safeguarding family. Additional facilitators included (1) Desire for honoring end-of-life (EoL) care wishes and (2) experience with EoL care decision making. Additional barriers include (1) Family's reluctance to participate in EoL communication and (2) Patient–clinicians’ lack of EoL communication. Practice suggestions include (1) Death education and support for family, (2) ACP education, and (3) Dialogue vs. documentation.
Significance of results
ACP functions not only as a decisional tool; its utility reflects complex dynamics in personal, social, and cultural domains. ACP approaches with this underserved population must consider family relationships as well as cultural implications, including language barriers.
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Abstract
The concept of culture includes many defining characteristics such race, ethnicity, gender, identity, socioeconomic status, beliefs, traditions, and habits. Multiculturalism is a concept that allows for respect, understanding and acknowledgement of a diversity of identities. The cases discussed in this manuscript indicate the importance of multiculturalism in the practice of pediatric surgery.
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