1
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Murray GF, Lakin JR, Paasche-Orlow MK, Tulsky JA, Volandes A, Davis AD, Zupanc SN, Carney MT, Burns E, Martins-Welch D, LaVine N, Itty JE, Fix GM. Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians' and Administrators' Experiences During a Pragmatic Trial. J Gen Intern Med 2023; 38:3558-3565. [PMID: 37488368 PMCID: PMC10713958 DOI: 10.1007/s11606-023-08320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients' goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients' and clinicians' awareness of the need for ACP. OBJECTIVE Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. DESIGN Qualitative interview study. PARTICIPANTS Clinicians and administrators across five sites that participated in the ACP-COVID trial. APPROACH We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. KEY RESULTS Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians' affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. CONCLUSIONS Despite high organizational commitment to ACP, we found that the health system channeled clinicians' ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Genevra F Murray
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Michael K Paasche-Orlow
- Tufts University School of Medicine, Division of General Internal Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - James A Tulsky
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Section of General Internal Medicine, Boston, MA, USA
- ACP Decisions, Waban, MA, USA
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria T Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Edith Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Diana Martins-Welch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Nancy LaVine
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jennifer E Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Gemmae M Fix
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Bedford VA Healthcare System, Bedford, MA, USA
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2
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Zupanc SN, Lakin JR, Volandes AE, Paasche-Orlow MK, Moseley ET, Gundersen DA, Das S, Penumarthy A, Martins-Welch D, Burns EA, Carney MT, Itty JE, Emmert K, Tulsky JA, Lindvall C. Forms or Free-Text? Measuring Advance Care Planning Activity Using Electronic Health Records. J Pain Symptom Manage 2023; 66:e615-e624. [PMID: 37536523 PMCID: PMC10592170 DOI: 10.1016/j.jpainsymman.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
Advance care planning (ACP) discussions seek to guide future serious illness care. These discussions may be recorded in the electronic health record by documentation in clinical notes, structured forms and directives, and physician orders. Yet, most studies of ACP prevalence have only examined structured electronic health record elements and ignored data existing in notes. We sought to investigate the relative comprehensiveness and accuracy of ACP documentation from structured and unstructured electronic health record data sources. We evaluated structured and unstructured ACP documentation present in the electronic health records of 435 patients with cancer drawn from three separate healthcare systems. We extracted structured ACP documentation by manually annotating written documents and forms scanned into the electronic health record. We coded unstructured ACP documentation using a rule-based natural language processing software that identified ACP keywords within clinical notes and was subsequently reviewed for accuracy. The unstructured approach identified more instances of ACP documentation (238, 54.7% of patients) than the structured ACP approach (187, 42.9% of patients). Additionally, 16.6% of all patients with structured ACP documentation only had documents that were judged as misclassified, incomplete, blank, unavailable, or a duplicate of a previously entered erroneous document. ACP documents scanned into electronic health records represent a limited view of ACP activity. Research and measures of clinical practice with ACP should incorporate information from unstructured data.
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Affiliation(s)
- Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Angelo E Volandes
- Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (A.E.V.), Massachusetts General Hospital, Boston, Massachusetts; ACP Decisions (A.E.V.), Waban, Massachusetts
| | | | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Computer Science (E.T.M.), School of Engineering, Tufts University, Medford, Massachusetts
| | - Daniel A Gundersen
- Survey and Qualitative Methods Core (D.A.G.), Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Social and Behavioral Sciences (D.A.G.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Akhila Penumarthy
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Diana Martins-Welch
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Edith A Burns
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Maria T Carney
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Jennifer E Itty
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York
| | - Kaitlin Emmert
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts.
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Koffler D, Eckstein J, Herman J, Martins-Welch D, Seetharamu N, Ghaly M, Kohn N, Potters L, Frank D, Sullivan K, Parashar B. Efficacy of ketamine mouthwash in the management of oral and pharyngeal toxicity associated with head and neck chemoradiotherapy: protocol for a phase II, Simon's two-stage trial. BMJ Open 2023; 13:e064809. [PMID: 37041046 PMCID: PMC10105995 DOI: 10.1136/bmjopen-2022-064809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
INTRODUCTION Curative intent treatment of head and neck cancer (HNC) is frequently radiation therapy over 7 weeks with concurrent chemotherapy. This regimen is effective but carries a burden of toxicity leading to severe pain and treatment breaks portending inferior outcomes. Conventional palliation methods include opioids, anticonvulsants and local anaesthetics. Breakthrough toxicities are nevertheless ubiquitous and present an urgent unmet need. Ketamine is an inexpensive drug with mechanisms of analgesia outside the opioid pathway including N-methyl-D-aspartate (NMDA) receptor antagonism and a pharmacologically unique property of opioid desensitisation. Systemic ketamine is validated in randomised controlled trials for efficacy in reducing pain and/or opioid burden in the oncologic setting. Literature supports peripherally administered ketamine for pain control without systemic toxicity. These data support our rationale of using ketamine mouthwash to decrease acute toxicity of curative treatment of HNC, the efficacy of which is our aim to elucidate. METHODS AND ANALYSIS This is a phase II, Simon's two-stage trial. Patients have pathologically confirmed HNC and an intended regimen of 70 Gy of radiation with concurrent cisplatin. The protocol is initiated on diagnosis of grade 3 mucositis and consists of 2 weeks of 4 times daily (QID) ketamine mouthwash use. The primary endpoint is pain response defined as a combination of pain score and opioid use. 23 subjects will be enrolled in stage 1. If statistical criteria are met, 33 subjects will be enrolled in stage 2. Secondary endpoints include daily pain, daily opioid use, dysphagia at baseline and completion, nightly sleep quality, feeding tube placement and any unscheduled treatment breaks. ETHICS AND DISSEMINATION All trial data will be stored in an Institutional Review Board (IRB) approved database. The protocol is registered under Northwell IRB registration number #22-0292 and U.S. Food and Drug Administration (FDA) Investigational New Drug (IND) approval has been granted under IND number 161609. Results are intended to be published in an open-source journal and further data, statistics and source documents are available on request. TRIAL REGISTRATION NUMBER NCT05331131.
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Affiliation(s)
- Daniel Koffler
- Department of Radiation Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Jacob Eckstein
- Department of Radiation Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Joseph Herman
- Department of Radiation Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Diana Martins-Welch
- Department of Palliative Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Nagashree Seetharamu
- Department of Medical Oncology, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Maged Ghaly
- Department of Radiation Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Nina Kohn
- Division of Biostatistics, Feinstein Institute for Medical Research, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Manhasset, New York, USA
| | - Louis Potters
- Department of Radiation Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Douglas Frank
- Department of Otolaryngology, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Kevin Sullivan
- Department of Medical Oncology, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
| | - Bhupesh Parashar
- Department of Radiation Medicine, Donald and Barbara Zucker SOM at Hofstra/Northwell and Northwell Health Cancer Institute, Lake Success, New York, USA
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4
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LaVine N, Emmert K, Itty J, Martins-Welch D, Carney M, Block A, Burgess L, Volandes AE, Zupanc SN, Jacome S, Gromova V, Davis AD, Schwartz P, Alvarez-Suarez A, Burns E. Reaching Ambulatory Older Adults with Educational Tools: Comparative Efficacy and Cost of Varied Outreach Modalities in Primary Care. J Gen Intern Med 2023; 38:125-130. [PMID: 36217070 PMCID: PMC9550308 DOI: 10.1007/s11606-022-07808-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 09/13/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Providing patients with access to health information that can be obtained outside of an office visit is an important part of education, yet little is known about the effectiveness of outreach modalities to connect older adults to online educational tools. The objective was to identify the effectiveness and cost of outreach modalities providing online information about advance care planning (ACP) for older adults. METHODS Six different outreach modalities were utilized to connect patients to online educational tools (ACP video decision aids). Participants were 13,582 patients aged 65 and older of 185 primary care providers with appointments over a 30-month period within a large health system in the greater New York City area. Main outcome measures were number of online video views and costs per outreach for each modality. KEY RESULTS There were 1150 video views for 21,407 remote outreach events. Text messages, sent to the largest volume of patients (8869), had the highest outcome rate (9.6%) and were the most economical ($0.09). Characterization of phone calls demonstrated 21.7% engagement in the topic of ACP but resulted in minimal video views (<1%) and incurred the highest cost per outreach ($2.88). In-office handouts had negligible results (<1%). CONCLUSIONS Text was the most cost-effective modality to connect older adults to an online educational tool in this pragmatic trial, though overall efficacy of all modalities was low.
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Affiliation(s)
- N LaVine
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - K Emmert
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - J Itty
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - D Martins-Welch
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - M Carney
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA.,Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - A Block
- New York Medical College School of Health Sciences and Practice, Westchester, NY, USA
| | - L Burgess
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - A E Volandes
- Harvard Medical School, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,ACP Decisions, Boston, MA, USA
| | - S N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - S Jacome
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - V Gromova
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | | | | | - A Alvarez-Suarez
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Edith Burns
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA. .,Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA.
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Lakhani S, Scalzitti DA, Padrone L, Martins-Welch D. From evidence to practice: early integration of palliative care in a comprehensive cancer center. Support Care Cancer 2022; 31:17. [PMID: 36513942 DOI: 10.1007/s00520-022-07510-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The American Society of Clinical Oncology (ASCO) recommends that all patients with a diagnosis of advanced cancer be referred to a palliative care team within 8 weeks of diagnosis. The benefits of early integrated palliative care are well recognized; however, there is a lack of consensus to guide operational aspects of a palliative care service within a comprehensive cancer center. In this study, we explore current palliative care referral patterns at an academic cancer center and provide recommendations for operationalizing palliative care services as a program within comprehensive cancer centers in order to adequately meet the needs of patients with advanced cancer. METHODS A retrospective chart review of patients with newly diagnosed metastatic cancer or advanced hematologic malignancy referred to the palliative care team at a comprehensive cancer center from January 1, 2021, to October 31, 2021, was conducted. Institutional Review Board (IRB) approval was obtained prior to the initiation of the chart review. RESULTS A total of 243 patients with newly diagnosed metastatic cancer or advanced hematologic malignancy were included in this review. Patients with gastrointestinal (26%), gynecologic (19%), and thoracic (21%) malignancies constituted 66% of the total cohort. The most frequent reason for referral was pain (52%). In total, 39% of patients were referred within 8 weeks of an advanced cancer diagnosis. CONCLUSION ASCO recommends that all patients with advanced cancer be referred to a palliative care specialist within 8 weeks of diagnosis. Of the newly referred patients with advanced cancer, only 39% were referred to the palliative care team within 8 weeks of their diagnosis. This considerable gap suggests the need for a consensus with regard to operationalizing the palliative care team.
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Affiliation(s)
- Shamsah Lakhani
- Advanced Clinical Providers, Northwell Health Cancer Institute, Northwell Health, New Hyde Park, NY, USA.
| | - David A Scalzitti
- Department of Health and Human Function and Rehabilitation Sciences, George Washington University, Washington, DC, USA
| | - Laura Padrone
- Northwell Health Cancer Institute, Northwell Health, New York, USA
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6
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Volandes AE, Zupanc SN, Paasche-Orlow MK, Lakin JR, Chang Y, Burns EA, LaVine NA, Carney MT, Martins-Welch D, Emmert K, Itty JE, Moseley ET, Davis AD, El-Jawahri A, Gundersen DA, Fix GM, Yacoub AM, Schwartz P, Gabry-Kalikow S, Garde C, Fischer J, Henault L, Burgess L, Goldman J, Kwok A, Singh N, Alvarez Suarez AL, Gromova V, Jacome S, Tulsky JA, Lindvall C. Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial. JAMA Netw Open 2022; 5:e220354. [PMID: 35201306 PMCID: PMC8874350 DOI: 10.1001/jamanetworkopen.2022.0354] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models. OBJECTIVE To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients. DESIGN, SETTING, AND PARTICIPANTS The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included. MAIN OUTCOMES AND MEASURES The primary outcome was ACP documentation. RESULTS A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001). CONCLUSIONS AND RELEVANCE This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Angelo E. Volandes
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- ACP Decisions, Boston, Massachusetts
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Edith A. Burns
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Nancy A. LaVine
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Maria T. Carney
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Diana Martins-Welch
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Kaitlin Emmert
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Jennifer E. Itty
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Edward T. Moseley
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Daniel A. Gundersen
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gemmae M. Fix
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts
| | - Andrea M. Yacoub
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | | | | | | | - Jonathan Fischer
- Department of Community Health and Family Medicine, Hospice and Palliative Care, Duke University Health System, Durham, North Carolina
| | - Lori Henault
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leah Burgess
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Julie Goldman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anne Kwok
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nimisha Singh
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Armando L. Alvarez Suarez
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Valeria Gromova
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Sonia Jacome
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A. Tulsky
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Wilson A, Martins-Welch D, Williams M, Tortez L, Kozikowski A, Earle B, Attivissimo L, Rosen L, Pekmezaris R. Risk Factor Assessment of Hospice Patients Readmitted within 7 Days of Acute Care Hospital Discharge. Geriatrics (Basel) 2018; 3:geriatrics3010004. [PMID: 31011052 PMCID: PMC6371090 DOI: 10.3390/geriatrics3010004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 11/16/2022] Open
Abstract
Factors surrounding readmission rates for hospice patients within seven days are still relatively unknown. The present study specifically investigates the seven-day readmission rate of patients newly discharged to hospice, and the predictive factors associated with readmission for this population. In a retrospective case-control study, we seek to identify potential predictors by comparing the characteristics of patients discharged to hospice and readmitted within one week to patients who were not readmitted. Cases (n = 46) were patients discharged to home hospice and readmitted to the hospital within seven days. Controls (n = 117) were patients discharged to home hospice and not readmitted to the hospital within seven days. Significant risk factors for readmission within seven days were found to be: age (p < 0.01), race (p < 0.001), language (p < 0.001), and insurance (p < 0.001). Further study of these predictors may identify opportunities for interventions that address patient and family concerns that may lead to readmission.
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Affiliation(s)
- Anthony Wilson
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | - Diana Martins-Welch
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | - Myia Williams
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
- Correspondence: ; Tel.: +1-516-600-1479
| | - Leanne Tortez
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | - Andrzej Kozikowski
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | - Bridget Earle
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | | | - Lisa Rosen
- Feinstein Institute for Medical Research, Manhasset, NY 11030, USA;
| | - Renee Pekmezaris
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
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Abstract
235 Background: According to the CDC, 117 million Americans have one or more chronic health conditions and 31% have used two or more prescription drugs in the past month. Approximately 40% of adults in the United States are using some form of Complementary and Alternative Medicine. Medical marijuana is one such medicine, and to date 29 states have legalized medical marijuana. Methods: A multicenter, anonymous, on-line survey of health care providers was distributed via e-mail within a large health system in the NY Metropolitan area. The survey was distributed in April and May of 2017. The specific aim was to collect information about health care providers’ perspectives on the use of MM in general and for specific medical conditions. Results: The sample (n = 137) consisted of 4% RNs, 10% NPs, 10% fellows, 21% resident physicians, and 52% attending physicians. Average experience was 13 years (range: 0-43), half (53%) were under 40 years old and just over half (56%) were female. Most practitioners recognized a benefit of MM for the treatment of cancer-associated symptoms, few were concerned with side effects and 5% of responders answered that MM was not appropriate at any stage of illness. Responders were “most likely to recommend or refer MM if other therapies were not effective” for cancer (83%), chronic pain (68%), spinal cord injury with spasticity (50%), MS (46%), epilepsy (42%), neuropathy (42%) and Parkinson’s disease (41%). Most providers (77%) believed that MM has the potential to reduce overall opioid use, this was found to be statistically more common in younger providers. The most common conditions that providers reported their patients were requesting MM for were cancer (37%), chronic pain (26%) and neuropathy (10%). The most common concerns about MM use were side effects (16%), addiction (13%), legal consequences (11%), cost (7%) and that other providers would judge MM use (7%). Conclusions: Our survey shows that providers are overwhelmingly in support of MM use in patients with chronic illness, particularly in cancer patients. However providers describe significant and practical concerns about MM utilization. Given the rate at which MM is being legalized throughout the country, it is imperative that there be increased focus on education and clinical studies on MM.
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Lester PE, Kawai F, Rodrigues L, Lolis J, Martins-Welch D, Shalshin A, Fazzari MJ, Pan CX. Palliative Care in New York State Nursing Homes: A Descriptive Study. Am J Hosp Palliat Care 2017; 35:203-210. [DOI: 10.1177/1049909117691229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To describe the current landscape of palliative care (PC) in nursing homes (NHs) in New York State (NYS). Measurements: A statewide survey was completed by 149 respondents who named 61 different NHs as their workplace. Questions were related to presence, type, and composition of PC programs; perceptions of PC; barriers to implementing PC; and qualifying medical conditions. Results: Hospice is less available than palliative or comfort care programs, with three-fourths of NYS NH responded providing a PC program. In general, medical directors and physicians were more similar in perspective about the role/impact of PC compared to nursing and others. There was general agreement about the positive impact and role of PC in the NH. Funding and staffing were recognized as barriers to implementing PC. Conclusion: There is growing penetration of PC programs in NH facilities in NYS, with good perception of the appropriate utilization of PC programs. Financial reimbursement and staffing are barriers to providing PC in the NH and need to be addressed by the health-care system.
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Affiliation(s)
- Paula E. Lester
- Division of Geriatric Medicine, Winthrop University Hospital, Mineola, NY, USA
| | - Fernando Kawai
- Division of Geriatrics and Palliative Care Medicine, Weill Cornell Medical College, New York–Presbyterian Queens, Flushing, NY, USA
| | - Lucan Rodrigues
- Division of Palliative Care, Flushing Hospital Medical Center, Flushing, NY, USA
| | - James Lolis
- Division of Geriatric and Palliative Medicine, Hofstra Northwell School of Medicine, Great Neck, NY, USA
- Department of Medicine, Highfield Gardens Care Center, Great Neck, NY, USA
| | - Diana Martins-Welch
- Division of Geriatric and Palliative Medicine, Hofstra Northwell School of Medicine, Great Neck, NY, USA
- Department of Medicine, Highfield Gardens Care Center, Great Neck, NY, USA
| | - Alexander Shalshin
- Division of Palliative Medicine, Plainview–Syosset Hospitals, Northwell Health, Great Neck, NY, USA
| | - Melissa J. Fazzari
- Department of Biostatistics, Stony Brook University School of Medicine, Winthrop University Hospital, Mineola, NY, USA
| | - Cynthia X. Pan
- Division of Geriatrics and Palliative Care Medicine, Weill Cornell Medical College, New York–Presbyterian Queens, Flushing, NY, USA
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Martins-Welch D, Liberman T, D'Olimpio J, Carney M. Developing a supportive oncology program in a cancer institute: Needs assessment. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.26_suppl.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
141 Background: Cancer patients experience significant symptom and psychosocial burden (Temel JS, et. al. N Engl J Med. 2010 Aug 19; 363(8):733-42. Early palliative care for patients with metastatic non-small-cell lung cancer.). Integration of supportive oncology programs within cancer centers has developed since the findings of Temel and Jackson. Addressing a growing need to manage patients comprehensively, the Northwell Health Divisions of Geriatric and Palliative Medicine and Hematology and Oncology partnered to initiate a community-based supportive oncology program. A needs assessment was completed of the providers staff, and important stakeholders. Methods: A sixteen-question survey was created and distributed to the staff at the cancer center. Questions focused on providers’ need for support in fifteen areas. The target audience included physicians, fellows, mid-level providers, registered nurses, social workers, dietitians, and care navigators. A student intern administered surveys over a six-week period. Results: A total of 61 surveys were collected. Of these, 30 were completed by registered nurses, 13 by physicians, 9 by mid-level practitioners, and 3 by social workers. Physicians expressed the highest level of need (> 4.5/5) related to nutritional status, psychosocial factors and pharmaceutical review. Mid-level providers expressed highest level of need related to pain and depression. Nurses expressed highest level of need related to psychosocial factors, pain, depression, fatigue and pharmaceutical review. The average level of need across all areas and all respondents was 4.2 on a 5 point scale. The biggest challenge identified was lack of time to perform comprehensive assessments of patients. Conclusions: A high level of need for a supportive oncology program was identified. Per our assessment, providing comprehensive care with an emphasis on symptom control, nutritional and psychosocial support, and pharmaceutical review would benefit both providers and patients. Time constraints were identified as an issue by all practitioners and staff. The survey results supported the need for an added level of multi-disciplinary support for oncologists to care for cancer patients in the community.
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Wilson AE, Martins-Welch D, Earle B, Kozikowski A, Attivissimo L, Rosen LM, Pekmezaris R. Risk factor assessment of hospice patients who are readmitted within 7 days of acute care hospital discharge. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.29_suppl.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
121 Background: Although 20% of adults 65 and older are re-hospitalized within 30 days of discharge, there is a dearth of research investigating readmission of patients discharged to hospice and the predictors of the readmissions. The study aim was to identify risk factors for hospital readmission within 7 days of discharge to home hospice. Methods: This was a retrospective case control study with cases being patients discharged to home hospice that were readmitted to the hospital within 7 days. Controls were patients discharged to home hospice and not readmitted to the hospital within 7 days. Descriptive statistics were used to describe demographic and clinical characteristics. The chi-square or Fisher’s Exact test were used to compare categorical predictors between cases and controls. The two-sample t-test or the Mann-Whitney test were used to compare continuous predictors between cases and controls. Results: There were 163 subjects; 46 cases (28.22%) and 117 controls (71.78%). The most frequent hospital diagnosis was cancer (56.4%). There was a significant association between 7-day readmission (i.e., case) and age (P < 0.0041), race (P < 0.0008), language (P < 0.0007) and insurance (P < 0.0001). Specifically, cases were significantly younger than controls (69.5 vs. 77.0). Cases were more likely to be Hispanic (15.2 vs. 5.1), Asian (15.2 vs. 5.1) and other (13.0 vs. 2.6) when compared to controls. Cases were more likely to speak Spanish (13.3 vs. 3.5) or other (20.0 vs. 5.3) and less likely to speak English (66.7 vs. 91.2). Cases were less likely to have Medicare (8.7 vs. 82.9) and more likely to have Medicaid (32.6 vs. 4.3), private insurance (13.0 vs. 10.3) or other form of insurance including dual eligibility (45.7 vs. 2.6). Gender, marital status, religion, hospital diagnosis, discharge day, family support at home, symptoms and emergency contact relationship were not significantly association with 7-day readmission. Conclusions: Our data highlights four risk factors, namely age, race, language and insurance status as factors predicting readmission within seven days of acute care hospital discharge. Further study of these predictors may identify opportunities for interventions to obviate these readmissions.
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Affiliation(s)
| | | | | | | | | | - Lisa M Rosen
- Hofstra North Shore-LIJ School of Medicine, Lake Success, NY
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