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Umberfield EE, Fields MC, Lenko R, Morgan TP, Adair ES, Fromme EK, Lum HD, Moss AH, Wenger NS, Sudore RL, Hickman SE. An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go? J Am Med Dir Assoc 2024; 25:557-564.e8. [PMID: 38395413 PMCID: PMC10996838 DOI: 10.1016/j.jamda.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research. DESIGN Integrative review. SETTING AND PARTICIPANTS Not applicable. METHODS We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization. RESULTS Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified. CONCLUSIONS AND IMPLICATIONS Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.
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Affiliation(s)
- Elizabeth E Umberfield
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA.
| | - Matthew C Fields
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Rachel Lenko
- Department of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA
| | - Teryn P Morgan
- Center for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA
| | | | - Erik K Fromme
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA; Divisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
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Wenger NS, Sanz Vidorreta FJ, Dudley MT, Walling AM, Hogarth M. Consequences of a Health System Not Knowing Which Patients Are Deceased. JAMA Intern Med 2024; 184:213-214. [PMID: 38048124 PMCID: PMC10696508 DOI: 10.1001/jamainternmed.2023.6428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/12/2023] [Indexed: 12/05/2023]
Abstract
This quality improvement study in a California health system investigates the proportion of active patients who were deceased but not noted as such in the electronic health record (EHR), as well as encounters after death.
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Affiliation(s)
- Neil S. Wenger
- UCLA Division of General Internal Medicine and Health Services Research, University of California, Los Angeles
| | | | - Michael T. Dudley
- UCLA Office of Health Informatics and Analytics, University of California, Los Angeles
| | - Anne M. Walling
- UCLA Division of General Internal Medicine and Health Services Research, University of California, Los Angeles
- VA Greater Los Angeles Health System, Los Angeles, California
| | - Michael Hogarth
- Division of Biomedical Informatics, Department of Medicine, University of California, San Diego
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Zingmond D, Powell D, Jennings LA, Escarce JJ, Liang LJ, Parikh P, Wenger NS. Relationship of POLST to Hospitalization and ICU Care Among Nursing Home Residents in California. J Gen Intern Med 2023; 38:3535-3540. [PMID: 37620715 PMCID: PMC10713885 DOI: 10.1007/s11606-023-08357-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Physician Orders for Life Sustaining Treatment (POLST) document instructions for intensity of care based upon patient care preferences. POLST forms generally reflect patients' wishes and dictate subsequent medical care, but it is not known how POLST use and content among nursing home residents is associated with inpatient utilization across a large population. OBJECTIVE Evaluate the relationship between POLST use and content with hospital utilization among nursing home residents in California. DESIGN Retrospective cohort study using the Minimum Data Set linked to California Section S (POLST documentation), the Medicare Beneficiary Summary File, and Medicare line item claims. PATIENTS California nursing home residents with Medicare fee-for-service insurance, 2011-2016. MAIN MEASURES Hospitalization, days in the hospital, and days in the intensive care unit (ICU) after adjustment for resident and nursing home characteristics. KEY RESULTS The 1,112,834 residents had a completed and signed (valid) POLST containing orders for CPR with Full treatment 29.6% of resident-time (in person-years) and a DNR order with Selective treatment or Comfort care 27.1% of resident-time. Unsigned POLSTs accounted for 11.3% of resident-time. Residents experienced 14 hospitalizations and a mean of 120 hospital days and 37 ICU days per 100 person-years. Residents with a POLST indicating CPR Full treatment had utilization nearly identical to residents without a POLST. A gradient of decreased utilization was related to lower intensity of care orders. Compared to residents without a POLST, residents with a POLST indicating DNR Comfort care spent 56 fewer days in the hospital and 22 fewer days in the ICU per 100 person-years. Unsigned POLST had a weaker and less consistent relationship with hospital utilization. CONCLUSIONS Among California NH residents, there is a direct relationship between intensity of care preferences in POLST and hospital utilization. These findings emphasize the importance of a valid POLST capturing informed preferences for nursing home residents.
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Affiliation(s)
- David Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
| | | | - Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Jose J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Punam Parikh
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Hays RD, Walling AM, Sudore RL, Chau A, Wenger NS. Support for Use of Consumer Assessment of Healthcare Providers and Systems Communication Items Among Seriously Ill Patients. J Palliat Med 2023; 26:1234-1239. [PMID: 37093298 PMCID: PMC10623076 DOI: 10.1089/jpm.2022.0572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Background: High-quality doctor-patient communication is essential for patients with serious illnesses. The reliability and validity of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) communication items among these patients are unknown. Methods: Five CAHPS communication items, a 4-item Advance Care Planning (ACP) engagement scale, 5-item confidence in others' knowledge of ACP medical wishes scale, and a question about confidence in filling out ACP-related medical forms were administered to 1100 patients (20% response rate) with serious illness receiving primary care at three University of California Health Systems. Results: Average age was 69 (range 22-102); 52% male, 18% Hispanic, 9% Asian, and 7% Black; 24% had high school or less education. Eigenvalues and internal consistency reliability (0.88) supported a 5-item communication scale. Item characteristic curves showed a monotonic relationship of response options with the communication score. Item thresholds indicated that most patients reported positive patient experiences (i.e., items were negatively skewed). Item slopes ranging from 2.52 to 5.10 confirmed that all items were strongly related to the communication score. Information (reliability) of the communication scale was higher for assessing patients with negative experiences of care than for the positive end of the spectrum. Communication was positively correlated with confidence in other's knowledge of ACP medical wishes (r = 0.32, p < 0.0001), ACP engagement (r = 0.14, p < 0.0001), and confidence in filling out ACP-related medical forms (r = 0.09, p = 0.0022). Conclusions: These findings support the use of CAHPS survey items to assess communication among patients with serious illnesses in primary care. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04012749.
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Affiliation(s)
- Ron D. Hays
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Anne M. Walling
- Department of Medicine, University of California, Los Angeles, California, USA
- VA Greater Los Angeles Health System, Los Angeles, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aaron Chau
- Department of Medicine, University of California, Irvine, Irvine, California, USA
| | - Neil S. Wenger
- Department of Medicine, University of California, Los Angeles, California, USA
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Zingmond DS, Powell D, Jennings LA, Liang LJ, Escarce JJ, Parikh P, Wenger NS. Changes over time in POLST use and content by race and ethnicity among California nursing home residents. J Am Geriatr Soc 2023; 71:2779-2787. [PMID: 37092747 PMCID: PMC10524124 DOI: 10.1111/jgs.18374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 03/08/2023] [Accepted: 03/27/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity. METHODS California requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content-orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned. RESULTS POLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two-thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p < 0.001). Increases over time in POLST with CPR and full treatment were greater for Black and Hispanic residents compared to White residents. The increase in POLST with DNR and DNR with Selective treatment and Comfort orders was greater for White compared to Black patients (p < 0.001). Unsigned POLST with CPR and DNR orders decreased across all racial and ethnic groups. CONCLUSIONS Racial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective. Studies of newer POLST data are imperative.
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Affiliation(s)
- David S Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jose J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Punam Parikh
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Sudore RL, Walling AM, Gibbs L, Rahimi M, Wenger NS. Implementation Challenges for a Multisite Advance Care Planning Pragmatic Trial: Lessons Learned. J Pain Symptom Manage 2023; 66:e265-e273. [PMID: 37098388 PMCID: PMC10358280 DOI: 10.1016/j.jpainsymman.2023.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/06/2023] [Accepted: 04/16/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND/PROBLEM Advance care planning (ACP) pragmatic trials are needed. PROPOSED SOLUTION We determined key system-level activities to implement ACP interventions for a cluster-randomized pragmatic trial. We identified patients with serious illness from 50 primary care clinics across three University of California health systems using a validated algorithm. If patients lacked documented ACP within the last 3 years, they were eligible for an intervention: (Arm 1) an advance directive (AD); (Arm 2) AD + PREPAREforYourCare.org; (Arm 3) AD + PREPARE + lay health navigator outreach. Triggered by an appointment, we mailed and sent interventions through automated electronic health record (EHR) messaging. We collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. We are currently finalizing 24 months follow-up data. OUTCOMES/METHODS We used the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to track secular trends and implementation efforts. KEY MESSAGE/RESULTS Required multisite, system-level activities: 1) obtaining leadership, legal/privacy, and EHR approvals; 2) standardizing ACP documentation; 3) providing clinician education; 3) validating an automated serious illness identification algorithm; 4) standardizing ACP messaging with input from over 100 key advisors; 5) monitoring secular trends (e.g., COVID); and 6) standardizing ACP workflows (e.g., scanned ADs). Of 8707 patients with serious illness, 6883 were eligible for an intervention. Across all arms, 99% received the mailed intervention, 78.3% had an active patient portal (64.2% opened intervention), and 90.5% of arm three patients (n = 2243) received navigator outreach. LESSONS LEARNED Implementing a multisite health system-wide ACP program and pragmatic trial, with automated EHR-based cohort identification and intervention delivery, requires a high level of multidisciplinary key advisor engagement, standardization, and monitoring. These activities provide guidance for the implementation of other large-scale, population-based ACP efforts.
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Affiliation(s)
- Rebecca L Sudore
- Department of Medicine (R.L.S.), University of California, San Francisco, California; San Francisco VA Medical Center (R.L.S), San Francisco, California
| | - Anne M Walling
- Department of Medicine (A.M.W., N.S.W.), University of California, Los Angeles, California; VA Greater Los Angeles Health System (A.M.W.), Los Angeles, California.
| | - Lisa Gibbs
- Division of Geriatric Medicine and Gerontology (L.G.), Department of Family Medicine, University of California, Irvine, California
| | - Maryam Rahimi
- Division of General Internal Medicine and Primary Care (M.R.), Department of Medicine, University of California, Irvine, California
| | - Neil S Wenger
- Department of Medicine (A.M.W., N.S.W.), University of California, Los Angeles, California
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Chau AJ, Sudore RL, Hays RD, Tseng CH, Walling AM, Rahimi M, Gibbs L, Patel K, Sanz Vidorreta FJ, Wenger NS. Telephone Outreach Enhances Recruitment of Underrepresented Seriously Ill Patients for an Advance Care Planning Pragmatic Trial. J Gen Intern Med 2023; 38:1848-1853. [PMID: 36717432 PMCID: PMC10271940 DOI: 10.1007/s11606-022-08000-7] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/23/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients experiencing systemic patterns of disadvantage, such as racial/ethnic minorities and those with limited English proficiency, are underrepresented in research. This is particularly true for large pragmatic trials of potentially sensitive research topics, such as advance care planning (ACP). It is unclear how phone outreach may affect research participation by underrepresented individuals. OBJECTIVE To assess the effect of phone outreach, in addition to standard mail survey recruitment, in a population-based ACP pragmatic trial at three academic health systems in California. DESIGN Retrospective cohort study PATIENTS: Primary care patients with serious illness were mailed a survey in their preferred language. Patients who did not initially respond by mail received up to three reminder phone calls with the option of survey completion by phone. MAIN MEASURES Effect of phone outreach on survey response rate associated with respondent demographic characteristics (e.g., Social Vulnerability Index [SVI], range 0 (low) to 1 (high)). RESULTS Across the health systems, 5998 seriously ill patients were mailed surveys. We obtained completed surveys from 1215 patients (20% response rate); 787 (65%) responded after mail alone and 428 (35%) participated only after phone outreach. Patients recruited after phone outreach compared to mail alone were more socially vulnerable (SVI 0.41 v 0.35, P < 0.001), were more likely to report being a racial/ethnic minority (35% v 28%, P = 0.006), and non-English speaking (16% v 10%, P = 0.005). Age and gender did not differ significantly. The inclusion of phone outreach resulted in a sample that better represented the baseline population than mail alone in racial/ethnic minority (28% mail alone, 30% including phone outreach, 36% baseline population), non-English language preference (10%, 12%, 15%, respectively), and SVI (0.35, 0.37, 0.38, respectively). CONCLUSIONS Phone outreach for a population-based survey in a pragmatic trial concerning a potentially sensitive topic significantly enhanced recruitment of underrepresented seriously ill patients.
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Affiliation(s)
- Aaron J Chau
- Division of Geriatric Medicine, Department of Family Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Rebecca L Sudore
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Ron D Hays
- UCLA Division of General Internal Medicine and Health Services Research, University of California, Los Angeles School of Medicine, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- UCLA Division of General Internal Medicine and Health Services Research, University of California, Los Angeles School of Medicine, Los Angeles, CA, USA
| | - Anne M Walling
- UCLA Division of General Internal Medicine and Health Services Research, University of California, Los Angeles School of Medicine, Los Angeles, CA, USA
- VA Greater Los Angeles Health System, Los Angeles, CA, USA
| | - Maryam Rahimi
- Department of Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Lisa Gibbs
- Division of Geriatric Medicine, Department of Family Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Kanan Patel
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Fernando Javier Sanz Vidorreta
- UCLA Division of General Internal Medicine and Health Services Research, University of California, Los Angeles School of Medicine, Los Angeles, CA, USA
| | - Neil S Wenger
- UCLA Division of General Internal Medicine and Health Services Research, University of California, Los Angeles School of Medicine, Los Angeles, CA, USA.
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Liu TC, Yoo SM, Sim MS, Motwani Y, Viswanathan N, Wenger NS. Perceived Cognitive Deficits in Patients With Symptomatic SARS-CoV-2 and Their Association With Post-COVID-19 Condition. JAMA Netw Open 2023; 6:e2311974. [PMID: 37145596 DOI: 10.1001/jamanetworkopen.2023.11974] [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] [Indexed: 05/06/2023] Open
Abstract
Importance Neuropsychiatric symptoms are common in acute SARS-CoV-2 infection and in post-COVID-19 condition (PCC; colloquially known as long COVID), but the association between early presenting neuropsychiatric symptoms and PCC is unknown. Objective To describe the characteristics of patients with perceived cognitive deficits within the first 4 weeks of SARS-CoV-2 infection and the association of those deficits with PCC symptoms. Design, Setting, and Participants This prospective cohort study was conducted from April 2020 to February 2021, with follow-up of 60 to 90 days. The cohort consisted of adults enrolled in the University of California, Los Angeles, SARS-CoV-2 Ambulatory Program who had a laboratory-confirmed symptomatic SARS-CoV-2 infection and were either hospitalized in a University of California, Los Angeles, hospital or one of 20 local health care facilities, or were outpatients referred by a primary care clinician. Data analysis was performed from March 2022 to February 2023. Exposure Laboratory-confirmed SARS-CoV-2 infection. Main Outcomes and Measures Patients responded to surveys that included questions about perceived cognitive deficits modified from the Perceived Deficits Questionnaire, Fifth Edition, (ie, trouble being organized, trouble concentrating, and forgetfulness) and symptoms of PCC at 30, 60, and 90 days after hospital discharge or initial laboratory-confirmed infection of SARS-CoV-2. Perceived cognitive deficits were scored on a scale from 0 to 4. Development of PCC was determined by patient self-report of persistent symptoms 60 or 90 days after initial SARS-CoV-2 infection or hospital discharge. Results Of 1296 patients enrolled in the program, 766 (59.1%) (mean [SD] age, 60.0 [16.7] years; 399 men [52.1%]; 317 Hispanic/Latinx patients [41.4%]) completed the perceived cognitive deficit items at 30 days after hospital discharge or outpatient diagnosis. Of the 766 patients, 276 (36.1%) perceived a cognitive deficit, with 164 (21.4%) having a mean score of greater than 0 to 1.5 and 112 patients (14.6 %) having a mean score greater than 1.5. Prior cognitive difficulties (odds ratio [OR], 1.46; 95% CI, 1.16-1.83) and diagnosis of depressive disorder (OR, 1.51; 95% CI, 1.23-1.86) were associated with report of a perceived cognitive deficit. Patients reporting perceived cognitive deficits in the first 4 weeks of SARS-CoV-2 infection were more likely to report symptoms of PCC than those without perceived cognitive deficits (118 of 276 patients [42.8%] vs 105 of 490 patients [21.4%]; χ21, 38.9; P < .001). Adjusting for demographic and clinical factors, perceived cognitive deficits in the first 4 weeks of SARS-CoV-2 were associated with PCC symptoms (patients with a cognitive deficit score of >0 to 1.5: OR, 2.42; 95% CI, 1.62-3.60; patients with cognitive deficit score >1.5: OR, 2.97; 95% CI, 1.86-4.75) compared to patients who reported no perceived cognitive deficits. Conclusions and Relevance These findings suggest that patient-reported perceived cognitive deficits in the first 4 weeks of SARS-CoV-2 infection are associated with PCC symptoms and that there may be an affective component to PCC in some patients. The underlying reasons for PCC merit additional exploration.
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Affiliation(s)
- Teresa C Liu
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California, Los Angeles
| | - Sun M Yoo
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California, Los Angeles
| | - Myung S Sim
- Department of Medicine Statistics Core, University of California, Los Angeles
| | - Yash Motwani
- Department of Medicine Statistics Core, University of California, Los Angeles
| | - Nisha Viswanathan
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California, Los Angeles
| | - Neil S Wenger
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California, Los Angeles
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Tarn DM, Pace WD, Tseng CH, Callen E, Loskutova NY, Stange KC, Wenger NS. Outcomes of A Virtual Practice-Tailored Medicare Annual Wellness Visit Intervention. J Am Board Fam Med 2023:jabfm.2022.220342R1. [PMID: 37028913 DOI: 10.3122/jabfm.2022.220342r1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/03/2023] [Accepted: 01/09/2023] [Indexed: 04/09/2023] Open
Abstract
INTRODUCTION Interventions are needed to promote utilization of the Medicare Annual Wellness Visit (AWV), an underused opportunity to perform screenings and plan individualized preventive health services. METHOD Using remote practice redesign and electronic health record (EHR) support, we implemented the Practice-Tailored AWV intervention in 2021 (during the COVID-19 pandemic) in 3 small community-based practices. The intervention combines EHR-based tools with practice redesign approaches and resources. Outcomes included completion of AWV and fulfillment of recommended preventive services. RESULTS At baseline the 3 practices had 1,513 Medicare patients with at least 1 visit in the past 12 months. AWV utilization went from 7% at baseline to 54% 8 months postintervention implementation; advance care planning increased 10.7% (from 7.9% to 18.6%); depression screening increased 16.3% (from 51.7% to 68.0%); and alcohol misuse screening increased 17.3% (from 42.6% to 59.9%). Every individual preventive health service was received more often by patients with an AWV than those without. At the patient level, fulfillment of all eligible preventive services (of a maximum of 12 evaluated) went from 47.5% to 53.8% (P < .001). Subgroup analyses showed that patients with AWVs completed a greater percentage of their total recommended preventive health services than those without an AWV. CONCLUSION Virtual implementation of an intervention that combined EHR-based tools with practice redesign approaches increased AWV and preventive services utilization in Medicare patients. Given the success of this intervention during the COVID-19 pandemic (when practices had many competing demands), greater consideration should be given to delivering future interventions virtually.
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Affiliation(s)
- Derjung M Tarn
- From the Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (DMT); DARTNet Institute, Aurora, CO (WDP); Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (C-HT, NSW); American Academy of Family Physicians, Leawood, KS (EC, NYL); and Center for Community Health Integration and Department of Family Medicine & Community Health, Population & Quantitative Health Sciences, and Sociology, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Wilson D Pace
- From the Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (DMT); DARTNet Institute, Aurora, CO (WDP); Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (C-HT, NSW); American Academy of Family Physicians, Leawood, KS (EC, NYL); and Center for Community Health Integration and Department of Family Medicine & Community Health, Population & Quantitative Health Sciences, and Sociology, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Chi-Hong Tseng
- From the Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (DMT); DARTNet Institute, Aurora, CO (WDP); Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (C-HT, NSW); American Academy of Family Physicians, Leawood, KS (EC, NYL); and Center for Community Health Integration and Department of Family Medicine & Community Health, Population & Quantitative Health Sciences, and Sociology, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Elisabeth Callen
- From the Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (DMT); DARTNet Institute, Aurora, CO (WDP); Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (C-HT, NSW); American Academy of Family Physicians, Leawood, KS (EC, NYL); and Center for Community Health Integration and Department of Family Medicine & Community Health, Population & Quantitative Health Sciences, and Sociology, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Natalia Y Loskutova
- From the Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (DMT); DARTNet Institute, Aurora, CO (WDP); Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (C-HT, NSW); American Academy of Family Physicians, Leawood, KS (EC, NYL); and Center for Community Health Integration and Department of Family Medicine & Community Health, Population & Quantitative Health Sciences, and Sociology, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Kurt C Stange
- From the Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (DMT); DARTNet Institute, Aurora, CO (WDP); Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (C-HT, NSW); American Academy of Family Physicians, Leawood, KS (EC, NYL); and Center for Community Health Integration and Department of Family Medicine & Community Health, Population & Quantitative Health Sciences, and Sociology, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Neil S Wenger
- From the Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (DMT); DARTNet Institute, Aurora, CO (WDP); Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA (C-HT, NSW); American Academy of Family Physicians, Leawood, KS (EC, NYL); and Center for Community Health Integration and Department of Family Medicine & Community Health, Population & Quantitative Health Sciences, and Sociology, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
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Neville TH, Taich Z, Walling AM, Bear D, Cook DJ, Tseng CH, Wenger NS. The 3 Wishes Program Improves Families' Experience of Emotional and Spiritual Support at the End of Life. J Gen Intern Med 2023; 38:115-121. [PMID: 35581456 PMCID: PMC9113739 DOI: 10.1007/s11606-022-07638-7] [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: 12/04/2021] [Accepted: 04/22/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL. AIM To assess whether the 3WP is associated with improved ratings of EOL care. PROGRAM DESCRIPTION In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families. SETTING 2-hospital academic healthcare system. PARTICIPANTS Dying patients in the ICU and their families. PROGRAM EVALUATION A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care). RESULTS Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups. DISCUSSION The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience.
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Affiliation(s)
- Thanh H Neville
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
| | - Zachary Taich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.,VA Greater Los Angeles Healthcare System, Veteran Affairs, Los Angeles, USA
| | - Danielle Bear
- UCLA Office of the Patient Experience, UCLA Health, Los Angeles, CA, USA
| | - Deborah J Cook
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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11
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Tarn DM, Wenger NS, Stange KC. Small Solutions for Primary Care Are Part of a Larger Problem. Ann Intern Med 2022; 175:1179-1180. [PMID: 35759763 PMCID: PMC9794382 DOI: 10.7326/m21-4509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Derjung Mimi Tarn
- Department of Family Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California (D.M.T.)
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California (N.S.W.)
| | - Kurt C Stange
- Center for Community Health Integration and Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, Oncology, and Sociology, Case Western Reserve University, Cleveland, Ohio (K.C.S.)
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12
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Yoo SM, Liu TC, Motwani Y, Sim MS, Viswanathan N, Samras N, Hsu F, Wenger NS. Factors Associated with Post-Acute Sequelae of SARS-CoV-2 (PASC) After Diagnosis of Symptomatic COVID-19 in the Inpatient and Outpatient Setting in a Diverse Cohort. J Gen Intern Med 2022; 37:1988-1995. [PMID: 35391623 PMCID: PMC8989256 DOI: 10.1007/s11606-022-07523-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/28/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND The incidence of persistent clinical symptoms and risk factors in Post-Acute Sequelae of SARS-CoV-2 (PASC) in diverse US cohorts is unclear. While there are a disproportionate share of COVID-19 deaths in older patients, ethnic minorities, and socially disadvantaged populations in the USA, little information is available on the association of these factors and PASC. OBJECTIVE To evaluate the association of demographic and clinical characteristics with development of PASC. DESIGN Prospective observational cohort of hospitalized and high-risk outpatients, April 2020 to February 2021. PARTICIPANTS One thousand thirty-eight adults with laboratory-confirmed symptomatic COVID-19 infection. MAIN MEASURES Development of PASC determined by patient report of persistent symptoms on questionnaires conducted 60 or 90 days after COVID-19 infection or hospital discharge. Demographic and clinical factors associated with PASC. KEY RESULTS Of 1,038 patients with longitudinal follow-up, 309 patients (29.8%) developed PASC. The most common persistent symptom was fatigue (31.4%) followed by shortness of breath (15.4%) in hospitalized patients and anosmia (15.9%) in outpatients. Hospitalization for COVID-19 (odds ratio [OR] 1.49, 95% [CI] 1.04-2.14), having diabetes (OR, 1.39; 95% CI 1.02-1.88), and higher BMI (OR, 1.02; 95% CI 1-1.04) were independently associated with PASC. Medicaid compared to commercial insurance (OR, 0.49; 95% CI 0.31-0.77) and having had an organ transplant (OR 0.44, 95% CI, 0.26-0.76) were inversely associated with PASC. Age, race/ethnicity, Social Vulnerability Index, and baseline functional status were not associated with developing PASC. CONCLUSIONS Three in ten survivors with COVID-19 developed a subset of symptoms associated with PASC in our cohort. While ethnic minorities, older age, and social disadvantage are associated with worse acute COVID-19 infection and greater risk of death, our study found no association between these factors and PASC.
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Affiliation(s)
- Sun M Yoo
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA.
| | - Teresa C Liu
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Yash Motwani
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Myung S Sim
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Nisha Viswanathan
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Nathan Samras
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Felicia Hsu
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Neil S Wenger
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
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Ramezani R, Zhang W, Roberts P, Shen J, Elashoff D, Xie Z, Stanton A, Eslami M, Wenger NS, Trent J, Petruse A, Weldon A, Ascencio A, Sarrafzadeh M, Naeim A. Physical Activity Behavior of Patients at a Skilled Nursing Facility: Longitudinal Cohort Study. JMIR Mhealth Uhealth 2022; 10:e23887. [PMID: 35604762 PMCID: PMC9171595 DOI: 10.2196/23887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 04/01/2021] [Accepted: 04/08/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND On-body wearable sensors have been used to predict adverse outcomes such as hospitalizations or fall, thereby enabling clinicians to develop better intervention guidelines and personalized models of care to prevent harmful outcomes. In our previous work, we introduced a generic remote patient monitoring framework (Sensing At-Risk Population) that draws on the classification of human movements using a 3-axial accelerometer and the extraction of indoor localization using Bluetooth low energy beacons, in concert. Using the same framework, this paper addresses the longitudinal analyses of a group of patients in a skilled nursing facility. We try to investigate if the metrics derived from a remote patient monitoring system comprised of physical activity and indoor localization sensors, as well as their association with therapist assessments, provide additional insight into the recovery process of patients receiving rehabilitation. OBJECTIVE The aim of this paper is twofold: (1) to observe longitudinal changes of sensor-based physical activity and indoor localization features of patients receiving rehabilitation at a skilled nursing facility and (2) to investigate if the sensor-based longitudinal changes can complement patients' changes captured by therapist assessments over the course of rehabilitation in the skilled nursing facility. METHODS From June 2016 to November 2017, patients were recruited after admission to a subacute rehabilitation center in Los Angeles, CA. Longitudinal cohort study of patients at a skilled nursing facility was followed over the course of 21 days. At the time of discharge from the skilled nursing facility, the patients were either readmitted to the hospital for continued care or discharged to a community setting. A longitudinal study of the physical therapy, occupational therapy, and sensor-based data assessments was performed. A generalized linear mixed model was used to find associations between functional measures with sensor-based features. Occupational therapy and physical therapy assessments were performed at the time of admission and once a week during the skilled nursing facility admission. RESULTS Of the 110 individuals in the analytic sample with mean age of 79.4 (SD 5.9) years, 79 (72%) were female and 31 (28%) were male participants. The energy intensity of an individual while in the therapy area was positively associated with transfer activities (β=.22; SE 0.08; P=.02). Sitting energy intensity showed positive association with transfer activities (β=.16; SE 0.07; P=.02). Lying down energy intensity was negatively associated with hygiene activities (β=-.27; SE 0.14; P=.04). The interaction of sitting energy intensity with time (β=-.13; SE 0.06; P=.04) was associated with toileting activities. CONCLUSIONS This study demonstrates that a combination of indoor localization and physical activity tracking produces a series of features, a subset of which can provide crucial information to the story line of daily and longitudinal activity patterns of patients receiving rehabilitation at a skilled nursing facility. The findings suggest that detecting physical activity changes within locations may offer some insight into better characterizing patients' progress or decline.
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Affiliation(s)
- Ramin Ramezani
- Center for Smart Health, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA, United States
| | - Wenhao Zhang
- Center for Smart Health, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA, United States
| | - Pamela Roberts
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - John Shen
- Department of Hematology and Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - David Elashoff
- Department of Medicine Statistics Core, Biostatistics and Computational Biology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Zhuoer Xie
- Department of Hematology and Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Annette Stanton
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michelle Eslami
- Rockport Healthcare Services, Los Angeles, CA, United States
| | - Neil S Wenger
- Division of General Internal Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jacqueline Trent
- Department of Hematology and Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Antonia Petruse
- Department of Hematology and Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Amelia Weldon
- Department of Hematology and Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Andy Ascencio
- Department of Hematology and Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Majid Sarrafzadeh
- Department of Computer Science, University of California, Los Angeles, Los Angeles, CA, United States
| | - Arash Naeim
- Center for Smart Health, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Hematology and Oncology, University of California, Los Angeles, Los Angeles, CA, United States
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Wenger NS, Stanton AL, Baxter-King R, Sepucha K, Vavreck L, Naeim A. The Impact of COVID-19 on Routine Medical Care and Cancer Screening. J Gen Intern Med 2022; 37:1450-1456. [PMID: 35013931 PMCID: PMC8744580 DOI: 10.1007/s11606-021-07254-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 03/01/2021] [Accepted: 10/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND COVID-19 restrictions and fear dramatically changed the use of medical care. Understanding the magnitude of cancelled and postponed appointments and associated factors can help identify approaches to mitigate unmet need. OBJECTIVE To determine the proportion of medical visits cancelled or postponed and for whom. We hypothesized that adults with serious medical conditions and those with higher anxiety, depressive symptoms, and avoidance-oriented coping would have more cancellations/postponements. DESIGN Four nationally representative cross-sectional surveys conducted online in May, July, October, and December 2020. PARTICIPANTS 59,747 US adults who completed 15-min online surveys. 69% cooperation rate. MEASURES Physical and mental health visits and cancer screening cancelled or postponed over prior 2 months. Plan to cancel or postpone visits over the next 2 months. Relationship with demographics, medical conditions, local COVID-19 death rate, anxiety, depressive symptoms, coping, intolerance of uncertainty, and perceived COVID-19 risk. KEY RESULTS Of the 58% (N = 34,868) with a medical appointment during the 2 months before the survey, 64% had an appointment cancelled or postponed in May, decreasing to 37% in December. Of the 41% of respondents with scheduled cancer screening, 20% cancelled/postponed, which was stable May to December. People with more medical conditions were more likely to cancel or postpone medical visits (OR 1.19 per condition, 95% CI 1.16, 1.22) and cancer screening (OR 1.20, 95% CI 1.15, 1.24). Race, ethnicity, and income had weak associations with cancelled/postponed visits, local death rate was unrelated, but anxiety and depressive symptoms were strongly related to cancellations, and this grew between May and December. CONCLUSIONS Cancelled medical care and cancer screening were more common among persons with medical conditions, anxiety and depression, even after accounting for COVID-19 deaths. Outreach and support to ensure that patients are not avoiding needed care due to anxiety, depression and inaccurate perceptions of risk will be important.
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Affiliation(s)
- Neil S Wenger
- Division of General Internal Medicine and Health Sciences Research, David Geffen School of Medicine at UCLA, 1100 Glendon Avenue #804, Los Angeles, CA, 90024, USA.
| | - Annette L Stanton
- Departments of Psychology and Psychiatry/Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Ryan Baxter-King
- Department of Political Science, UCLA College, Los Angeles, CA, USA
| | - Karen Sepucha
- Health Decision Sciences Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lynn Vavreck
- Departments of Political Science and Communication, UCLA College, Los Angeles, CA, USA
| | - Arash Naeim
- UCLA Center for SMART Health, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Neville TH, Hays RD, Tseng CH, Gonzalez CA, Chen L, Hong A, Yamamoto M, Santoso L, Kung A, Schwab K, Chang SY, Qadir N, Wang T, Wenger NS. Survival After Severe COVID-19: Long-Term Outcomes of Patients Admitted to an Intensive Care Unit. J Intensive Care Med 2022; 37:1019-1028. [PMID: 35382627 PMCID: PMC8990100 DOI: 10.1177/08850666221092687] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Understanding the long-term sequelae of severe COVID-19 remains limited, particularly in the United States. OBJECTIVE To examine long-term outcomes of patients who required intensive care unit (ICU) admission for severe COVID-19. DESIGN, PATIENTS, AND MAIN MEASURES This is a prospective cohort study of patients who had severe COVID-19 requiring an ICU admission in a two-hospital academic health system in Southern California. Patients discharged alive between 3/21/2020 and 12/31/2020 were surveyed approximately 6 months after discharge to assess health-related quality of life using Patient-Reported Outcomes Measurement Information System (PROMIS®)-29 v2.1, post-traumatic stress disorder (PTSD) and loneliness scales. A preference-based health utility score (PROPr) was estimated using 7 PROMIS domain scores. Patients were also asked their attitude about receiving aggressive ICU care. KEY RESULTS Of 275 patients admitted to the ICU for severe COVID-19, 205 (74.5%) were discharged alive and 132 (64%, median age 59, 46% female) completed surveys a median of 182 days post-discharge. Anxiety, depression, fatigue, sleep disturbance, ability to participate in social activities, pain interference, and cognitive function were not significantly different from the U.S. general population, but physical function (44.2, SD 11.0) was worse. PROPr mean score of 0.46 (SD 0.30, range -0.02 to 0.96 [<0 is worse than dead and 1 represents perfect health]) was slightly lower than the U.S. general population, with an even distribution across the continuum. Poor PROPr was associated with chronic medical conditions and receipt of life-sustaining treatments, but not demographics or social vulnerability. PTSD was suspected in 20% and loneliness in 29% of patients. Ninety-eight percent of patients were glad they received life-saving treatment. CONCLUSION Most patients who survive severe COVID-19 achieve positive outcomes, with health scores similar to the general population at 6 months post-discharge. However, there is marked heterogeneity in outcomes with a substantial minority reporting severely compromised health.
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Affiliation(s)
- Thanh H Neville
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Ron D Hays
- Department of Medicine, Division of General Internal Medicine and Health Services Research, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Chi-Hong Tseng
- Department of Medicine, Division of General Internal Medicine and Health Services Research, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Cynthia A Gonzalez
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Lucia Chen
- Department of Medicine, Division of General Internal Medicine and Health Services Research, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Ashley Hong
- 8783University of California, Los Angeles, California, USA
| | - Myrtle Yamamoto
- Department of Medicine, Quality, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Laura Santoso
- Department of Medicine, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Alina Kung
- Department of Medicine, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Kristin Schwab
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Steve Y Chang
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Nida Qadir
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Tisha Wang
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Neil S Wenger
- Department of Medicine, Division of General Internal Medicine and Health Services Research, 12222David Geffen School of Medicine, UCLA, Los Angeles, California, USA
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Burton CS, Gonzalez G, Choi E, Bresee C, Nuckols TK, Eilber KS, Wenger NS, Anger JT. The Impact of Provider Sex and Experience on the Quality of Care Provided for Women with Urinary Incontinence. Am J Med 2022; 135:524-530.e1. [PMID: 34861198 PMCID: PMC9261287 DOI: 10.1016/j.amjmed.2021.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although specialists are skilled in the management of urinary incontinence, primary care clinicians are integral in early diagnosis and initiation of management in order to decrease overuse of specialty care and improve the quality of specialist visits. We measured the quality of incontinence care provided by primary care clinicians prior to referral to a specialist and evaluated the impact of provider variables on quality of care. METHODS We performed a retrospective review of 200 women referred for urinary incontinence to a Female Pelvic Medicine and Reconstructive Surgery specialist between March 2017 and July 2018. We measured primary care adherence to 12 quality indicators in the 12 months prior to specialist consultation. We stratified adherence to quality indicators by clinician sex and years of experience. RESULTS Half of women with incontinence underwent a pelvic examination or had a urinalysis ordered. Few patients with urge urinary incontinence were recommended behavioral therapy (14%) or prescribed medication (8%). When total aggregate scores were compared, female clinicians performed the recommended care 47% ± 25% of the time, compared with 35% ± 23% for male clinicians (P = .003). Increasing years of experience was associated with worse overall urinary incontinence care (r -0.157, P = .02). CONCLUSIONS We found low rates of adherence to a set of quality indicators for women with urinary incontinence, with male clinicians performing significantly worse than female clinicians. Improvement of incontinence care in primary care could significantly reduce costs of care and preserve outcomes.
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Affiliation(s)
- Claire S Burton
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | | | - Eunice Choi
- Division of Urology, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Catherine Bresee
- Biostatistics Core, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Karyn S Eilber
- Division of Urology, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, Calif
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Malkani RG, Wenger NS. Correction to: REM Sleep Behavior Disorder as a Pathway to Dementia: If, When, How, What, and Why Should Physicians Disclose the Diagnosis and Risk for Dementia. Curr Sleep Medicine Rep 2022. [DOI: 10.1007/s40675-022-00225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Jennings LA, Wenger NS, Liang LJ, Parikh P, Powell D, Escarce JJ, Zingmond D. Care preferences in physician orders for life sustaining treatment in California nursing homes. J Am Geriatr Soc 2022; 70:2040-2050. [PMID: 35275398 DOI: 10.1111/jgs.17737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/02/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Physician Orders for Life-Sustaining Treatment (POLST) facilitates documentation and transition of patients' life-sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016. METHODS California requires NHs to document in the Minimum Data Set whether residents complete a POLST and orders within POLST. Using a serial cross-sectional design for each year, we describe POLST completion and orders for all California NH residents from 2011 to 2016 (N = 1,112,668). We used logistic mixed-effects regression models to estimate POLST completion and resuscitation orders to understand the relationship with resident and facility characteristics, including Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare overall five-star quality rating. RESULTS POLST completion significantly increased from 2011 to 2016 with most residents having a POLST in 2016 (short-stay:68%; long-stay:81%). Among those with a POLST in 2016, 54% of long-stay and 41% of short-stay residents had a DNR order. Among residents with DNR, >90% had orders for limited medical interventions or comfort measures. Few residents (<6%) had a POLST with contradictory orders. In regression analyses, POLST completion was greater among residents with more functional dependence, but was lower among those with more cognitive impairment. Greater functional and cognitive impairment were associated with DNR orders. Racial and ethnic minorities indicated more aggressive care preferences. Higher CMS five-star facility quality rating was associated with greater POLST completion. CONCLUSIONS Six years after a state mandate to document POLST completion in NHs, most California NH residents have a POLST, and about half of long-stay residents have orders to limit life-sustaining treatment. Future work should focus on determining the quality of care preference decisions documented in POLST.
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Affiliation(s)
- Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Punam Parikh
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Jose J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - David Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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19
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Lee KC, Walling AM, Senglaub SS, Bernacki R, Fleisher LA, Russell MM, Wenger NS, Cooper Z. Improving Serious Illness Care for Surgical Patients: Quality Indicators for Surgical Palliative Care. Ann Surg 2022; 275:196-202. [PMID: 32502076 DOI: 10.1097/sla.0000000000003894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients. SUMMARY OF BACKGROUND DATA PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery. METHODS We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion. RESULTS After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care. CONCLUSIONS This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode.
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Affiliation(s)
- Katherine C Lee
- Department of Surgery, University of California, San Diego, La Jolla, CA
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA
- Affiliated Adjunct Staff, RAND Health, Santa Monica, CA
| | - Steven S Senglaub
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Lee A Fleisher
- Department of Anesthesiology and Medicine, Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Philadelphia, PA
| | - Marcia M Russell
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
- Department of Surgery, Dave Geffen School of Medicine, University of California, Los Angeles, CA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA
- Affiliated Adjunct Staff, RAND Health, Santa Monica, CA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
- Hebrew SeniorLife Marcus Institute for Aging Research, Boston, MA
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20
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Zingmond DS, Powell D, Jennings LA, Escarce JJ, Liang LJ, Parikh P, Wenger NS. POLST completion and continuity in California nursing homes. J Am Geriatr Soc 2021; 70:2148-2150. [PMID: 34927721 DOI: 10.1111/jgs.17610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/29/2022]
Affiliation(s)
- David S Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jose J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Punam Parikh
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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21
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D'Ambruoso SF, Glaspy JA, Hurvitz SA, Wenger NS, Pietras C, Ahmed K, Drakaki A, Goldman JW, Anand S, Simon W, Kung J, Coscarelli A, Rosen LS, Peddi PF, Wong DJL, Santos K, Phung P, Karlin D, Walling AM. Impact of a Palliative Care Nurse Practitioner in an Oncology Clinic: A Quality Improvement Effort. JCO Oncol Pract 2021; 18:e484-e494. [PMID: 34748398 DOI: 10.1200/op.21.00046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Guidelines support early integration of palliative care (PC) into standard oncology practice; however, little is known as to whether outcomes can be improved by modifying health care delivery in a real-world setting. METHODS We report our 6-year experience of embedding a nurse practitioner in an oncology clinic (March 2014-March 2020) to integrate early, concurrent advance care planning and PC. RESULTS Compared with patients with advanced cancer not enrolled in the palliative care nurse practitioner program, in March 2020, patients who are enrolled are more likely to have higher quality of PC (eg, goals of care note documentation [82% v 15%; P < .01], referral to the psychosocial oncology program [67% v 37%; P < .01], and referral to hospice [61% v 34%; P < .01]) and less inpatient utilization in the last 6 months of life (eg, hospital days [12 v 18; P < .01] and intensive care unit days [1.2 v 2.3; P < .01]). The program expanded over time with the support of faculty skills training for advance care planning and PC, supporting a shared mental model of PC delivery within the oncology clinic. CONCLUSION Embedding a trained palliative care nurse practitioner in oncology clinics to deliver early integrated PC can lead to improved quality of care for patients with advanced cancer.
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Affiliation(s)
| | - John A Glaspy
- Department of Medicine, University of California, Los Angeles, CA
| | - Sara A Hurvitz
- Department of Medicine, University of California, Los Angeles, CA
| | - Neil S Wenger
- Department of Medicine, University of California, Los Angeles, CA
| | | | - Kauser Ahmed
- Simms/Mann-UCLA Center for Integrative Oncology, Los Angeles, CA
| | | | | | - Sidharth Anand
- Department of Medicine, University of California, Los Angeles, CA
| | - Wendy Simon
- Department of Medicine, University of California, Los Angeles, CA
| | - Jennie Kung
- Hospital Operations, University of California, Los Angeles, CA
| | - Anne Coscarelli
- Department of Medicine, University of California, Los Angeles, CA
| | - Lee S Rosen
- Department of Medicine, University of California, Los Angeles, CA
| | - Parvin F Peddi
- Department of Medicine, University of California, Los Angeles, CA
| | - Deborah J L Wong
- Department of Medicine, University of California, Los Angeles, CA
| | - Katherine Santos
- Department of Medicine, University of California, Los Angeles, CA
| | - Peter Phung
- Department of Medicine, University of California, Los Angeles, CA
| | - Daniel Karlin
- Department of Medicine, University of California, Los Angeles, CA
| | - Anne M Walling
- Department of Medicine, University of California, Los Angeles, CA.,VA Greater Los Angeles Healthcare System, Los Angeles, CA
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22
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Patel AA, Ryan GW, Tisnado D, Chuang E, Walling AM, Saab S, Khemichian S, Sundaram V, Brook RH, Wenger NS. Deficits in Advance Care Planning for Patients With Decompensated Cirrhosis at Liver Transplant Centers. JAMA Intern Med 2021; 181:652-660. [PMID: 33720273 PMCID: PMC7961470 DOI: 10.1001/jamainternmed.2021.0152] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis. OBJECTIVE To describe the experience of ACP in patients with decompensated cirrhosis at liver transplant centers. DESIGN, SETTING, AND PARTICIPANTS For this multicenter qualitative study, face-to-face semistructured interviews were conducted between July 1, 2017, and May 30, 2018, with clinicians and patients with decompensated cirrhosis at 3 high-volume transplant centers in California. Patient participants were adults and had a diagnosis of cirrhosis, at least 1 portal hypertension-related complication, and current or previous Model for End-Stage Liver Disease with sodium score of 15 or higher. Clinician participants were health care professionals who provided care during the illness trajectory. MAIN OUTCOMES AND MEASURES Experiences with ACP reported by patients and clinicians. Participants were asked about the context, behaviors, thoughts, and decisions concerning elements of ACP, such as prognosis, health care preferences, values and goals, surrogate decision-making, and documentation. RESULTS The study included 42 patients (mean [SD] age, 58.2 [11.2] years; 28 men [67%]) and 46 clinicians (13 hepatologists [28%], 11 transplant coordinators [24%], 9 hepatobiliary surgeons [20%], 6 social workers [13%], 5 hepatology nurse practitioners [11%], and 2 critical care physicians [4%]). Five themes that represent the experiences of ACP were identified: (1) most patient consideration of values, goals, and preferences occurred outside outpatient visits; (2) optimistic attitudes from transplant teams hindered the discussions about dying; (3) clinicians primarily discussed death as a strategy for encouraging behavioral change; (4) transplant teams avoided discussing nonaggressive treatment options with patients; and (5) surrogate decision makers were unprepared for end-of-life decision-making. CONCLUSIONS AND RELEVANCE This study found that, despite a guarded prognosis, patients with decompensated cirrhosis had inadequate ACP throughout the trajectory of illness until the end of life. This finding may explain excessively aggressive life-sustaining treatment that patients receive at the end of life.
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Affiliation(s)
- Arpan Arun Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles.,Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Gery W Ryan
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Diana Tisnado
- Department of Public Health, California State University, Fullerton
| | - Emmeline Chuang
- School of Social Welfare, University of California, Berkeley, Berkeley.,Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Anne M Walling
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
| | - Sammy Saab
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles.,Division of Liver Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Saro Khemichian
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles
| | - Vinay Sundaram
- Karsh Division of Gastroenterology and Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California
| | - Robert H Brook
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA.,RAND Health Care, Santa Monica, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA
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23
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Peipert JD, Jennings LA, Romero T, Hays RD, Wenger NS, Keeler E, Reuben DB. Validation of a Brief Multi-Dimensional Assessment of Dementia Severity. J Am Geriatr Soc 2020; 69:512-516. [PMID: 33258124 DOI: 10.1111/jgs.16930] [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: 02/11/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Briefer measures of symptoms and functional limitations may reduce assessment burden and facilitate monitoring populations of persons with dementia (PWD). DESIGN Prospective follow-up study. SETTING University-based dementia care management program. PARTICIPANTS 1,091 PWD. MEASUREMENTS We assessed cognition (Mini Mental State Examination (MMSE)-11 tasks), neuropsychiatric symptom severity (Neuropsychiatric Inventory Questionnaire Severity Scale (NPIQ-S)-12 items), and functional ability (Activities of Daily Living (ADL)-6 items; Functional Activities Questionnaire (FAQ)-10 items). Item response theory was used to select subsets of items by identifying low item discrimination (<1.50), poor item fit (χ2 ), local dependence (LD), and with difficulty similar to other items. We estimated correlations between original and shorter scales and compared their associations with mortality. We added two symptoms (trouble swallowing, coughing when eating) reflecting late-stage dementia complications, created a multi-dimensional dementia assessment composite, and examined its association with mortality. RESULTS Five MMSE tasks were eliminated: two with low discrimination, two with difficulty similar to other items, and one with poor fit. The remaining tasks were correlated with the full MMSE at r = 0.82. We retained three ADLs that were correlated with the total ADL set at r = 0.95 and kept five FAQ items that were not LD (correlation with full FAQ, r = 0.97). Associations with mortality were similar between the longer and shorter scales. A higher score on the composite (range 0-100) indicates worse dementia impact and was associated with mortality (hazard ratio (HR) per scale point: 1.03 (1.02-1.04)). CONCLUSION These brief assessments and dementia composite may reduce administration time while preserving validity.
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Affiliation(s)
- John D Peipert
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California, USA
| | - Ron D Hays
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California, USA
| | - Emmett Keeler
- Department of Medicine, RAND Health, Santa Monica, California, USA
| | - David B Reuben
- Department of Medicine, Division of Geriatrics, University of California Los Angeles, Los Angeles, California, USA
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24
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Naeim A, Xie Z, Johansen L, Wenger NS, Elashoff D, Petruse A, Rahbar G. Using Tablets to Collect Breast Cancer Risk Information in an Underserved Population. International Journal of E-Health and Medical Communications 2020. [DOI: 10.4018/ijehmc.20201001.oa1] [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: 11/09/2022]
Abstract
The authors tested the use of tablets to collect breast cancer risk data and compared the approach against paper-based scantrons. The goal was to examine the usability of digital technology for data collection in underserved populations. A total of 340 individuals were randomized to answer a breast health survey via either tablets (170) or paper forms (170). Post questionnaire surveys were conducted to evaluate the usability of tablets. Outcomes included completion time, satisfaction, and the numbers and types of questions raised by patients during the survey. There was no significant difference in questionnaire completion time between two groups (12.5 vs. 12.1 minutes, p = 0.07). The tablet group was more satisfied with the experience (p < 0.001). Low health literacy women spent more time on the questionnaire (p < 0.05). Electronic devices can be utilized to collect breast cancer risk data in underserved, ethnically diverse populations. Future healthcare questionnaire applications should focus on accessibility improvements for these populations.
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Affiliation(s)
| | - Zhuoer Xie
- David Geffen School of Medicine, UCLA, USA
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25
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Neville TH, Wiley JF, Kardouh M, Curtis JR, Yamamoto MC, Wenger NS. Change in inappropriate critical care over time. J Crit Care 2020; 60:267-272. [PMID: 32932112 DOI: 10.1016/j.jcrc.2020.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 08/09/2020] [Accepted: 08/31/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Intensive care interventions that prolong life without achieving meaningful benefit are considered clinically "inappropriate". In 2012, the frequency of perceived-inappropriate critical care was 10.8% at one academic health system; and we aimed to re-evaluate this frequency. METHODS For 4 months in 2017, we surveyed critical care physicians daily and asked whether each patient was receiving appropriate, probably inappropriate, or inappropriate critical care. Patients were categorized into three groups: 1) patients for whom treatment was never inappropriate, 2) patients with at least one assessment that treatment was probably inappropriate, but no inappropriate treatment assessments, and 3) patients who had at least one assessment of inappropriate treatment. RESULTS Fifty-five physicians made 10,105 assessments on 1424 patients. Of these, 94 (6.6%) patients received at least one assessment of inappropriate critical care, which is lower than 2012 (10.8% (p < 0.01)). Comparing 2017 and 2012, patient age, MS-DRG, length of stay, and hospital mortality were not significantly different (p > 0.05). Inpatient mortality in 2017 was 73% for patients receiving inappropriate critical care. CONCLUSIONS Over five years the proportion of patients perceived to be receiving inappropriate critical care dropped by 40%. Understanding the reasons for such change might elucidate how to continue to reduce inappropriate critical care.
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Affiliation(s)
- Thanh H Neville
- UCLA, Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, USA.
| | - Joshua F Wiley
- Turner Institute for Brain and Mental Health and School of Psychological Sciences, Monash University, Australia
| | - Miramar Kardouh
- UCLA, Department of Medicine, David Geffen School of Medicine, USA
| | - J Randall Curtis
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA
| | - Myrtle C Yamamoto
- UCLA, Department of Medicine, Quality Improvement, David Geffen School of Medicine, USA
| | - Neil S Wenger
- UCLA, Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, USA
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26
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Fedyk M, Black H, Yarborough M, Fairman N, Wenger NS. Bioethics Emergencies Can Be Used to Perform a Real-World Test of Utilitarian Policies. Am J Bioeth 2020; 20:101-103. [PMID: 32716765 DOI: 10.1080/15265161.2020.1779398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Mark Fedyk
- University of California Davis School of Medicine
- University of California Davis Betty Irene Moore School of Nursing
| | - Hugh Black
- University of California Davis School of Medicine
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27
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Jennings LA, Hollands S, Keeler E, Wenger NS, Reuben DB. The Effects of Dementia Care
Co‐Management
on Acute Care, Hospice, and Long‐Term Care Utilization. J Am Geriatr Soc 2020; 68:2500-2507. [DOI: 10.1111/jgs.16667] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Lee A. Jennings
- Reynolds Section of Geriatrics, Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA
| | | | | | - Neil S. Wenger
- Division of General Internal Medicine and Health Services Research David Geffen School of Medicine, University of California Los Angeles California USA
| | - David B. Reuben
- Multicampus Program in Geriatric Medicine and Gerontology David Geffen School of Medicine, University of California Los Angeles California USA
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28
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FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, Abeles AM, Gelber AC, Harrold LR, Khanna D, King C, Levy G, Libbey C, Mount D, Pillinger MH, Rosenthal A, Singh JA, Sims JE, Smith BJ, Wenger NS, Sharon Bae S, Danve A, Khanna PP, Kim SC, Lenert A, Poon S, Qasim A, Sehra ST, Sharma TSK, Toprover M, Turgunbaev M, Zeng L, Zhang MA, Turner AS, Neogi T. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res (Hoboken) 2020; 72:744-760. [PMID: 32391934 PMCID: PMC10563586 DOI: 10.1002/acr.24180] [Citation(s) in RCA: 327] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/28/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. METHODS Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. RESULTS Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. CONCLUSION Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.
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Affiliation(s)
- John D. FitzGerald
- University of California, Los Angeles and VA Greater Los Angeles Health Care System, Los Angeles, California
| | | | - Ted Mikuls
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care System, Omaha, Nebraska
| | | | | | | | | | - Leslie R. Harrold
- University of Massachusetts Medical School, Worcester Massachusetts, and Corrona, Waltham, Massachusetts
| | | | | | | | - Caryn Libbey
- Boston University School of Medicine, Boston, Massachusetts
| | - David Mount
- VA Boston Healthcare System, Boston, Massachusetts
| | | | | | - Jasvinder A. Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | | | - Benjamin J. Smith
- Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | | | | | | | - Puja P. Khanna
- University of Michigan, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Seoyoung C. Kim
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Samuel Poon
- US Department of Veterans Affairs, Manchester, New Hampshire
| | - Anila Qasim
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Linan Zeng
- McMaster University, Hamilton, Ontario, Canada
| | - Mary Ann Zhang
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Tuhina Neogi
- Boston University School of Medicine, Boston, Massachusetts
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29
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Tsugawa Y, Kato H, Jha AK, Wenger NS, Zingmond DS, Gross N, Jena AB. Characteristics of Physicians Who Adopted Medicare's New Advance Care Planning Codes in the First Year. J Gen Intern Med 2020; 35:1914-1916. [PMID: 31637655 PMCID: PMC7280371 DOI: 10.1007/s11606-019-05368-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, 1100 Glendon Avenue Suite 850, Los Angeles, CA, 90024, USA. .,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Hirotaka Kato
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, 1100 Glendon Avenue Suite 850, Los Angeles, CA, 90024, USA.,Keio University Graduate School of Business Administration, Yokohama, Japan
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,VA Boston Healthcare System, Boston, MA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, 1100 Glendon Avenue Suite 850, Los Angeles, CA, 90024, USA
| | - David S Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, 1100 Glendon Avenue Suite 850, Los Angeles, CA, 90024, USA
| | | | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA, 02115, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Brook RH, Wang CJ, Wenger NS. How Community and Unity Can Help Americans Survive. J Gen Intern Med 2020; 35:1879-1880. [PMID: 32291724 PMCID: PMC7155156 DOI: 10.1007/s11606-020-05829-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Robert H Brook
- Health Care Services, RAND Corporation, Santa Monica, CA, USA. .,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - C Jason Wang
- Departments of Pediatrics and Medicine, Stanford University, Stanford, CA, USA.,Center for Policy Outcomes and Prevention, Stanford University, Stanford, CA, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, Abeles AM, Gelber AC, Harrold LR, Khanna D, King C, Levy G, Libbey C, Mount D, Pillinger MH, Rosenthal A, Singh JA, Sims JE, Smith BJ, Wenger NS, Bae SS, Danve A, Khanna PP, Kim SC, Lenert A, Poon S, Qasim A, Sehra ST, Sharma TSK, Toprover M, Turgunbaev M, Zeng L, Zhang MA, Turner AS, Neogi T. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Rheumatol 2020; 72:879-895. [PMID: 32390306 DOI: 10.1002/art.41247] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/28/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. METHODS Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. RESULTS Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. CONCLUSION Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.
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Affiliation(s)
- John D FitzGerald
- University of California, Los Angeles and VA Greater Los Angeles Health Care System, Los Angeles, California
| | | | - Ted Mikuls
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | | | | | - Aryeh M Abeles
- New York University School of Medicine, New York City, New York
| | | | - Leslie R Harrold
- University of Massachusetts Medical School, Worcester Massachusetts, and Corrona, Waltham, Massachusetts
| | | | | | | | - Caryn Libbey
- Boston University School of Medicine, Boston, Massachusetts
| | - David Mount
- VA Boston Healthcare System, Boston, Massachusetts
| | | | | | - Jasvinder A Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham
| | | | - Benjamin J Smith
- Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | | | | | | | - Puja P Khanna
- University of Michigan, VA Ann Arbor Healthcare System, Ann Arbor
| | - Seoyoung C Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Samuel Poon
- US Department of Veterans Affairs, Manchester, New Hampshire
| | - Anila Qasim
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Linan Zeng
- McMaster University, Hamilton, Ontario, Canada
| | - Mary Ann Zhang
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Tuhina Neogi
- Boston University School of Medicine, Boston, Massachusetts
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Walling AM, Sudore RL, Bell D, Tseng CH, Ritchie C, Hays RD, Gibbs L, Rahimi M, Sanz J, Wenger NS. Population-Based Pragmatic Trial of Advance Care Planning in Primary Care in the University of California Health System. J Palliat Med 2019; 22:72-81. [PMID: 31486723 PMCID: PMC6916115 DOI: 10.1089/jpm.2019.0142] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction: Varying intensity of advance care planning (ACP) interventions at the population level has not been compared among seriously ill patients in primary care. This project will implement, test, and disseminate real-world scalable ACP interventions among primary care clinics across three University of California Health systems. The three ACP interventions are (1) distribution of an advance directive (AD) with targeted ACP messaging, (2) the AD, messaging, plus prompting patients to engage with the Prepare For Your Care website (PREPARE), and (3) the AD, messaging, PREPARE, plus Care Coordinator engagement with patients and clinicians. Methods: We will identify a population cohort of seriously ill primary care patients and implement the ACP interventions using electronic health record (EHR) patient portals and postal mailings. Forty-five clinics across the three health systems will be cluster randomized to one of the three ACP interventions. The primary outcome for the population cohort is AD or Physician Orders for Life-Sustaining Treatment documentation in the EHR. A subset of the population cohort will be surveyed to assess patient-centered outcomes, including care consistent with goals at baseline, 12 months, and 24 months. Caregivers will be interviewed if patients are unable to be surveyed or die. ACP documentation, goal concordant care, and among decedents, health care utilization will be compared among intervention arms. Study Implementation: Challenges and Contributions: The project is guided by a Study Advisory Group and Community Advisory Groups at each site to ensure rigorous patient-centered methods and consistency of implementation. Intervention fidelity will be evaluated using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Challenges to implementation of this three-site health system trial and to intervention fidelity stem from site/clinic/system cultures, increasing attention to end-of-life care from payers and regulators, and growing pressures by health systems to implement ACP interventions. Stakeholder engagement is required to ensure consistent interventions across sites.
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Affiliation(s)
- Anne M. Walling
- Department of Medicine, University of California, Los Angeles, California
- VA Greater Los Angeles Health System, Los Angeles, California
| | - Rebecca L. Sudore
- Department of Medicine, University of California, San Francisco, California
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Doug Bell
- Department of Medicine, University of California, Los Angeles, California
| | - Chi-Hong Tseng
- Department of Medicine, University of California, Los Angeles, California
| | - Christine Ritchie
- Department of Medicine, University of California, San Francisco, California
| | - Ron D. Hays
- Department of Medicine, University of California, Los Angeles, California
| | - Lisa Gibbs
- Departments of Medicine and Family Medicine, University of California, Irvine, California
| | - Maryam Rahimi
- Departments of Medicine and Family Medicine, University of California, Irvine, California
| | - Javier Sanz
- Department of Medicine, University of California, Los Angeles, California
| | - Neil S. Wenger
- Department of Medicine, University of California, Los Angeles, California
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Reuben DB, Tan ZS, Romero T, Wenger NS, Keeler E, Jennings LA. Patient and Caregiver Benefit From a Comprehensive Dementia Care Program: 1-Year Results From the UCLA Alzheimer's and Dementia Care Program. J Am Geriatr Soc 2019; 67:2267-2273. [PMID: 31355423 DOI: 10.1111/jgs.16085] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [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: 02/14/2019] [Revised: 05/17/2019] [Accepted: 06/21/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND/OBJECTIVES Persons with Alzheimer disease and related dementias (ADRDs) require comprehensive care that spans health systems and community-based organizations. This study examined the clinical outcomes of a comprehensive dementia care program and identified subgroups who were more likely to benefit. DESIGN Observational, baseline and 1 year after intervention. SETTING Urban, academic medical center. PARTICIPANTS A total of 554 persons with dementia and their caregivers who had 1-year follow-up evaluations and data on clinical outcomes. INTERVENTION Health system-based comprehensive dementia care management program using nurse practitioner dementia care managers. MEASUREMENTS Patient measures included the Mini-Mental State Examination (MMSE), the Functional Activities Questionnaire, Basic and Instrumental Activities of Daily Living scales, the Cornell Scale for Depression in Dementia, and the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity. Caregiver measures included the Modified Caregiver Strain Index, the Patient Health Questionnaire-9, NPI-Q Distress, and the Dementia Burden Scale-Caregiver). We used established minimal clinically important differences and lowest tertiles of baseline symptoms to define improving symptoms and maintaining low symptoms as clinical benefit for patients and caregivers. RESULTS At year 1, persons with ADRD improved on all scales, except MMSE and functional status measures; caregivers improved on all scales. Using validated instruments, 314/543 (58%) of patients, 282/447 (63%) of caregivers, and 376/501 (75%) of patients or caregivers demonstrated clinical benefit. In adjusted multivariate models, at year 1, more behavioral symptoms and fewer depression symptoms at baseline were associated with patient improvement; and fewer baseline depression symptoms were associated with maintaining low behavioral symptoms. Male caregiver sex, higher baseline caregiver burden, and caring for patients with fewer baseline depression symptoms were associated with caregiver improvement. Male caregiver sex and patients with fewer depression symptoms, fewer behavioral symptoms, and more functional impairment at baseline were associated with caregivers maintaining low burden at 1 year. CONCLUSIONS Health system-based comprehensive dementia care management is a promising approach to improving clinical outcomes, with benefits for both patients and caregivers. J Am Geriatr Soc 67:2267-2273, 2019.
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Affiliation(s)
- David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Zaldy S Tan
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, California
| | | | - Lee A Jennings
- Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Cain CL, Koenig BA, Starks H, Thomas J, Forbes L, McCleskey S, Wenger NS. Hospital and Health System Policies Concerning the California End of Life Option Act. J Palliat Med 2019; 23:60-66. [PMID: 31298605 DOI: 10.1089/jpm.2019.0169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The End of Life Option Act (EOLOA) legalized physician aid in dying for competent, terminally ill Californians in 2016. The law allows clinicians, hospitals, and health systems to decide whether to participate. About 4 in 10 California hospitals permit the EOLOA, but little is known about their approaches and concerns. Objective: Describe hospital EOLOA policies and challenges. Design and Measurements: Survey study of hospitals in California, administered September 2017 to March 2018. We describe hospital policies concerning the EOLOA and perform thematic analysis of open-ended questions about challenges, including availability of providers, process of implementing EOLOA, experiences of distress by providers and patients, and questions about medications. Results: Of 315 hospitals surveyed, 270 (86%) responded. Every surveyed hospital had established a position on the EOLOA. Among hospitals permitting EOLOA, 38% required safeguards not required in the law, 87% provided for referral to another provider if the patient's physician did not participate, and 65% counseled staff, if needed. Among hospitals not permitting the EOLOA, nearly all allowed providers to follow patients choosing to pursue the EOLOA elsewhere and most permitted a provider to refer to another provider or system. Most hospitals expressed concerns about implementation of the EOLOA and interest in sharing promising practices. Conclusions: This survey of California hospitals demonstrates considerable heterogeneity in implementing the EOLOA. For many Californians, access to the EOLOA depends on where one receives medical care. Implementation would be improved by hospitals and health systems sharing promising practices.
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Affiliation(s)
- Cindy L Cain
- Department of Sociology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara A Koenig
- Program in Bioethics, University of California San Francisco, San Francisco, California
| | - Helene Starks
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington
| | - Judy Thomas
- Coalition for Compassionate Care of California, Sacramento, California
| | - Lindsay Forbes
- Program in Bioethics, University of California San Francisco, San Francisco, California
| | - Sara McCleskey
- Department of Health Policy and Management, University of California Los Angeles, Los Angeles, California
| | - Neil S Wenger
- Division of General Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California
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Cain CL, Koenig BA, Starks H, Thomas J, Forbes L, McCleskey S, Wenger NS. Hospital Responses to the End of Life Option Act: Implementation of Aid in Dying in California. JAMA Intern Med 2019; 179:985-987. [PMID: 30958507 PMCID: PMC6583824 DOI: 10.1001/jamainternmed.2018.8690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This survey study of statewide California hospitals evaluates the prevalence and institutional characteristics of hospitals and health systems that have either implemented or opted out of the state’s End of Life Option Act.
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Affiliation(s)
- Cindy L Cain
- Department of Sociology, University of Alabama at Birmingham, Birmingham
| | - Barbara A Koenig
- Progam in Bioethics, University of California, San Francisco, San Francisco
| | - Helene Starks
- Department of Bioethics and Humanities, University of Washington, Seattle
| | - Judy Thomas
- Coalition for Compassionate Care of California, Sacramento
| | - Lindsay Forbes
- Progam in Bioethics, University of California, San Francisco, San Francisco
| | - Sara McCleskey
- Department of Health Policy & Management, University of California, Los Angeles, Los Angeles
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles
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Jennings LA, Turner M, Keebler C, Burton CH, Romero T, Wenger NS, Reuben DB. The Effect of a Comprehensive Dementia Care Management Program on End-of-Life Care. J Am Geriatr Soc 2019; 67:443-448. [PMID: 30675898 PMCID: PMC9859712 DOI: 10.1111/jgs.15769] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND/OBJECTIVES Although Alzheimer disease and other dementias are life limiting, only a minority of these patients or their proxy decision makers participate in advance care planning. We describe end-of-life care preferences and acute care and hospice use in the last 6 months of life for persons enrolled in a comprehensive dementia care management program. DESIGN Observational, retrospective cohort. SETTING Urban, academic medical center. PARTICIPANTS A total of 322 persons enrolled in dementia care management after July 1, 2012, who died before July 1, 2016. INTERVENTION Dementia care comanagement model using nurse practitioners partnered with primary care providers and community organizations to provide comprehensive dementia care, including advance care planning. MEASUREMENTS Advance care preferences, use of Physician Orders for Life Sustaining Treatment (POLST), hospice enrollment, and hospitalizations and emergency department (ED) visits in the last 6 months of life obtained from electronic health record data. RESULTS Nearly all decedents (99.7%, N = 321) had a goals-of-care conversation documented (median = 3 conversations; interquartile range = 2-4 conversations), and 64% had advance care preferences recorded. Among those with recorded preferences, 88% indicated do not resuscitate, 48% limited medical interventions, and 35% chose comfort-focused care. Most patients (89%) specified limited artificial nutrition, including withholding feeding tubes. Over half (54%) had no hospitalizations or ED visits in the last 6 months of life, and intensive care unit stays were rare (5% of decedents). Overall, 69% died on hospice. Decedents who had completed a POLST were more likely to die in hospice care (74% vs 62%; P = .03) and die at home (70% vs 59%; P = .04). CONCLUSIONS Enrollees in a comprehensive dementia care comanagement program had high engagement in advance care planning, high rates of hospice use, and low acute care utilization near the end of life. Wider implementation of such programs may improve end-of-life care for persons with dementia. J Am Geriatr Soc 67:443-448, 2019.
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Affiliation(s)
- Lee A. Jennings
- Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center
| | - Maurice Turner
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School Medicine, University of California, Los Angeles
| | - Chandra Keebler
- Division of Geriatrics and Supportive Care, Kaiser Permanente, Vallejo, California
| | - Carl H. Burton
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School Medicine, University of California, Los Angeles
| | - Tahmineh Romero
- Statistics Core, David Geffen School of Medicine, University of California, Los Angeles
| | - Neil S. Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - David B. Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School Medicine, University of California, Los Angeles
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Haynes CA, Dashiell-Earp CN, Wenger NS, Simon WM, Skootsky SA, Clarke R, Watts FA, Walling AM. Improving Communication About Resuscitation Preference for Patients Discharged from Hospital to Nursing Home: A Quality Improvement Project. J Palliat Med 2019; 22:557-560. [PMID: 30762475 DOI: 10.1089/jpm.2018.0419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Physician Orders for Life-Sustaining Treatment (POLST) can help ensure continuity of do-not-resuscitate (DNR) decisions and other care preferences after discharge from the hospital. Objective: We aimed to improve POLST completion rates for patients with DNR orders who were being discharged to a nursing home (NH) after an acute hospitalization at our institution. Design: We implemented an interprofessional quality improvement intervention involving education, communication skills, and nursing and case manager cues regarding POLST use. The intervention was later augmented with performance feedback and financial incentives for resident physicians who completed a POLST at NH transfer. Measure: Whether patients with DNR orders at hospital discharge have a POLST at NH transfer. Results: The intervention resulted in increased POLST use for patients with DNR orders discharged to NH: baseline 25/65 (38%), intervention 36/71 (51%), and augmented intervention 44/63 (70%) (p < 0.01). Conclusions: An interdisciplinary intervention can increase POLST use for patients with DNR orders transitioning to NH. Multiple components, including financial incentives and performance feedback, may be needed to effect statistically significant change.
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Affiliation(s)
- Christine A Haynes
- 1 Department of Medicine, University of Colorado School of Medicine, Denver, Colorado.,2 Department of General Internal Medicine, Denver Health and Hospital, Denver, Colorado
| | - Cody N Dashiell-Earp
- 1 Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Neil S Wenger
- 3 Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Wendy M Simon
- 3 Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Samuel A Skootsky
- 3 Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Robin Clarke
- 2 Department of General Internal Medicine, Denver Health and Hospital, Denver, Colorado
| | | | - Anne M Walling
- 3 Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.,5 VA Greater Los Angeles Healthcare System, Los Angeles, California
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Jennings LA, Laffan AM, Schlissel AC, Colligan E, Tan Z, Wenger NS, Reuben DB. Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries. JAMA Intern Med 2019; 179:161-166. [PMID: 30575846 PMCID: PMC6439653 DOI: 10.1001/jamainternmed.2018.5579] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE An estimated 4 to 5 million Americans have Alzheimer disease or another dementia. OBJECTIVE To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries. DESIGN, SETTING, AND PARTICIPANTS In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups. INTERVENTIONS Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week. MAIN OUTCOMES AND MEASURES Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates. RESULTS Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, -$1198 to -$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of -$284 (95% CI, -$881 to $312) per program participant per quarter. CONCLUSIONS AND RELEVANCE Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.
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Affiliation(s)
- Lee A Jennings
- Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center, Oklahoma City
| | | | | | - Erin Colligan
- Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation, Baltimore, Maryland
| | - Zaldy Tan
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
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Jennings LA, Ramirez KD, Hays RD, Wenger NS, Reuben DB. Personalized Goal Attainment in Dementia Care: Measuring What Persons with Dementia and Their Caregivers Want. J Am Geriatr Soc 2018; 66:2120-2127. [PMID: 30298901 DOI: 10.1111/jgs.15541] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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: 06/19/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To develop a process of goal-setting and measurement of goal attainment in a dementia care management program. DESIGN Observational. SETTING Dementia care management program in an urban academic medical center. PARTICIPANTS Persons with dementia (N=101) and their caregivers; nurse practitioner dementia care managers (N=5). INTERVENTION Specification of a personalized health goal and action plan and measurement of goal attainment using goal attainment scaling in a clinical care visit. MEASUREMENTS Goal attainment at 6 and 12 months; focus groups of 5 dementia care managers. RESULTS Eighty-four percent of participant goals were nonmedical, 47% were related to quality of life, and 29% were caregiver support goals. Eighty-eight percent of participants felt that the goal they set was meaningful and 74% that the goal-setting process captured something different from usual care, and 85% found the process helpful in planning for future care. At 6 months, 74% of dyads had achieved or exceeded their expected level of goal attainment. Dementia care managers felt that the goal-setting process improved their understanding of what was most important to the patient, helped set expectations about disease progression and care needs, and provided positive reinforcement when goals were accomplished and an opportunity for revision when goals were not met. CONCLUSION Goal setting using goal attainment scaling can be incorporated into the care of persons with dementia to establish and attain person-centered goals. Research is needed to further develop personalized goal attainment as an outcome measure for dementia care. J Am Geriatr Soc 66:2120-2127, 2018.
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Affiliation(s)
- Lee A Jennings
- Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Los Angeles, Los Angeles, California
| | - Karina D Ramirez
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Ron D Hays
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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Colaiaco B, Roth CP, Ganz DA, Hanson M, Smith P, Wenger NS. Continuity of Information Between Mental Health and Primary Care Providers After a Mental Health Consultation. Psychiatr Serv 2018; 69:1081-1086. [PMID: 30041587 DOI: 10.1176/appi.ps.201800025] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Information sharing between mental health providers (MHPs) and primary care providers (PCPs) is important for persons with mental illnesses. The authors determined the level of information continuity between MHPs who saw a patient for a new consult and PCPs and whether continuity varied between providers with and without access to a shared electronic health record (EHR). METHODS Data were analyzed for 141 randomly selected enrollees in six Medicare Advantage plans receiving a new outpatient mental health consultation in 2012. Medical records of MHPs and PCPs were abstracted to evaluate whether PCP records recognized the consultation, documented mental health hospitalizations and emergency department visits, and acknowledged psychotropic medications. Measures were compared between patients whose providers used and did not use mutual-access EHRs. RESULTS For 21% of patients, the PCP record documented communication from the MHP within three months of the consultation. The PCP record showed evidence of timely communication (within seven days) for 42% of mental health hospitalizations and emergency department visits. Of 152 medications recorded by MHPs, 103 (68%) were acknowledged in the PCP record by the next visit. For patients with mutual-access EHRs, provider communication about the consultation was documented for a greater percentage of patients, compared with those without mutual-access EHRs (46% versus 11%, p<.001), as was communication about psychotropic medication (100% versus 57%, p<.001). CONCLUSIONS This small but detailed study of patients receiving new outpatient mental health consults found poor continuity of information between MHPs and PCPs. A mutual-access EHR facilitated but did not guarantee such information sharing.
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Affiliation(s)
- Ben Colaiaco
- The authors are with the RAND Corporation, Santa Monica, California. Dr. Ganz is also with the U.S. Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles. Dr. Wenger is also with the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Carol P Roth
- The authors are with the RAND Corporation, Santa Monica, California. Dr. Ganz is also with the U.S. Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles. Dr. Wenger is also with the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - David A Ganz
- The authors are with the RAND Corporation, Santa Monica, California. Dr. Ganz is also with the U.S. Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles. Dr. Wenger is also with the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Mark Hanson
- The authors are with the RAND Corporation, Santa Monica, California. Dr. Ganz is also with the U.S. Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles. Dr. Wenger is also with the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Patricia Smith
- The authors are with the RAND Corporation, Santa Monica, California. Dr. Ganz is also with the U.S. Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles. Dr. Wenger is also with the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Neil S Wenger
- The authors are with the RAND Corporation, Santa Monica, California. Dr. Ganz is also with the U.S. Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles. Dr. Wenger is also with the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
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Peipert JD, Jennings LA, Hays RD, Wenger NS, Keeler E, Reuben DB. A Composite Measure of Caregiver Burden in Dementia: The Dementia Burden Scale-Caregiver. J Am Geriatr Soc 2018; 66:1785-1789. [PMID: 30094817 DOI: 10.1111/jgs.15502] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/25/2018] [Accepted: 05/30/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To better capture the scope of caregiver burden by creating a composite of 3 existing measures that assess different health domains. DESIGN Prospective follow-up study. SETTING University-based dementia care management program. PARTICIPANTS Caregivers of persons with dementia (PWD) (N=1,091). MEASUREMENTS The composite measure (the Dementia Burden Scale-Caregiver (DBS-CG)) was based on the Modified Caregiver Strain Index, Neuropsychiatric Inventory Questionnaire Distress Scale, and Patient Health Questionnaire (PHQ-9). Alternative factor structures were evaluated using 2 confirmatory factor analysis (CFA) models: a bifactor model and a 3 correlated factors model. Good model fit was defined as a root mean square error of approximation (RMSEA) of less than 0.06 and comparative fit index (CFI) value greater than 0.95. Coefficient omega was used to estimate scale reliability. Minimally important differences (MIDs) were estimated by anchoring the magnitude of DBS-CG change to change in caregiver self-efficacy and functional ability of PWD. RESULTS The bifactor CFA model fit best (RMSEA = 0.04, CFI = 0.95). Based on this model, a DBS-CG scale was created wherein all items were transformed to a possible range of 0 to 100 and then averaged. Higher scores indicate higher burden. Mean DBS-CG score was 27.3. The reliability was excellent (coefficient omega=0.93). MID estimates ranged from 4 to 5 points (effect sizes: 0.20-0.49). CONCLUSION This study provides support for the reliability and validity of the DBS-CG. It can be used as an outcome measure to assess the effect of interventions to reduce dementia caregiver burden.
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Affiliation(s)
- John D Peipert
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lee A Jennings
- Reynolds Department of Geriatric Medicine, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma
| | - Ron D Hays
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, California
| | | | - David B Reuben
- Department of Medicine, Division of Geriatrics, University of California Los Angeles, Los Angeles, California
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Abstract
BACKGROUND Advance care planning (ACP) is fundamental to guiding medical care at the end of life. Understanding the economic impact of ACP is critical to implementation, but most economic evaluations of ACP focus on only a few actors, such as hospitals. OBJECTIVE To develop a framework for understanding and quantifying the economic effects of ACP, particularly its distributional consequences, for use in economic evaluations. DESIGN Literature review of economic analyses of ACP and related costs to estimate magnitude and direction of costs and benefits for each actor and how data on these costs and benefits could be obtained or estimated. RESULTS ACP can lead to more efficient allocation of resources by reducing low-value care and reallocating resources to high-value care, and can increase welfare by aligning care to patient preferences. This economic framework considers the costs and benefits of ACP that accrue to or are borne by six actors: the patient, the patient's family and caregivers, healthcare providers, acute care settings, subacute and home care settings, and payers. Program implementation costs and nonhealthcare costs, such as time costs borne by patients and caregivers, are included. Findings suggest that out-of-pocket costs for patients and families will likely change if subacute or home care is substituted for acute care, and subacute care utilization is likely to increase while primary healthcare providers and acute care settings may experience heterogeneous effects. CONCLUSIONS A comprehensive economic evaluation of ACP should consider how costs and benefits accrue to different actors.
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Affiliation(s)
- Claire E O'Hanlon
- 1 Pardee RAND Graduate School , RAND Corporation, Santa Monica, California
| | - Anne M Walling
- 2 Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California.,3 Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles , Los Angeles, California.,4 RAND Health, RAND Corporation, Santa Monica, California
| | | | - Sharon Stevenson
- 6 Bellweather Care, Inc. and Okapi Venture Capital, Laguna Beach, California
| | - Neil S Wenger
- 3 Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles , Los Angeles, California.,4 RAND Health, RAND Corporation, Santa Monica, California
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43
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Gotanda H, Ganz DA, Wenger NS. Association Between Estimated Mortality Risk and Measured Quality of Care in Older Adults. J Am Geriatr Soc 2018; 66:1838-1844. [PMID: 30080251 DOI: 10.1111/jgs.15491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/14/2018] [Accepted: 05/20/2018] [Indexed: 11/30/2022]
Abstract
Quality measures based on processes of care (e.g., breast cancer screening) are frequently used to compare performance of providers and healthcare organizations in a value-based reimbursement system, but using these measures to make performance comparisons could penalize clinicians caring for older adults with multiple comorbidities. These clinicians may more frequently withhold recommended care based on limited prognosis, patient preference, or potential adverse effects and, as a result, may incur financial penalties because of poor measured performance. Alternatively, they may need to perform additional administrative work to exclude patients from quality measurement. To examine the potential performance handicap associated with caring for complex populations, we cross-sectionally examined the association between broad outpatient processes of care and 5-year mortality risk in a nationally representative older adult sample (≥ 65) from the 2002 to 2015 Medical Expenditure Panel Survey (n=26,006). In adjusted analyses, performance score based on process-of-care measures was significantly worse in the high-risk group (5-year mortality risk ≥50; adjusted performance score 67.4%; adjusted absolute difference 6.7%, 95% confidence interval (CI)=5.3-8.1%, p<.001) and in the intermediate-risk group (5-year mortality risk 25-49%; adjusted performance score 71.7%; adjusted absolute difference 2.4%, 95% CI=1.7-3.1%, p<.001) than in the low-risk group (5-year mortality risk <25%); adjusted performance score 74.1% following <25%. The trend was overall constant across types of care processes and was more prominent in the younger age brackets of our sample. These results suggest that use of process-of-care measures can lead to disproportionate burden for clinicians and organizations primarily taking care of complex populations.
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Affiliation(s)
- Hiroshi Gotanda
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - David A Ganz
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Division of Geriatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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44
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Sampurno F, Zheng J, Di Stefano L, Millar JL, Foster C, Fuedea F, Higano C, Huland H, Mark S, Moore C, Richardson A, Sullivan F, Wenger NS, Wittmann D, Evans S. Quality Indicators for Global Benchmarking of Localized Prostate Cancer Management. J Urol 2018; 200:319-326. [DOI: 10.1016/j.juro.2018.02.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Fanny Sampurno
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jia Zheng
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lydia Di Stefano
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeremy L. Millar
- William Buckland Radiotherapy Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Claire Foster
- Faculty of Health Sciences, University of Southampton and University Hospital Southampton, Southampton and Urology, London, United Kingdom
| | - Ferran Fuedea
- Radiation Oncology Department, Institut Català d'Oncologia, Radiation Oncology, Barcelona University and Radiobiology and Cancer Group, Bellvitge Biochemical Research Institute, Barcelona, Spain
| | - Celestia Higano
- Department of Medicine, Division of Medical Oncology, University of Washington and Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Hartwig Huland
- Martini-Klinik, Prostate Cancer Centre, University Hamburg, Hamburg, Germany
| | - Stephen Mark
- Department of Urology, Christchurch Hospital and University of Otago, Christchurch, New Zealand
| | - Caroline Moore
- Division of Surgical and Interventional Science, University College London, London, United Kingdom
| | - Alison Richardson
- Cancer Nursing and End of Life Care, Faculty of Health Sciences, University of Southampton and University Hospital Southampton, Southampton and Urology, London, United Kingdom
| | - Frank Sullivan
- Prostate Cancer Institute, National University of Ireland Galway and Department of Radiation Oncology, Galway Clinic, Galway, Ireland
| | - Neil S. Wenger
- Division of General Internal Medicine, University of California-Los Angeles, Los Angeles, California
| | - Daniela Wittmann
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Sue Evans
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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45
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Abstract
The number of hospitalized patients receiving treatment perceived to be futile is not insignificant. Blood products are valuable resources that are donated to help others in need. We aimed to quantify the amount of blood transfused into patients who were receiving treatment that the critical care physician treating them perceived to be futile. During a 3-month period, critical care physicians in 5 adult intensive care units completed a daily questionnaire to identify patients perceived as receiving futile treatment. Of 1136 critically ill patients, physicians assessed 123 patients (11%) as receiving futile treatment. Fifty-nine (48%) of the 123 patients received blood products after they were assessed to be receiving futile treatment: 242 units of packed red blood cells (PRBCs) (7.6% of all PRBC units transfused into critical care patients during the 3-month study period); 161 (9.9%) units of plasma, 137 (12.1%) units of platelets, and 21 (10.5%) units of cryoprecipitate. Explicit guidelines on the use of blood products should be developed to ensure that the use of this precious resource achieves meaningful goals.
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Affiliation(s)
- Thanh H Neville
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
| | - Alyssa Ziman
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Neil S Wenger
- University of California Health Ethics Center, Los Angeles, California, USA
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- RAND Health, Santa Monica, California, USA
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46
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Walling AM, D'Ambruoso SF, Malin JL, Hurvitz S, Zisser A, Coscarelli A, Clarke R, Hackbarth A, Pietras C, Watts F, Ferrell B, Skootsky S, Wenger NS. Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic. J Oncol Pract 2017; 13:e792-e799. [PMID: 28813191 DOI: 10.1200/jop.2017.020990] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic. METHODS We evaluated the effect of the intervention in two oncologists' clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies. RESULTS Of approximately 10,000 patients with active cancer treated in the health system, 2,829 patients had advanced cancer and were treated by 42 oncologists. Documentation of advance care planning increased for patients of the two intervention oncologists compared with patients of the other oncologists. Hospice referral before death was not different at baseline, but was significantly higher for patients of intervention oncologists compared with patients of control oncologists (53% v 23%; P = .02) over the intervention period. Efficiency evaluation revealed that approximately half the time spent by the embedded NP potentially could have been completed by other staff (eg, a nurse, a social worker, or administrative staff). CONCLUSION An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.
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Affiliation(s)
- Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Sarah F D'Ambruoso
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Jennifer L Malin
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Sara Hurvitz
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Ann Zisser
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Anne Coscarelli
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Robin Clarke
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Andrew Hackbarth
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Christopher Pietras
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Frances Watts
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Bruce Ferrell
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Samuel Skootsky
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Neil S Wenger
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
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47
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Neville TH, Tarn DM, Yamamoto M, Garber BJ, Wenger NS. Understanding Factors Contributing to Inappropriate Critical Care: A Mixed-Methods Analysis of Medical Record Documentation. J Palliat Med 2017; 20:1260-1266. [PMID: 28967808 DOI: 10.1089/jpm.2017.0023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Factors leading to inappropriate critical care, that is treatment that should not be provided because it does not offer the patient meaningful benefit, have not been rigorously characterized. OBJECTIVE We explored medical record documentation about patients who received inappropriate critical care and those who received appropriate critical care to examine factors associated with the provision of inappropriate treatment. DESIGN Medical records were abstracted from 123 patients who were assessed as receiving inappropriate treatment and 66 patients who were assessed as receiving appropriate treatment but died within six months of intensive care unit (ICU) admission. We used mixed methods combining qualitative analysis of medical record documentation with multivariable analysis to examine the relationship between patient and communication factors and the receipt of inappropriate treatment, and present these within a conceptual model. SETTING One academic health system. RESULTS Medical records revealed 21 themes pertaining to prognosis and factors influencing treatment aggressiveness. Four themes were independently associated with patients receiving inappropriate treatment according to physicians. When decision making was not guided by physicians (odds ratio [OR] 3.76, confidence interval [95% CI] 1.21-11.70) or was delayed by patient/family (OR 4.52, 95% CI 1.69-12.04), patients were more likely to receive inappropriate treatment. Documented communication about goals of care (OR 0.29, 95% CI 0.10-0.84) and patient's preferences driving decision making (OR 0.02, 95% CI 0.00-0.27) were associated with lower odds of receiving inappropriate treatment. CONCLUSIONS Medical record documentation suggests that inappropriate treatment occurs in the setting of communication and decision-making patterns that may be amenable to intervention.
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Affiliation(s)
- Thanh H Neville
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine , UCLA, Los Angeles, California
| | - Derjung M Tarn
- 2 Department of Family Medicine, David Geffen School of Medicine , UCLA, Los Angeles, California
| | - Myrtle Yamamoto
- 3 Department of Medicine, Quality Improvement, David Geffen School of Medicine , UCLA, Los Angeles, California
| | - Bryan J Garber
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine , UCLA, Los Angeles, California
| | - Neil S Wenger
- 4 Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Health Ethics Center , RAND Health, David Geffen School of Medicine, UCLA, Los Angeles, California
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48
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Walling AM, Beron PJ, Kaprealian T, Kupelian PA, Wenger NS, McCloskey SA, King CR, Steinberg M. Considerations for Quality Improvement in Radiation Oncology Therapy for Patients with Uncomplicated Painful Bone Metastases. J Palliat Med 2017; 20:478-486. [PMID: 28437208 DOI: 10.1089/jpm.2016.0339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: There is an increasing need for evidence-based efficiency in providing a growing amount of cancer care. One example of a quality gap is the use of multiple-fraction palliative radiation for patients with advanced cancer who have uncomplicated bone metastases; evidence suggests similar pain outcomes for treatment regimens with a lower burden of treatments. Methods: During the first phase of quality improvement work, we used RAND/UCLA appropriateness methodology to understand how radiation oncologists at one academic medical center rate the appropriateness of different treatment regimens for painful uncomplicated bone metastases. We compared radiation oncologist appropriateness ratings for radiation treatments with radiation therapy provided by these oncologists to patients with painful bone metastases between July 2012 and June 2013. Results: Appropriateness ratings showed that single-fraction (8 Gy) treatment (a low burden treatment) was consistently considered an appropriate option to treat a variety of uncomplicated bone metastases. The use of >10 fractions was consistently rated as inappropriate regardless of other factors. Eighty-one patients receiving radiation therapy for painful bone metastases during the study period had an available medical record for chart abstraction. Almost one-third of metastases were considered complicated because of a concern of spinal cord compression, a history of prior irradiation, or an associated pathological fracture. Among uncomplicated bone metastases, 25% were treated with stereotactic body radiation treatment (SBRT). Among the 54 uncomplicated bone metastases treated with conformal radiation, only one was treated with single-fraction treatment and 32% were treated with greater than 10 fractions. Conclusions: Treatment at the study site demonstrates room for improvement in providing low-burden radiation oncology treatments for patients with painful bone metastases. Choosing a radiation treatment schedule for patients with advanced cancer and painful bone metastases requires consideration of many medical and patient-centered factors. Our experience suggests that it will take more than the existence of guidelines to change practice in this area.
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Affiliation(s)
- Anne M Walling
- VA Greater Los Angeles Healthcare System, Los Angeles, California.,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Phillip J Beron
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Tania Kaprealian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Patrick A Kupelian
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California.,RAND Health, Santa Monica, California
| | - Susan A McCloskey
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Michael Steinberg
- Department of Radiation Oncology, David Geffen School of Medicine at University of California, Los Angeles, California
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49
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Reuben DB, Hackbarth AS, Wenger NS, Tan ZS, Jennings LA. An Automated Approach to Identifying Patients with Dementia Using Electronic Medical Records. J Am Geriatr Soc 2017; 65:658-659. [PMID: 28152164 DOI: 10.1111/jgs.14744] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Andrew S Hackbarth
- UCLA Faculty Practice Group, University of California, Los Angeles, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Zaldy S Tan
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Lee A Jennings
- Reynolds Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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50
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Abstract
Provider and payer groups have endorsed the goal of improving the integration of primary care and behavioral health across a variety of programs and settings. There is an interest in sharing patients' medical information, a goal that is permissible within HIPAA, but there are concerns about more restrictive state medical privacy laws. This article assesses whether a substantial number of state medical privacy laws are, or could be interpreted to be, more restrictive than HIPAA. Preliminary investigation found that in almost one third of the states (including large-population states such as Florida, Georgia, Massachusetts, New York, and Texas), primary care physicians (PCPs) may have difficulty accessing mental health treatment records without the patient's (or his/her guardian/conservator's) written consent. If a comprehensive legal analysis supports this conclusion, then those advocating integration of behavioral and primary care may need to consider seeking appropriate state legislative solutions.
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Affiliation(s)
- Leslie S Rothenberg
- , 16751 Edgar Street, Pacific Palisades, CA, 90272-3226, USA. .,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA. .,The RAND Corporation, Santa Monica, CA, USA.
| | - David A Ganz
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,The RAND Corporation, Santa Monica, CA, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Neil S Wenger
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,The RAND Corporation, Santa Monica, CA, USA.,UCLA Health Ethics Center, Los Angeles, CA, USA
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