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Zupanc SN, Durieux BN, Walling AM, Lindvall C. Bolstering Advance Care Planning Measurement Using Natural Language Processing. J Palliat Med 2024; 27:447-450. [PMID: 38324042 DOI: 10.1089/jpm.2023.0528] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Despite its growth as a clinical activity and research topic, the complex dynamic nature of advance care planning (ACP) has posed serious challenges for researchers hoping to quantitatively measure it. Methods for measurement have traditionally depended on lengthy manual chart abstractions or static documents (e.g., advance directive forms) even though completion of such documents is only one aspect of ACP. Natural language processing (NLP), in the form of an assisted electronic health record (EHR) review, is a technological advancement that may help researchers better measure ACP activity. In this article, we aim to show how NLP-assisted EHR review supports more accurate and robust measurement of ACP. We do so by presenting three example applications that illustrate how using NLP for this purpose supports (1) measurement in research, (2) detailed insights into ACP in quality improvement, and (3) identification of current limitations of ACP in clinical settings.
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Affiliation(s)
- Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- UCSF School of Medicine, San Francisco, California, USA
| | - Brigitte N Durieux
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anne M Walling
- Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
- VDepartment of Medicine, A Greater Los Angeles Health System, Los Angeles, California, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
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Murray GF, Lakin JR, Paasche-Orlow MK, Tulsky JA, Volandes A, Davis AD, Zupanc SN, Carney MT, Burns E, Martins-Welch D, LaVine N, Itty JE, Fix GM. Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians' and Administrators' Experiences During a Pragmatic Trial. J Gen Intern Med 2023; 38:3558-3565. [PMID: 37488368 PMCID: PMC10713958 DOI: 10.1007/s11606-023-08320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients' goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients' and clinicians' awareness of the need for ACP. OBJECTIVE Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. DESIGN Qualitative interview study. PARTICIPANTS Clinicians and administrators across five sites that participated in the ACP-COVID trial. APPROACH We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. KEY RESULTS Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians' affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. CONCLUSIONS Despite high organizational commitment to ACP, we found that the health system channeled clinicians' ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Genevra F Murray
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Michael K Paasche-Orlow
- Tufts University School of Medicine, Division of General Internal Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - James A Tulsky
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Section of General Internal Medicine, Boston, MA, USA
- ACP Decisions, Waban, MA, USA
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria T Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Edith Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Diana Martins-Welch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Nancy LaVine
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jennifer E Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Gemmae M Fix
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Bedford VA Healthcare System, Bedford, MA, USA
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Zupanc SN, Lakin JR, Volandes AE, Paasche-Orlow MK, Moseley ET, Gundersen DA, Das S, Penumarthy A, Martins-Welch D, Burns EA, Carney MT, Itty JE, Emmert K, Tulsky JA, Lindvall C. Forms or Free-Text? Measuring Advance Care Planning Activity Using Electronic Health Records. J Pain Symptom Manage 2023; 66:e615-e624. [PMID: 37536523 PMCID: PMC10592170 DOI: 10.1016/j.jpainsymman.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
Advance care planning (ACP) discussions seek to guide future serious illness care. These discussions may be recorded in the electronic health record by documentation in clinical notes, structured forms and directives, and physician orders. Yet, most studies of ACP prevalence have only examined structured electronic health record elements and ignored data existing in notes. We sought to investigate the relative comprehensiveness and accuracy of ACP documentation from structured and unstructured electronic health record data sources. We evaluated structured and unstructured ACP documentation present in the electronic health records of 435 patients with cancer drawn from three separate healthcare systems. We extracted structured ACP documentation by manually annotating written documents and forms scanned into the electronic health record. We coded unstructured ACP documentation using a rule-based natural language processing software that identified ACP keywords within clinical notes and was subsequently reviewed for accuracy. The unstructured approach identified more instances of ACP documentation (238, 54.7% of patients) than the structured ACP approach (187, 42.9% of patients). Additionally, 16.6% of all patients with structured ACP documentation only had documents that were judged as misclassified, incomplete, blank, unavailable, or a duplicate of a previously entered erroneous document. ACP documents scanned into electronic health records represent a limited view of ACP activity. Research and measures of clinical practice with ACP should incorporate information from unstructured data.
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Affiliation(s)
- Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Angelo E Volandes
- Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (A.E.V.), Massachusetts General Hospital, Boston, Massachusetts; ACP Decisions (A.E.V.), Waban, Massachusetts
| | | | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Computer Science (E.T.M.), School of Engineering, Tufts University, Medford, Massachusetts
| | - Daniel A Gundersen
- Survey and Qualitative Methods Core (D.A.G.), Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Social and Behavioral Sciences (D.A.G.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Akhila Penumarthy
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Diana Martins-Welch
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Edith A Burns
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Maria T Carney
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Jennifer E Itty
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York
| | - Kaitlin Emmert
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts.
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Volandes AE, Zupanc SN, Lakin JR, Cabral HJ, Burns EA, Carney MT, Lopez S, Itty J, Emmert K, Martin NJ, Cole T, Dobie A, Cucinotta T, Joel M, Caruso LB, Henault L, Dugas JN, Astone K, Winter M, Wang N, Davis AD, Garde C, Rodriguez PM, El-Jawahri A, Moseley ET, Das S, Sciacca K, Ramirez AM, Gromova V, Lambert S, Sanghani S, Lindvall C, Paasche-Orlow MK. Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332556. [PMID: 37695586 PMCID: PMC10495866 DOI: 10.1001/jamanetworkopen.2023.32556] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/27/2023] [Indexed: 09/12/2023] Open
Abstract
Importance Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians. Objective To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation. Design, Setting, and Participants This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022. Intervention The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care. Main Outcome and Measures The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing. Results A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool. Trial Registration ClinicalTrials.gov Identifier: NCT04857060.
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Affiliation(s)
- Angelo E. Volandes
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- ACP Decisions, Waban, Massachusetts
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Howard J. Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Edith A. Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Maria T. Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Santiago Lopez
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Jennifer Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Kaitlin Emmert
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Narda J. Martin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Therese Cole
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Alexandra Dobie
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Traci Cucinotta
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Milton Joel
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Lisa B. Caruso
- Department of Medicine, Section of Geriatrics, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Lori Henault
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Julianne N. Dugas
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Kristina Astone
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | | | | | - Perla Macip Rodriguez
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Edward T. Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ana Maria Ramirez
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Valeria Gromova
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Sherene Lambert
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Shreya Sanghani
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Department of Medicine, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts
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Connell NB, Zupanc SN, Lorenz KA, Bhatnagar S, Fereydooni S, Gamboa RC, Ganesh A, Satija A, Singh N, Spruijt O, Giannitrapani KF. Facilitators of palliative care quality improvement team cohesion: Lessons from a seven-site implementation project in India. Health Care Manage Rev 2023; 48:219-228. [PMID: 37158411 DOI: 10.1097/hmr.0000000000000368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND The Palliative Care: Promoting Access and Improvement of the Cancer Experience (PC-PAICE) initiative is a team-based, palliative care (PC) quality improvement (QI) project working to promote high-quality PC in India. As a PC QI initiative, PC-PAICE implementation relied upon building interdisciplinary teams, providing the ideal context for understanding facilitators of team cohesion that compelled clinical, organizational, and administrative team members to work together. There is an opportunity to leverage the intersection between QI implementation and organizational theory to inform and improve implementation science. PURPOSE As a subaim of a larger implementation evaluation, we aimed to identify facilitators of team cohesion within QI implementation context. METHODOLOGY A quota sampling approach captured the perspectives of 44 stakeholders across three strata (organizational leaders, clinical leaders, and clinical team members) from all seven sites through a semistructured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). We used a combination of inductive and deductive approaches informed by organizational theory to identify facilitators. RESULT We identified three facilitators of PC team cohesion: (a) balancing formalization and flexibility around team roles, (b) establishing widespread awareness of the QI project, and (c) prioritizing a nonhierarchical organizational culture. PRACTICE IMPLICATIONS Leveraging CFIR to analyze PC-PAICE stakeholder interviews created a data set conducive to understanding complex multisite implementation. Layering role and team theory to our implementation analysis helped us identify facilitators of team cohesion across levels within the team (bounded team), beyond the team (teaming), and surrounding the team (culture). These insights demonstrate the value of team and role theories in implementation evaluation efforts.
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LaVine N, Emmert K, Itty J, Martins-Welch D, Carney M, Block A, Burgess L, Volandes AE, Zupanc SN, Jacome S, Gromova V, Davis AD, Schwartz P, Alvarez-Suarez A, Burns E. Reaching Ambulatory Older Adults with Educational Tools: Comparative Efficacy and Cost of Varied Outreach Modalities in Primary Care. J Gen Intern Med 2023; 38:125-130. [PMID: 36217070 PMCID: PMC9550308 DOI: 10.1007/s11606-022-07808-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 09/13/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Providing patients with access to health information that can be obtained outside of an office visit is an important part of education, yet little is known about the effectiveness of outreach modalities to connect older adults to online educational tools. The objective was to identify the effectiveness and cost of outreach modalities providing online information about advance care planning (ACP) for older adults. METHODS Six different outreach modalities were utilized to connect patients to online educational tools (ACP video decision aids). Participants were 13,582 patients aged 65 and older of 185 primary care providers with appointments over a 30-month period within a large health system in the greater New York City area. Main outcome measures were number of online video views and costs per outreach for each modality. KEY RESULTS There were 1150 video views for 21,407 remote outreach events. Text messages, sent to the largest volume of patients (8869), had the highest outcome rate (9.6%) and were the most economical ($0.09). Characterization of phone calls demonstrated 21.7% engagement in the topic of ACP but resulted in minimal video views (<1%) and incurred the highest cost per outreach ($2.88). In-office handouts had negligible results (<1%). CONCLUSIONS Text was the most cost-effective modality to connect older adults to an online educational tool in this pragmatic trial, though overall efficacy of all modalities was low.
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Affiliation(s)
- N LaVine
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - K Emmert
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - J Itty
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - D Martins-Welch
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA
| | - M Carney
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA.,Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - A Block
- New York Medical College School of Health Sciences and Practice, Westchester, NY, USA
| | - L Burgess
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - A E Volandes
- Harvard Medical School, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,ACP Decisions, Boston, MA, USA
| | - S N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - S Jacome
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - V Gromova
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | | | | | - A Alvarez-Suarez
- Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Edith Burns
- Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Hempstead, NY, USA. .,Institute for Health Systems Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA.
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7
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Lakin JR, Sciacca K, Leiter R, Killeen K, Gelfand S, Tulsky JA, Anderson S, Zupanc SN, Williams T, Mandel EI. Creating KidneyPal: A Specialty-Aligned Palliative Care Service for People with Kidney Disease. J Pain Symptom Manage 2022; 64:e331-e339. [PMID: 36058402 DOI: 10.1016/j.jpainsymman.2022.08.014] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/02/2022] [Accepted: 08/18/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with kidney disease have notable unmet palliative care needs and represent an underserved population for specialty palliative care teams. INTERVENTION We designed a specialty-aligned interprofessional palliative care service called KidneyPal that is aimed at improving delivery of palliative care to patients with kidney disease through focus groups and iterative improvement cycles. MEASURES We iteratively measured the development of KidneyPal through clinical process metrics: percent of the inpatient nephrology census followed by KidneyPal, patient demographics, consult origin, clinician feedback, and self-reported team interventions. OUTCOMES KidneyPal saw 314 unique patients from January 2019 to January 2021. The majority of consultations came from nephrology services though the source of consultation changed over time. We consulted on an average of 13.5% of the entire inpatient nephrology patient hospital census with highest involvement with patients on the inpatient nephrology hemodialysis service (mean of 29.9%). KidneyPal was rated highly by surveyed nephrology clinicians and provided high rates of psychosocial support and goals of care interventions. LESSONS LEARNED The creation of KidneyPal led to us to serve a new cohort of patients with specialty palliative care. We grew over time to serve the full range of patients with kidney disease as defined by our nephrology service lines. We succeeded in doing so by embedding in nephrology and building relationships with those caring for people with kidney disease while tailoring our service and interventions over time.
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Affiliation(s)
- Joshua R Lakin
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts.
| | - Kate Sciacca
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Richard Leiter
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts
| | - Kelsey Killeen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Samantha Gelfand
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts; Division of Renal Medicine, Brigham and Women's Hospital (S.G., E.I.M.), Boston, Massachusetts
| | - James A Tulsky
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Trey Williams
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Ernest I Mandel
- Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts; Division of Renal Medicine, Brigham and Women's Hospital (S.G., E.I.M.), Boston, Massachusetts
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Lakin JR, Zupanc SN, Lindvall C, Moseley ET, Das S, Sciacca K, Cabral HJ, Burns EA, Carney MT, Itty J, Lopez S, Emmert K, Martin NJ, Lambert S, Polo J, Sanghani S, Dugas JN, Gomez M, Winter MR, Wang N, Gabry-Kalikow S, Dobie A, Amshoff M, Cucinotta T, Joel M, Caruso LB, Ramirez AM, Salerno K, Ogunneye Q, Henault L, Davis AD, Volandes A, Paasche-Orlow MK. Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital. BMJ Open 2022; 12:e065236. [PMID: 35879001 PMCID: PMC9328081 DOI: 10.1136/bmjopen-2022-065236] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Despite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer's disease and related Dementias, regardless of age. METHODS AND ANALYSIS The Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included. ETHICS AND DISSEMINATION The Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT04857060; ClinicalTrials.gov.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Howard J Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Edith A Burns
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Maria T Carney
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jennifer Itty
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Santiago Lopez
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Kaitlin Emmert
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Narda J Martin
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Sherene Lambert
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Jennifer Polo
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Shreya Sanghani
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Julianne N Dugas
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michele Gomez
- Commonwealth Care Alliance, Boston, Massachusetts, USA
| | - Michael R Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Alexandra Dobie
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Meredith Amshoff
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Traci Cucinotta
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Milton Joel
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lisa B Caruso
- Boston University School of Medicine, Department of Medicine, Section of Geriatrics, Boston Medical Center, Boston, Massachusetts, USA
| | - Ana Maria Ramirez
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Kathleen Salerno
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Qausarat Ogunneye
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions, Waban, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
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9
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Eneanya ND, Lakin JR, Paasche-Orlow MK, Lindvall C, Moseley ET, Henault L, Hanchate AD, Mandel EI, Wong SPY, Zupanc SN, Davis AD, El-Jawahri A, Quintiliani LM, Chang Y, Waikar SS, Bansal AD, Schell JO, Lundquist AL, Tamura MK, Yu MK, Unruh ML, Argyropoulos C, Germain MJ, Volandes A. Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial. BMJ Open 2022; 12:e059313. [PMID: 35396311 PMCID: PMC8996022 DOI: 10.1136/bmjopen-2021-059313] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes. METHODS AND ANALYSIS The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites. ETHICS AND DISSEMINATION Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results. TRIAL REGISTRATION NUMBER NCT04347629.
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, Massachusetts, USA
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Edward T Moseley
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ernest I Mandel
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal (Kidney) Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan P Y Wong
- University of Washington, Seattle, Washington State, USA
| | - Sophia N Zupanc
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa M Quintiliani
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Amar D Bansal
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Andrew L Lundquist
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine; and Geriatric Research Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Margaret K Yu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark L Unruh
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christos Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Michael J Germain
- Baystate Medical Center-University of Massachusetts Springfield, Springfield, Massachusetts, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions Non-profit Foundation, Newton, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Volandes AE, Zupanc SN, Paasche-Orlow MK, Lakin JR, Chang Y, Burns EA, LaVine NA, Carney MT, Martins-Welch D, Emmert K, Itty JE, Moseley ET, Davis AD, El-Jawahri A, Gundersen DA, Fix GM, Yacoub AM, Schwartz P, Gabry-Kalikow S, Garde C, Fischer J, Henault L, Burgess L, Goldman J, Kwok A, Singh N, Alvarez Suarez AL, Gromova V, Jacome S, Tulsky JA, Lindvall C. Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial. JAMA Netw Open 2022; 5:e220354. [PMID: 35201306 PMCID: PMC8874350 DOI: 10.1001/jamanetworkopen.2022.0354] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models. OBJECTIVE To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients. DESIGN, SETTING, AND PARTICIPANTS The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included. MAIN OUTCOMES AND MEASURES The primary outcome was ACP documentation. RESULTS A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001). CONCLUSIONS AND RELEVANCE This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Angelo E. Volandes
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- ACP Decisions, Boston, Massachusetts
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Edith A. Burns
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Nancy A. LaVine
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Maria T. Carney
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Diana Martins-Welch
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Kaitlin Emmert
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Jennifer E. Itty
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Edward T. Moseley
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Daniel A. Gundersen
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gemmae M. Fix
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts
| | - Andrea M. Yacoub
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | | | | | | | - Jonathan Fischer
- Department of Community Health and Family Medicine, Hospice and Palliative Care, Duke University Health System, Durham, North Carolina
| | - Lori Henault
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leah Burgess
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Julie Goldman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anne Kwok
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nimisha Singh
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Armando L. Alvarez Suarez
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Valeria Gromova
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Sonia Jacome
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A. Tulsky
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Affiliation(s)
- Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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Brizzi K, Zupanc SN, Udelsman BV, Tulsky JA, Wright AA, Poort H, Lindvall C. Natural Language Processing to Assess Palliative Care and End-of-Life Process Measures in Patients With Breast Cancer With Leptomeningeal Disease. Am J Hosp Palliat Care 2019; 37:371-376. [DOI: 10.1177/1049909119885585] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Palliative care consultation during serious life-limiting illness can reduce symptom burden and improve quality of care. However, quantifying the impact of palliative care is hindered by the limitations of manual chart review and administrative coding. Objectives: Using novel natural language process (NLP) techniques, we examined associations between palliative care consultations and performance on nationally endorsed metrics for high-quality end-of-life (EOL) care in patients with leptomeningeal disease (LMD) secondary to metastatic breast cancer. Methods: Patients with breast cancer with LMD were identified using administrative billing codes and NLP review of magnetic resonance imaging reports at 2 tertiary care centers between 2010 and 2016. Next, NLP was used to review clinical notes to (1) determine the presence of palliative care consultations and (2) determine the performance of process measures associated with high-quality EOL care, including discussions of goals of care, code status limitations, and hospice. Associations between palliative care consultation and documentation of EOL process measures were assessed using logistic regression. Results: We identified 183 cases of LMD. Median age was 56 (interquartile range [IQR]: 46-64) years and median survival was 150 days (IQR: 67-350). Within 6 months of diagnosis, 88.5% of patients had documentation of ≥1 process measure, including discussions of goals of care (63.4%), code status limitations (62.8%), or hospice (72.1%). Palliative care consultation was a predictor of subsequent documentation of goals of care (odds ratio [OR], 3.15; 95% confidence interval [CI], 1.58-6.27) and hospice discussions (OR, 4.61; 95% CI, 2.12-10.03). Conclusion: Palliative care involvement is associated with increased performance of EOL process measures in patients with breast cancer with LMD.
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Affiliation(s)
- Kate Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alexi A. Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hanneke Poort
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Palliative Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Lindvall C, Lilley EJ, Zupanc SN, Chien I, Udelsman BV, Walling A, Cooper Z, Tulsky JA. Natural Language Processing to Assess End-of-Life Quality Indicators in Cancer Patients Receiving Palliative Surgery. J Palliat Med 2018; 22:183-187. [PMID: 30328764 DOI: 10.1089/jpm.2018.0326] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Palliative surgical procedures are frequently performed to reduce symptoms in patients with advanced cancer, but quality is difficult to measure. OBJECTIVE To determine whether natural language processing (NLP) of the electronic health record (EHR) can be used to (1) identify a population of cancer patients receiving palliative gastrostomy and (2) assess documentation of end-of-life process measures in the EHR. DESIGN/SETTING Retrospective cohort study of 302 adult cancer patients who received a gastrostomy tube at a single tertiary medical center. MEASUREMENTS Sensitivity and specificity of NLP compared to gold standard of manual chart abstraction in identifying a palliative indication for gastrostomy tube placement and documentation of goals of care discussions, code status determination, palliative care referral, and hospice assessment. RESULTS Among 302 cancer patients who underwent gastrostomy, 68 (22.5%) were classified by NLP as having a palliative indication for the procedure compared to 71 patients (23.5%) classified by human coders. Human chart abstraction took >2600 times longer than NLP (28 hours vs. 38 seconds). NLP identified the correct patients with 95.8% sensitivity and 97.4% specificity. NLP also identified end-of-life process measures with high sensitivity (85.7%-92.9%,) and specificity (96.7%-98.9%). In the two months leading up to palliative gastrostomy placement, 20.5% of patients had goals of care discussions documented. During the index hospitalization, 67.7% had goals of care discussions documented. CONCLUSIONS NLP offers opportunities to identify patients receiving palliative surgical procedures and can rapidly assess established end-of-life process measures with an accuracy approaching that of human coders.
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Affiliation(s)
- Charlotta Lindvall
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth J Lilley
- 3 Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,4 Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sophia N Zupanc
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Isabel Chien
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,5 Department of Electrical Engineering and Computer Science, CSAIL, MIT, Cambridge, Massachusetts
| | - Brooks V Udelsman
- 6 Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne Walling
- 7 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California.,8 Palliative Care, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Zara Cooper
- 4 Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - James A Tulsky
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,2 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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