scholarly journals If We Don’t Ask, Our Patients Might Never Tell: The Impact of the Routine Use of a Patient Values Assessment

2017 ◽  
Vol 13 (10) ◽  
pp. e831-e837 ◽  
Author(s):  
J. Russell Hoverman ◽  
Cynthia Taniguchi ◽  
Kathryn Eagye ◽  
Sabrina Mikan ◽  
Angela Kalisiak ◽  
...  
Keyword(s):  
End Of Life ◽  
Metastatic Cancer ◽  
Place Of Death ◽  
Continuous Variables ◽  
Exact Test ◽  
Good Communication ◽  
Values Assessment ◽  
Patient Values ◽  
Aggressive Care ◽  
The Impact

Purpose: Good communication can be associated with better end-of-life outcomes. The US Oncology Network developed and tested a Values Assessment (VA) for facilitating advance care planning (ACP). The results of the first 1,268 patients are reported. Methods: The VA consists of 10 questions of the format “How valuable is it to me to…” (eg, “...know that I am not a burden to my family, friends, or helpers?”). Responses were on a four-point scale from unsure to very valuable. VA data on 1,286 patients with metastatic cancer from April 1, 2013, to July 31, 2015, were extracted from the electronic health record, including demographics, diagnosis, stage, chemotherapy, and outcomes (hospice enrollment, place of death). These demographics were compared by using the χ2 or Fisher’s exact test or the Wilcoxon rank sum test for continuous variables. Results: A total of 1,268 patients completed the VA (56.7% were ≥ 65 years of age, 57.8% completed advance directives [ADs]). There were 438 deaths of which 308 had a place of death or a hospice enrollment recorded. Of these, 78% died at home or inpatient hospice; 14.6% died in the hospital. Hospice enrollment with ADs was 76.1% and without, 60.9%. Median length of stay in hospice was 21 days with ADs versus 12.5 days without. Chemotherapy in the last 14 days of life was 8.8% with ADs and 15.5% without. The VA was well accepted by patients. Conclusion: A VA as a routine part of practice is feasible and scalable. It facilitates ACP discussions that lead to ADs. The results suggest that VA and ACP lead to less-aggressive care at the end of life.

Using a values assessment as a bridge to advance care planning: Results of 1286 patient reports.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 12-12
Author(s):  
John Russell Hoverman ◽  
Cynthia Taniguchi ◽  
Kathryn J Eagye ◽  
Susan Ash-Lee ◽  
Angela Kalisiak ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Advance Care Planning ◽  
Metastatic Cancer ◽  
Care Planning ◽  
Continuous Variables ◽  
Exact Test ◽  
Patient Reports ◽  
Values Assessment ◽  
Advance Care

12 Background: Recent studies have shown that formal Palliative Care (PC) improves care at the end of life for cancer patients. The role of communication in PC is not defined. Other studies have shown that communication alone can be associated with better end of life outcomes. The US Oncology Network developed and tested a Values Assessment (VA) instrument for routinely broaching difficult topics to facilitate more formal advance care planning (ACP). The results of the first 28 months of the program on over 1200 patients are reported here. Methods: The VA consists of 10 questions of the format “How valuable is it to me to….”, for example “know that I am not a burden to my family, friends or helpers?” Responses were on a 4 point scale from unsure to very valuable. The VA was completed either in person in the clinic or telephonically. VA participation by n = 1286 metastatic cancer patients treated at participating practices from 4/1/2013-7/31/2015 were extracted from the EHR and confirmed by chart review, as were demographic (age, gender, ethnicity), clinical (diagnosis and stage), chemotherapy treatment and outcomes (hospice enrollment and place of death). Demographics and outcomes were compared using the Chi-Squared or Fisher’s Exact Test, or Wilcoxon Rank Sums test for continuous variables. Results: 1268 patients completed the VA. 56.7% were 65 or over. 57.8% went on to complete Advance Directives (AD). 52% had colon or lung cancer. There were 438 deaths of which 431 had a date of last chemotherapy recorded. Of these 431 patients, 78% died at home or inpatient hospice, 14.6% in the hospital. Hospice enrollment with AD was 76.1%, without 60.9%. (p = .008) Median LOS in hospice was 21 days vs. 12.5 (p = .025). Chemotherapy in the last 14 days of life was 7.05% with AD, 13.4% without. The VA was well accepted by patients. Conclusions: A VA as a routine part of practice is feasible and scalable. It can be delivered successfully either face to face or telephonically. It facilitates ACP discussion leading to AD. The results suggest VA and ACP lead to less aggressive care at the end of life.

Implementing values-based advance care planning (ACP) in a community oncology network.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 105-105
Author(s):  
Cynthia Taniguchi ◽  
Marcus A. Neubauer
Keyword(s):  
Patient Education ◽  
End Of Life ◽  
Metastatic Cancer ◽  
Healthcare Team ◽  
Health Record ◽  
Code Status ◽  
Community Oncology ◽  
Metastatic Setting ◽  
Essential Components ◽  
Patient Values

105 Background: Oncologists often embrace the concept of having discussions with patients regarding end-of-life care. Still, challenges remain with initiating these discussions early in the metastatic setting so that the full ACP process can be satisfied. A framework and infrastructure are needed to systematically initiate and promote the ACP process at a time when metastatic disease is identified and patients are better able to make thoughtful decisions regarding their future care. Methodology is needed for documenting and updating the ACP process within the patient’s health record. Methods: During a 15 month period, 32 independent sites of service within a nationwide community oncology network implemented an electronic health record (EHR)-based program for initiating ACP conversations with patients having a metastatic cancer diagnosis. Patients were identified for program engagement based on clinical criteria populated within the EHR. Identified patients received a brief introduction to ACP by the physician or other clinician and were encouraged to meet with a trained ACP Counselor to engage the full process. ACP Counselors provided guidance to the patient to discover and share personal values and goals for care. Values for care were documented within the EHR. Counselors provided appropriate patient education regarding code status and state-specific advance directives. At end-of-life, practices included hospice and death details within the EHR. Results: For metastatic patients (n = 29,389), ACP counseling was provided for 1,034 individuals (4%). Code status was visible in 3648 health records (12%) and patient values were included for 376 patients (1%). 2,206 patients (8%) transitioned to hospice care during the 14-month period. EHR-based infrastructure allowed for ongoing ACP visibility by the healthcare team. Conclusions: Use of an EHR-based ACP process demonstrates promising outcomes for realizing meaningful delivery of ACP. Essential components are patient identification early in the metastatic trajectory, assessment of patient values for care, thorough patient education regarding code status and advance directive documents, and full visibility of the ACP process within the health record.

Trends in health care utilization, cost, and aggressive care at end of life among older cancer patients in the Deep South.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 155-155
Author(s):  
Elizabeth Ann Kvale ◽  
Gabrielle Rocque ◽  
Kerri S. Bevis ◽  
Aras Acemgil ◽  
Richard A. Taylor ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Utilization ◽  
End Of Life ◽  
Healthcare Utilization ◽  
Linear Models ◽  
Care Utilization ◽  
Deep South ◽  
Medicare Beneficiaries ◽  
Aggressive Care ◽  
The Impact

155 Background: Healthcare utilization and costs escalate near diagnosis and in the final months of life. There is a national trend toward aggressive care at end of life (EOL). We examined patterns in utilization and cost across the trajectory of care and during the last two weeks of life during implementation of a lay navigation intervention. Methods: Claims data were obtained for Medicare beneficiaries ≥ 65 years old with cancer in the UAB Health System Cancer Community Network (UAB CCN). For 10 quarters from January 2012 -June 2014, we examined healthcare utilization for the population at large, navigated patients, and decedents. All analyses included ER visits, hospitalizations, and ICU admissions and use of chemotherapy in the last 2 weeks of life, and hospice utilization (admission or less than 3 days of hospice) in the quarter of death for decedents. Descriptive analyses and linear regression were used to test trends over time; general linear models evaluated changes in health care utilization and cost. Results: Across the population reduction of 13.4% to 11% for hospitalization (18% decrease, p < 0.01), 8.0% to 7.1% for ER visits (12% decrease, p < 0.01), 2.9% to 2.5% for ICU admissions (14% decrease, p = 0.04) and an increase of 3.9% to 4.3% for hospice (9.2% increase p = 0.37) were found. Among 5,861 decedents, in the last 2 weeks of life, there were decreases in ICU admissions (14.6% decrease, p = 0.11), from 39.2% to 32.0%, ER visits (18.4% decrease, p = 0.03), and chemotherapy, from 4.7% to 3.5% (25.5% decrease, p = 0.11).Over the 10 quarters, hospice enrollment increased from 70.7% to 77.4% (9.48% increase; p = 0.06), and the proportion of patients on hospice for less than 3 days changed from 7.8% to 7.5% (3.85% decrease, p = 0.30). Costs decreased about $158 per quarter per beneficiary. A significant pre-post decrease of $952 per beneficiary (p < 0.01) led to an estimated reduction in Medicare costs of $18,406,920 for the 19,335 beneficiaries in the UAB CCN for the five quarters post-implementation. Conclusions: We observed decreased healthcare utilization and cost and trends toward decreased aggressive care at EOL in the UAB CCN. Further work is needed to determine the impact of navigation on utilization trends.

scholarly journals Changes in Pediatric Faculty Burnout During the COVID-19 Pandemic

2021 ◽  
Author(s):  
Audrey M. Uong ◽  
Michael D. Cabana ◽  
Janet R. Serwint ◽  
Carol A. Bernstein ◽  
Elaine E. Schulte
Keyword(s):  
Emotional Exhaustion ◽  
Tertiary Care ◽  
Categorical Variables ◽  
Academic Rank ◽  
Continuous Variables ◽  
Cross Sectional ◽  
Exact Test ◽  
Faculty Burnout ◽  
Student’S T ◽  
The Impact

OBJECTIVES To examine the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated workflow changes, such as deployment on pediatric faculty burnout in an early epicenter of the pandemic. We hypothesized burnout would increase during the COVID-19 surge. METHODS We conducted serial cross-sectional surveys of pediatric faculty at an academic, tertiary-care children’s hospital that experienced a COVID-19 surge in the Northeastern United States. Surveys were administered pre-surge (February 2020), during the surge (April 2020), and postsurge (September 2020). The primary outcome was burnout prevalence. We also measured areas of worklife scores. We compared responses between all 3 survey periods. Continuous variables were analyzed by using Student’s t or Mann–Whitney tests, and categorical variables were analyzed by using χ2 or Fisher’s exact test, as appropriate. RESULTS Our response rate was 89 of 223 (40%) presurge, 100 of 267 (37%) during the surge, and 113 of 275 (41%) postsurge. There were no differences in demographics, including sex, race, and academic rank between survey periods. Frequency of burnout was similar in all 3 periods (20% to 26%). The mean scores of emotional exhaustion improved during the surge (2.25 to 1.9; P = .04). CONCLUSIONS Contrary to our hypothesis, we found no changes in pediatric faculty burnout after a COVID-19 surge. Emotional exhaustion improved during the COVID-19 surge. However, these findings represent short-term responses to the COVID-19 surge. Longer-term monitoring of the impact of the COVID-19 surge on pediatric faculty burnout may be necessary for health care organizations to mitigate burnout.

Exploring End-of-Life Care Team Communication: An Interprofessional Simulation Study

2019 ◽  
Vol 37 (1) ◽  
pp. 65-71 ◽  
Author(s):  
Megan Lippe ◽  
Alexandra Stanley ◽  
Allison Ricamato ◽  
Anne Halli-Tierney ◽  
Robert McKinney
Keyword(s):  
Health Care ◽  
End Of Life ◽  
Communication Skills ◽  
End Of Life Care ◽  
Life Care ◽  
Team Communication ◽  
Quality Health Care ◽  
Good Communication ◽  
Quality Health ◽  
The Impact

Effective team communication is necessary for the provision of high-quality health care. Yet, recent graduates from diverse health-care disciplines report inadequate training in communication skills and end-of-life care. This study explored the impact of a withdrawal of life-sustaining measures interprofessional simulation on team communication skills of students representing medicine, nursing, and social work. The 3-phase simulation required teams to communicate with the patient, family, and one another in the care of a seriously ill patient at the end of life. Team communication in the filmed simulations was analyzed via the Gap-Kalamazoo Communication Checklist. Results revealed fair to good communication across the 9 communication domains. Overall team communication was strongest in “shares information” and lowest in “understands the patient’s and family’s perspective” domains. Field notes revealed 5 primary themes— Team Dynamics, Awkwardness, Empathy is Everything, Build a Relationship, and Communicating Knowledge When You Have It—in the course of the data analysis. Logistical challenges encountered in simulation development and implementation are presented, along with proposed solutions that were effective for this study. This simulation provided an opportunity for interprofessional health-care provider students to learn team communication skills within an end-of-life care context.

The impact of emergency general surgery on end-of-life care among older patients with metastatic cancer.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 56-56
Author(s):  
Katherine C Lee ◽  
Elizabeth J. Lilley ◽  
Daniel Sturgeon ◽  
Stuart R. Lipsitz ◽  
Joaquim M Havens ◽  
...  
Keyword(s):  
End Of Life ◽  
General Surgery ◽  
End Of Life Care ◽  
Older Patients ◽  
Metastatic Cancer ◽  
Cancer Type ◽  
Life Care ◽  
Emergency General Surgery ◽  
Icu Stay ◽  
The Impact

56 Background: Despite high post-discharge mortality among older patients with metastatic cancer who undergo emergency general surgery (EGS), little is known about the impact of EGS on the type of end-of-life care received. We sought to examine the association between EGS and established markers of high intensity or poor quality end-of-life care for cancer patients. Methods: This retrospective cohort study used 2001-2013 Surveillance, Epidemiology, and End Results-Medicare to identify beneficiaries 65 years or older, diagnosed initially with stage IV cancer (lung, colorectal, breast, ovarian, pancreatic, or melanoma), who received one of the seven highest-burden EGS operations, and died within 180 days of surgery. Non-EGS controls were exact-matched by age, sex, race, cancer type, and cancer diagnosis date then assigned a pseudo-exposure date corresponding to the EGS date. Conditional logistic regression adjusting for region and Charlson score was performed among pairs discharged alive to compare location of death (facility or home/hospice), healthcare utilization (hospitalization, intensive care unit (ICU) stay, emergency department (ED) visit) in the last 30 days of life, and hospice use (death in hospice, hospice enrollment less than three days from death). Results: Among 1,129 matched pairs, EGS patients had higher odds of death in facility (OR [95% CI]: 1.29 [1.05 - 1.58]) as well as hospitalization (1.83 [1.54 - 2.18]), ICU stay (2.05 [1.66 - 2.53]) or ED visit (1.76 [1.47 - 2.10]) in the last 30 days of life compared to non-EGS patients. EGS patients had higher odds of dying in hospice (1.22 [1.02 - 1.45]), but also experienced higher odds of hospice enrollment less than three days from death (1.72 [1.20 - 2.46]). Conclusions: Older patients with metastatic cancer who survive EGS experienced higher intensity end-of-life care than similar non-EGS patients. Such EGS patients may benefit from targeted interventions during the emergent hospitalization to improve the end-of-life care received.

Racial disparities in end-of-life care among Louisiana cancer decedents in a population-based study from 2011-2017.

2019 ◽  
Vol 37 (31_suppl) ◽  
pp. 46-46
Author(s):  
Laura M Perry ◽  
Leah E. Walsh ◽  
Ronald Horswell ◽  
Lucio Miele ◽  
San Chu ◽  
...  
Keyword(s):  
End Of Life ◽  
End Of Life Care ◽  
Metastatic Cancer ◽  
Population Based ◽  
Cancer Type ◽  
Deep South ◽  
Life Care ◽  
Eligibility Criteria ◽  
Inpatient Hospitalizations ◽  
Aggressive Care

46 Background: Cancer patients’ comfort near the end of life is often undermined by unnecessary aggressive treatments. Furthermore, Black adults receive more aggressive end of life care compared to White adults. We hypothesized that these inequalities would be especially pronounced in Louisiana given regional trends of high cancer mortality coupled with inaccessibility to high quality cancer care. Methods: This was a retrospective analysis of end-of-life care using a Patient-Centered Outcomes Research Institute (PCORI)-funded PCORnet database in the Deep South, called Research Action for Health Network (REACHnet). Of 3,089,092 individuals included, 1,290 met eligibility criteria for the present study: 1) died in Louisiana with a metastatic cancer diagnosis between January 1, 2011 and December 31, 2017, 2) had at least one outpatient clinic visit within six months of death, and 3) self-identified as White or Black. In collaboration with the Louisiana Clinical and Translational Science (LA CaTS) Center, we extracted data on five validated indicators of aggressive care in the final 30 days of life: chemotherapy use, inpatient hospitalizations, ED admissions, ICU admissions, and mechanical ventilation. Hypotheses were analyzed using binary logistic regression to examine whether patient race (White vs. Black) was associated with receipt of each indicator of aggressive end-of-life care, while controlling for sex, age, number of comorbidities, and cancer type. Results: Patients were either White ( n = 875, 67.8%) or Black ( n = 415, 32.2%) adults, and the majority were ≥60 years old (72.4%). Most patients (85.0%) received at least one indicator of aggressive care in the last 30 days of life ( M = 1.91, SD = 1.23), most commonly inpatient hospitalizations (77.0%). Black individuals were more likely than White individuals to be hospitalized ( OR = 1.66, 95% CI: 1.21 to 2.27, p= .002) or admitted to the ED ( OR= 1.57, 95% CI: 1.16 to 2.13, p= .004) during their last month of life, but race was not associated with other indicators. Conclusions: Findings have implications for informing healthcare decision making near the end of life for patients, families, and clinicians in the Deep South.

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