Advance care planning billing practices and documentation quality for cancer patients requiring hospitalization.

e24000 Background: Advance Care Planning (ACP) is an important component of comprehensive cancer care, yet barriers exist to successful implementation. In 2016, Medicare introduced billing codes to provide reimbursement for ACP discussions. Our aim was to evaluate the usage of ACP billing codes and quality of accompanying documentation in patients with a prior oncology admission at an academic medical center. Methods: Using an electronic health record data warehouse tool, we identified a cohort of cancer patients who had been admitted to the inpatient oncology service and had an ACP billing encounter (CPT codes 99497 or 99498) over a 4-year period (8/1/2016 to 8/1/2020). We collected patient and provider demographics and performed descriptive statistics. We assessed ACP documentation quality for 30 patients selected at random based on 5 domains (healthcare proxy, health values or goals, scope of treatment/code status, prognosis/illness understanding, and end of life [EOL]care planning/hospice) previously identified from a literature review. Results: We identified 170 unique patients (180 ACP encounters), representing a small fraction (170/5636, 0.03%) of hospitalized oncology patients over the study period. Patients were 52% female with mean age of 64 (SD 12.9). Mean number of oncology hospitalizations was 2.6 (SD 1.96). ACP encounters took place in both inpatient (135/180; 75%) and outpatient (45/180; 25%) settings. In the outpatient setting, the majority of billing encounters were in palliative care (27/45; 60%), followed by oncology (12/45;27%) and primary care (5/45;11%). Of the sample of patient charts reviewed (n = 30), provider documentation frequently included scope of treatment (27/30; 90%), prognosis (27/30; 90%), EOL planning (21/30; 70%), and health values (19/30, 63%); healthcare proxy was infrequently included (4/30, 13%). Conclusions: ACP billing remains infrequently utilized for a cohort of oncology patients requiring hospitalization at a large academic center. In cases for which an ACP discussion is billed, the accompanied documentation is of high clinical utility and meets several key quality domains. This work lays a foundation for future research and quality improvement efforts to improve ACP and documentation.[Table: see text]

Chinese Americans’ Priorities and Practices for Designating a Healthcare Proxy

Many Americans need decision-making from someone else due to cognitive impairment. Chinese comprises the largest Asian group in the U.S.; few studies have investigated factors influencing Chinese Americans’ health care proxy (HCP) designation. The aim of this study was to examine factors associated with Chinese Americans’ HCP designation, using Andersen’s Behavioral Model as a lens. Data were from the 2015 Asian American Quality of Life Survey. Hierarchical logistic regression analyses were conducted to test the incremental predictive power of predisposing, enabling, and needs factors. We found that age, marital status, religious affiliation, health insurance, acculturation, and self-rated health were predictors for HCP designation. The odds of having an HCP designation were 1.96 times higher for those aged 65 and above, compared to those aged 18-64 (p=0.045); The odds were 2.40 times higher for those who were married (p=0.006); The odds were 1.79 times higher for Protestants (p=0.042) and 2.25 times higher for Buddhists (p=0.025), compared to those with no religious affiliation; Having a health insurance increased the odds of having an HCP designation by 2.23 (p=0.022); For each additional unit in acculturation score, the odds of having an HCP designation increased by 0.65 (p=0.011); Compared to those who rated their health as excellent/very good/good, those rating health as fair/poor had a 2.97 times higher odds of HCP designation (p=0.001). We concluded that various factors influence Chinese Americans’ HCP designation, and appropriate and innovative practices should be used to assist HCP discussion and designation among Chinese and other ethnic minority populations.

ADVANCE CARE PLANNING AMONG LGBT PEOPLE: AN INTEGRATIVE REVIEW AND ANALYSIS

Lesbian, gay, bisexual, and transgender people (LGBT) with advanced illness need culturally competent advanced care planning (ACP) services but often encounter structural and communication barriers. The aim of this study was to examine the ACP behaviors of LGBT people. An integrative rapid review method was used to search electronic databases for peer reviewed and non-peer reviewed publications between 2010 to 2017. Eight survey instruments comprising 30 prevalence estimates were analyzed. ACP discussions between LGBT people and their primary health care providers were rare, with an overall prevalence of 10%. Transgender people were 50–70% less likely than their LGB counterparts to have a living will or to have appointed a healthcare proxy. These results suggest there is a critical need for greater cultural competency among health care providers serving LGBT populations. Social workers can play a key role in advocacy and social justice for LGBT individuals with advanced illness.

Informed Consent and Advance Care Directives: Cornerstones and Outstanding Issues in the Newly Enacted Italian Legislation

This article’s authors delve into, and comment on, some of the key provisions within law no. 219, passed in 2017, which came into full effect in 2018. The legislation presents several innovative aspects: (a) communication time is equated to care; (b) patients may turn down lifesaving treatments, yet doctors must put in place all suitable support processes, from a psychological standpoint as well, in order to make sure that patients make informed decisions in full awareness; (c) refusal to treatment may be expressed prior to the onset of the disease making the patient incapable, as long as the advance directive is laid out by a mentally capable adult who has been provided with all relevant medical information available as to the consequence of a refusal to undergo a given treatment; (d) artificial nutrition and hydration are tantamount to treatment; thus, they may not be carried out and kept in place in absence of valid consent; (e) patients may appoint a healthcare proxy holder, tasked with interacting with doctors and caregivers and expressing consent or refusal; (f) patient will, whether current or advance, must be complied with even under emergency or urgency conditions, provided that clinical conditions and circumstances make it possible to acquire it; (g) doctors may disregard advance directives only when specifically provided for by the law; (h) patients may not demand treatment deemed to be illegal or running counter to ethical codes or scientific evidence. The new legislation, therefore, is meant to uphold the right to exercise self-determination as well as the patient’s quality of life, yet ensuring that doctors remain fully capable of making the decisions that they are best positioned to. Summary: The Italian Parliament has for the first time regulated the issue of consent and refusal of healthcare treatments, whether currently expressed or advance. This article elaborates on recent Italian legislation that details a patient's right to consent to or refuse treatment in advance, including refusal of artificial nutrition and hydration, the duty of doctors in the event of an emergency, the shared planning treatment, the role of durable power of attorney, and advance healthcare directives.

Abstract 156: Facilitating End-of-Life Decision-Making and Preparedness Planning Among Heart Failure Patients Hospitalized for Advanced Disease

Background: To address the increasingly strident call for better, more informed shared decision-making about treatment decisions and goals of care in patients with end-stage heart failure (HF), we designed and implemented a supportive care intervention for hospitalized patients with a very poor prognosis. Methods: All patients admitted to the advanced HF service at a single hospital over a 6-mo. period were screened for inclusion criteria (deemed non-candidacy for LVAD/transplantation and high likelihood for death or persistently poor quality of life at 6 months, based on the Allen risk score). Enrollees were given a written exercise, The Conversation Starter Kit, to complete with their healthcare proxy before an outpatient visit with a HF nurse practitioner (NP) trained in supportive care techniques. The intervention provided at this visit consisted of 5 domains: disease understanding, symptom control, legal matters, goals of care, and the role of the healthcare proxy. The KCCQ, PEACE Illness Acceptance Scale, Decisional Conflict Scale, and Kaldjian’s Goals of Care were collected at enrollment and 1 month after the intervention, along with 6-month outcomes of readmission and death. Results: Of 77 patients admitted to the service who were not candidates for advanced therapies, 16 met eligibility criteria. Nine declined participation and 7 of a planned 10 were enrolled; the pilot was terminated early due to low enrollment. Only 2 patients completed the intervention; reasons for not completing varied for the 5 remaining patients. (Table) Despite a pre-existing relationship between patients and NPs, rigorous facilitator training, and a comprehensive, evidence-based, outpatient intervention, significant barriers to implementation included patient reluctance/fear, uncertainty surrounding disease progression, time constraints of completing the intervention within a scheduled clinic visit, and lack of efficacy due to patients having too-advanced disease. Conclusions: An intervention to engage very high-risk, advanced HF patients in shared decision-making about end-of-life care failed to be successfully and sustainably implemented. Future work should assess the feasibility and efficacy of designing an early and iterative intervention in a larger population of HF patients with less advanced disease.