Achieving goal-concordant care: Formal and informal advance care planning for White, Black, and Hispanic older adults.

INTRODUCTION: Advance care planning (ACP) aims to ensure that patients receive goal-concordant care (GCC), which is especially important for racially or ethnically minoritized populations at greater risk of poor end-of-life outcomes. However, few studies have evaluated the impact of advance directives (i.e., formal ACP) or goals-of-care conversations (i.e., informal ACP) on such care. This study aimed to examine the relationship between each of formal and informal ACP and goal-concordant end-of-life care among older Americans and to determine whether their impact differed between individuals identified as White, Black, or Hispanic. METHODS: We conducted a retrospective cohort study using 2012-2018 data from the biennial Health and Retirement Study. We examined the relationships of interest using two, separate multivariable logistic regression models. Model 1 regressed a proxy report of GCC on formal and informal ACP and sociodemographic and health-related covariates. Model 2 added interaction terms between race/ethnicity and the two types of ACP. RESULTS: Our sample included 2048 older adults. There were differences in the proportions of White, Black, and Hispanic decedents who received GCC (83.1%, 75.3%, and 71.3%, respectively, p < 0.001) and in the use of each type of ACP by racial/ethnic group. In model 1, informal compared with no informal ACP was associated with higher odds of GCC (adjusted odds ratio = 1.38 [95% confidence interval, 1.05-1.82]). In model 2, Black decedents who had formal ACP were more likely to receive GCC than those who did not, but there were no statistically significant differences between decedents of different racial/ethnic groups who had no ACP, informal ACP only, or both types of ACP. CONCLUSIONS: Our results build on previous work by indicating the importance of incorporating goals-of-care conversations into routine healthcare for older adults and encouraging ACP usage among racially and ethnically minoritized populations who use ACP tools at lower rates.

An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go?

OBJECTIVES: POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research. DESIGN: Integrative review. SETTING AND PARTICIPANTS: Not applicable. METHODS: We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization. RESULTS: Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified. CONCLUSIONS AND IMPLICATIONS: Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.

Biopsychosocial Attributes of Single-region and Multi-region Body Pain During Early Adolescence: Analysis of the ABCD Cohort.

OBJECTIVES: Multi-region pain during adolescence is associated with a higher symptom burden and lower quality of life. The purpose of this study was to describe and compare the biopsychosocial attributes of single-region and multi-region pain among healthy young adolescents. MATERIALS AND METHODS: We analyzed data from 10,320 children aged 10.6 to 14 years who self-reported pain in the Adolescent Brain and Cognitive Development Study. Pain was coded as single-region or multi-region based on body map data. RESULTS: One in 5 young adolescents indicated recent multi-region pain. Sequential regression supported improved model fit when psychological and sociocultural factors were added to a biological model of pain; however, these models improved the classification of multi-region but not single-region pain. A significant interaction effect of sex and puberty remained constant across models with increased odds of pain at each advancing pubertal stage for both sexes compared with prepuberty, but no difference between girls and boys at late puberty (adjusted odds ratio [OR]=2.45 [1.72, 3.49] and adjusted OR=1.63 [1.20, 2.23], respectively). Psychological factors improved the classification of multi-region pain with significant effects of anxiety, somatic symptoms, and somnolence. Finally, compared with White and non-Hispanic children, Black and Hispanic children were less likely to report pain (adjusted OR=0.70 [0.61, 0.80]; adjusted OR=0.88 [0.78, 0.99], respectively) but had significantly higher pain interference when pain was present (adjusted OR=1.49 [1.29, 1.73] and adjusted OR=1.20 [1.06, 1.35], respectively). DISCUSSION: Pain is a biopsychosocial phenomenon, but psychological and sociocultural features may be more relevant for multi-region compared with single-region pain during early adolescence.

Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults.

OBJECTIVE: To examine advance care planning (ACP) trends among an increasingly diverse aging population, we compared informal and formal ACP use by race/ethnicity among U.S. older adults (≤65 years). METHODS: We used Health and Retirement Study data (2012-2018) to assess relationships between race/ethnicity and ACP type (i.e., no ACP, informal ACP only, formal ACP only, or both ACP types). We reported adjusted risk ratios with 95% confidence intervals. RESULTS: Non-Hispanic Black and Hispanic respondents were 1.77 (1.60, 1.96) and 1.76 (1.55, 1.99) times as likely, respectively, to report no ACP compared to non-Hispanic White respondents. Non-Hispanic Black and Hispanic respondents were 0.74 (0.71, 0.78) and 0.74 (0.69, 0.80) times as likely, respectively, to report using both ACP types as non-Hispanic White respondents. DISCUSSION: Racial/ethnic differences in ACP persist after controlling for a variety of barriers to and facilitators of ACP which may contribute to disparities in end-of-life care.

Enhancing risk perception may be insufficient to curtail prescription opioid use and misuse among youth after surgery: A randomized controlled trial.

OBJECTIVE: This randomized controlled trial examined whether an interactive, risk-focused educational program was associated with higher risk perceptions and decreased prescription opioid use/misuse among emerging adults. METHODS: 503 participants aged 15-24 years scheduled for ambulatory surgery were randomized to routine prescription education with or without our Scenario-Tailored Opioid Messaging Program (STOMP) provided prior to receipt of a prescribed opioid. Surveys were completed preoperatively, and at days 7&14, months 1&3 postoperatively. Outcomes included analgesic risk perceptions, opioid use, and misuse intentions/behavior. RESULTS: Compared to Controls, STOMP was associated with stable but higher risk perceptions on day 14 (ß = 1.76 [95% CI 0.53, 2.99], p = .005) and month 3 (ß = 2.13 [95% CI 0.86, 3.40], p = .001). There was no effect of STOMP or analgesic misuse risk perceptions on days of opioid use or subsequent misuse intentions/behavior. The degree to which participants valued pain relief over analgesic risk (trade-off preference) was, however, associated with prolonged postoperative opioid use and later misuse. CONCLUSION: Education emphasizing the risks of opioids was insufficient in reducing opioid use and misuse in youth who were prescribed these analgesics for acute pain relief. PRACTICE IMPLICATIONS: Education may need to better address analgesic expectations to shorten opioid use and mitigate misuse.

To relieve pain or avoid opioid-related risk? A comparison of parents' analgesic trade-off preferences and decision-making in 2019 versus 2013 in a single U.S. pediatric hospital.

BACKGROUND: Analgesic trade-off preferences, or the relative preference for pain relief vs. risk aversion, shape parents' decisions to give prescription opioids to their children. These preferences may be influenced by personal experiences and societal factors. AIM: To examine whether parental analgesic trade-off preferences and opioid decision-making have shifted toward risk aversion during the opioid crisis in the United States. METHODS: We conducted a secondary analysis of the preoperative survey data of parents from a single U.S. pediatric hospital whose children aged 5-17 years were to undergo painful surgery in 2013 (Time 1) or 2017/2019 (Time 2). Surveys assessed parents' analgesic trade-off preference (-12 or risk-averse to +12 or pain relief preferent, scores around 0=ambivalent) and their hypothetical decisions to give a prescribed opioid to a child in pain. RESULTS: Data from 847 parents were included (Time 1, n = 361; Time 2, n = 486). Parents at Time 2 were significantly more risk-averse compared with Time 1 (adj.ß: -0.84 [95% CI: -1.09, -0.60]). Parents at Time 2 were more than twice as likely to be risk-averse or ambivalent (OR: 2.17 [95% CI: 1.62, 2.91]). There was a significant interaction effect of Time*Preference on parents' decision to give the opioid (adj. OR: 1.09 [95% CI: 1.03, 1.16]). At Time 2, parents who were ambivalent or risk-averse were less likely than those who preferred to relieve pain to administer the prescribed opioid (OR: 0.57 [95% CI: 0.37, 0.89]). In contrast, there was no association between the preference group and the opioid decision at Time 1. CONCLUSION: Findings suggest that parents of children scheduled for painful surgery at our pediatric hospital have become more analgesic risk-averse during the past decade. Parents' analgesic trade-off preferences may influence their decisions to administer prescribed opioids after surgery, which may contribute to children's pain outcomes.