Prevalence of Cognitive Impairment and Relationships with Other Factors in Patients with End Stage Kidney Disease Receiving Hemodialysis.

Despite recommendations, cognitive screening in patients with end stage kidney disease (ESKD) rarely happens, leading to underestimates of cognitive impairment (CI) prevalence and missed opportunities for intervention. We aimed to describe CI prevalence and associated factors in 100 patients receiving in-center hemodialysis aged 50 years and older. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA). Descriptive analysis techniques characterized the sample and estimated mean scores. Non-parametric and parametric tests explored relationships among MoCA scores and other patient factors. Of the 100 patients, 32% had normal cognitive function, 56% mild CI, and 12% moderate CI. Age, income, and education level significantly corelated with cognitive function in our sample. Identifying clinical factors and appropriate follow up for abnormal screening are crucial next steps in managing cognitive impairment in patients with ESKD receiving in-center hemodialysis.

Initiating and Continuing Long-Term Exercise in Heart Failure: A Qualitative Analysis From the GEtting iNTo Light Exercise-Heart Failure Study.

BACKGROUND: Exercise is a class 1A recommendation to improve the lives of patients with heart failure, yet less than one-third adhere to physical activity guidelines, and less than 3% attend cardiac rehabilitation. OBJECTIVE: The aim of this study was to determine the effect of gentle nonaerobic exercise on initial and long-term adherence in patients with heart failure. METHODS: We used a qualitative descriptive approach with qualitative content analysis to analyze previously recorded interview data collected as part of the 6-month GEtting iNTo Light Exercise-Heart Failure study and looked for trends in responses among our sample. Thematic statements, representing salient aspects of the participants' experiences, were created and supported by illustrative excerpts from the data. RESULTS: Twenty-two interviews were analyzed. Eight participants had ≥80% adherence, and the remaining 14 participants were super-adherers (>100% adherence). Super-adherers tended to be male and 65 years or older, and have no exercise for 3 months before the study, a body mass index ≥ 30, and poor to good Kansas City Cardiomyopathy Questionnaire scores. Participants initially enrolled because they saw the program as an opportunity to improve a health issue and to exercise. Long-term adherence was facilitated by convenience, individualization, experiencing psychological and physical improvements, and peer fellowship. CONCLUSIONS: The GEtting iNTo Light Exercise-Heart Failure study that used home-based gentle nonaerobic exercise had 64% of participants come more than was asked. It is imperative that clinicians incorporate what participants with heart failure have directly stated is important for their initiation and long-term adherence to exercise so that we can work toward bridging sedentary patients to the full exercise guidelines to reduce morbidity and mortality.

Effectiveness of an Advance Care Planning Intervention in Adults Receiving Dialysis and Their Families: A Cluster Randomized Clinical Trial.

Importance: Evidence of effectiveness of advance care planning (ACP) strategies for patients receiving dialysis and their families is needed. Objectives: To test the effectiveness of an ACP intervention to prepare patients and their surrogates for end-of-life (EOL) decision-making and to improve surrogate bereavement outcomes. Design, Setting, and Participants: This cluster randomized clinical trial, An Effectiveness-Implementation Trial of SPIRIT (Sharing Patients' Illness Representations to Increase Trust) in ESRD, was conducted from December 2017 to March 2023 and included 42 dialysis clinics in 5 US states (Georgia, New Mexico, North Carolina, Pennsylvania, and Virginia) randomized to provide intervention or usual care. Recruitment was from February 15, 2018, to January 31, 2022, and patient-surrogate dyads were followed up for 21 months (until January 17, 2023) or until patient death. Intervention: Each clinic selected 1 or 2 health care workers (eg, nurse practitioner, registered nurse, or social worker) to conduct 45- to 60-minute ACP discussions with dyads in the clinic or remotely. After March 13, 2020 (commencement of the COVID-19 emergency declaration), all discussions were conducted remotely. An ACP summary was placed in patients' medical records. Main Outcomes and Measures: The primary, 2-week preparedness outcomes were dyad congruence on EOL goals of care, patient decisional conflict, surrogate decision-making confidence, and a composite of dyad congruence and surrogate decision-making confidence. Secondary bereavement outcomes were anxiety, depression, and posttraumatic distress 3 months after patient death. To adjust for COVID-19 pandemic effects on bereavement outcomes, a variable to indicate the timing of baseline and 3-month assessment relative to the COVID-19 emergency declaration was created. Results: Of the 426 dyads enrolled, 231 were in the intervention clinics, and 195 were in the control clinics. Among all dyads, the mean (SD) patient age was 61.9 (12.7) years, and the mean (SD) surrogate age was 53.7 (15.4) years. At 2 weeks, after adjusting for baseline values, dyad congruence (odds ratio [OR], 1.61; 95% CI, 1.12-2.31; P = .001), decisional conflict scores (ß, -0.10; 95% CI, -0.13 to -0.07; P < .001), and the composite (OR, 1.57; 95% CI, 1.06-2.34; P = .03) were higher in the intervention group than in the control group. Surrogate decision-making confidence was similar between groups (ß, 0.06; 95% CI, -0.01 to 0.13; P = .12). Among 77 bereaved surrogates, after adjusting for baseline values and assessment timing, intervention group anxiety was lower than control group anxiety (ß, -1.55; 95% CI, -3.08 to -0.01; P = .05); however, depression (ß, -0.18; 95% CI, -2.09 to 1.73; P = .84) and posttraumatic distress (ß, -0.96; 95% CI, -7.39 to 5.46; P = .75) were similar. Conclusions and Relevance: In this randomized clinical trial, the ACP intervention implemented by health care workers at dialysis centers improved preparation for EOL decision-making but showed mixed effectiveness on bereavement outcomes. The ACP intervention implemented in dialysis centers may be an effective strategy to the dyad preparation for end-of-life care as opposed to the current focus on advance directives. Trial Registration: ClinicalTrials.gov Identifier: NCT03138564.

Getting Into Light Exercise (GENTLE-HF) for Patients With Heart Failure: the Design and Methodology of a Live-Video Group Exercise Study.

OBJECTIVE: Newer therapies have increased heart failure (HF) survival rates, but these therapies are rarely curative. The consequence of increased longevity is the likelihood that patients with HF will experience higher symptom burdens over time. Exercise such as cardiac rehabilitation programs can palliate symptom burdens, but numerous barriers prevent exercise participation and adherence. Small pilot studies indicate short-term beneficial effects of gentle forms of exercise such as yoga to address symptom burdens and accommodate comorbidities. Long-term symptom benefit and adherence to yoga are currently unknown. Therefore, a novel a home-based, gentle-stretching intervention that addresses issues of exercise access and adherence is described in this article. PURPOSE: The purpose of this article is to describe the background, design and study methodology of the Getting Into Light Exercise for HF (GENTLE-HF) randomized controlled trial. Gentle-HF will test a gentle stretching and education intervention compared to an education control group concerning symptom burden (dyspnea, exercise, activity adherence, depression, and anxiety) and quality of life. As an exploratory aim, we also will determine whether rurality moderates the relationships between exercise participation and symptom burden as a measure of health equity. METHODS: We designed a randomized controlled trial study (n = 234) with 2 arms: a gentle stretching intervention arm with HF education and an HF education-only control. Participants will be recruited from U.S. cardiology clinics in the mid-Atlantic and the San Francisco Bay areas. This recruitment strategy will include individuals from urban, suburban and rural areas and individuals that have diverse racial and ethnic backgrounds. All participants will be provided with an iPad set up to access HF educational topics, and the intervention arm will have both educational and gentle-stretching class links. Both arms will access the HF health education icons on their iPads weekly; they correspond to the 6 months (26 weeks) of study participation. Symptom burden (dyspnea, fatigue, exercise intolerance, depression, anxiety) and quality of life will be measured at the study's start and completion. Study adherence will be measured by using attendance rates and number of class minutes attended. RESULTS: The GENTLE-HF study is a randomized study that will test the effect of a home-based, video-conference-delivered gentle stretching and HF education intervention designed for patients with HF. The findings will inform whether gentle stretching can decrease symptom burden and potentially provide access to symptom palliation for a diverse population of patients with HF.

Perceptions of Caregiving Experience, Level of Burden, and Sense of Well-Being Among Caregivers of Patients Receiving In-Center Hemodialysis.

Family caregivers are essential to the well-being of patients receiving hemodialysis. Yet poor understanding of caregivers' most pressing needs and factors that adversely affect caregivers impede targeted intervention development. To address this gap, 46 caregivers (38 female, 28 White, 21 spouses/partners, mean age 54 years) of patients from seven hemodialysis centers completed surveys and semi-structured interviews via telephone. Most caregivers denied depressive symptoms and negative impact of caregiving on their self-esteem, but reported adverse effects on their health, schedule, and finances. Greater acknowledgment of the important role of family caregivers, assistance with instrumental activities of daily living, transportation, and resources for education and emotional support may address their most pressing challenges. Age, race, and relationship to the patient influenced caregiver perspectives. Interventions to support these invaluable members of the health care team are warranted.

A Study Describing Patients' Perspectives on Cognitive Function Screening During Hemodialysis.

Routine screening of cognitive function in patients with end stage kidney disease (ESKD) is recommended, yet rarely it happens. This study sought to identify barriers to cognitive function screening for patients with ESKD receiving in-center hemodialysis. To ascertain their perceptions of cognitive function screening, 100 patients aged 50 years and older (48% female, 49% Black/African-American) from seven hemodialysis centers participated in structured interviews after completing the Montreal Cognitive Assessment and Geriatric Depression Scale. Participants rated the screening experience favorably, indicating cognitive function screening is acceptable to patients receiving hemodialysis. The level of cognitive impairment was the only factor significantly associated with screening evaluation scores, with participants with scores indicating mild or moderate impairment evaluating screening less favorably than those with normal cognitive function scores. Next steps include identifying systems level barriers and establishing appropriate follow up for patients with abnormal screening results.

Cultivating inclusive learning environments that foster nursing education program resiliency during the Covid-19 pandemic.

Nursing education programs faced multiple challenges to increase the size, diversity, and skill set of the nursing workforce while contending with shortage of clinical placement sites and retiring faculty. A program that is unable to be resilient in the face of crisis will fail in its mission to graduate resilient nurses. The purpose of this paper is to describe how nursing programs can respond to the challenge of creating a resilient program poised to graduate a diverse, inclusive, and resilient workforce. Utilizing resilience-oriented strategies to impact educational services solidified program relevancy, promoted student belonging, and enhanced student recruitment/retention. While programs have become accustomed to doing more with fewer resources, many of these programs may not survive these unprecedented times without incorporating a holistic approach for organizational well-being that promotes resilience through inclusivity.

Nephrology and Palliative Care Collaboration in the Care of Patients With Advanced Kidney Disease: Results of a Clinician Survey.

RATIONALE & OBJECTIVE: Despite calls for integrating palliative care into chronic kidney disease (CKD) care, uptake remains low. The study aim was to describe clinicians' perceptions of the clinical and research priorities in CKD care and the main barriers to collaboration. STUDY DESIGN: This was a descriptive cross-sectional study using an online survey developed by clinicians and researchers as the primary data collection method. SETTING & PARTICIPANTS: Clinicians in nephrology and palliative care departments (N = 195) at an academic health center in Virginia were invited to participate. Of the 48.7% (n = 95) who responded, most were registered nurses (65.3%) in nephrology (80%) with more than 15 years' experience (40%). PREDICTORS: Factors including discipline (nursing, social work, and physician) and practice area (palliative care or nephrology) were assessed. OUTCOMES: Main outcomes of interest included clinicians' perceptions of the role of palliative care, barriers to collaboration, and the top clinical and research priorities for patients with advanced CKD. ANALYTIC APPROACH: Survey data were analyzed using SPSS using descriptive statistics. RESULTS: Respondents reported being comfortable caring for patients near the end of life and endorsed advance care planning and collaboration between nephrology and palliative care teams. However, both rarely happen. Fragmentation, or poor coordination of care, was perceived to be the main barrier to collaboration. Perceptions regarding collaboration facilitation differed; nephrology clinicians identified patient/family education as the most important facilitator while palliative care clinicians identified clinician education as most important. Top clinical priorities differed. Palliative care clinicians reported pain/symptom management as taking priority while nephrology clinicians identified caregiver/family support. Developing interventions to support treatment-related decision making was the top research priority. LIMITATIONS: Results reflect perceptions of about half the clinicians at 1 academic health center. CONCLUSIONS: Additional studies to capture patients' and families' perspectives and examine end-of-life care processes are needed. Results may inform future targeted interventions.

A Narrative Review of Management Strategies for Common Symptoms in Advanced CKD.

Patients with advanced chronic kidney disease (CKD) experience multiple bothersome symptoms, undermining their quality of life (QOL). With growing attention to the importance of symptom management in advanced CKD, the evidence regarding symptoms is increasing. In this review, we briefly summarize the current evidence of effective pharmacologic and nonpharmacologic interventions to improve symptoms and QOL in patients with advanced CKD, including those on dialysis. We focused on symptoms that are commonly experienced by patients, such as pain, fatigue, sleep disturbances, itching, nausea and vomiting, cognitive impairment, and anxiety and depression. We noted that research in symptom science focused on improving symptom management in CKD is still very limited. In addition to the lack of clinical practice guidelines to address those common symptoms, the major gaps in the current literature include the evidence regarding mechanistic pathways to inform the development of effective symptom management for CKD populations, the evidence to confirm effective pharmacologic interventions in other populations for CKD populations, and research on how to incorporate effective symptom management approaches into clinical care. Although improving mortality remains as an important area in the kidney community, there is an urgent need to focus on improving symptom management to improve QOL in advanced CKD.

Association between Palliative Care Consultation and Advance Palliative Care Rates: A Descriptive Cohort Study in Patients at Various Stages in the Continuum of Chronic Kidney Disease.

Background: Despite evidence that advance care planning (ACP) benefits patients with serious illnesses, there is a dearth of information about "who" is referred for palliative care (PC) consultation, the rate of PC consultation, and the outcomes of referrals in patients with advanced chronic kidney disease/end-stage kidney disease (aCKD/ESKD). Objectives: (1) To describe patient characteristics associated with PC consultations and (2) to determine the frequency and outcome of PC consultation on documented ACP discussions for patients with aCKD/ESKD. Methodology/Design: This is retrospective observational electronic health record cohort review. Settings: University of Virginia (UVA) hospital, clinics, and dialysis units. Participants: Patients were studied along two time intervals. Time period January 1, 2015 to June 30, 2017 included all patients admitted to UVA during that time period with estimated glomerular filtration rate (eGFR) <60 mL/minute. Time period January 1, 2018 to March 31, 2019 included two cohorts: patients with eGFR <15 mL/minute who had died during study period excluding those who withdrew from dialysis and those who were dialysis dependent and withdrew from dialysis. Results: Aside from higher rates of PC consultation in patients with heart failure, none of the demographic and comorbidity data studied affected whether or not a patient is referred to PC in patients with aCKD/ESKD. PC consultation rates were low among all patients studied: 14.7% in patients with eGFR <60 mL/minute, 28.9% in dialysis patients withdrawing from dialysis, and 57.1% in terminally ill patients with eGFR <15 mL/minute. In all cohorts, PC consultations were associated with improved ACP. Conclusion: PC consultation is significantly associated with better end-of-life outcomes with more completion of ACP and hospice referral in patients with aCKD/ESKD. PC consultation rates remain low. Even in terminally ill patients with more aCKD, >40% were never seen by PC. Until policies and curricula better prepare nephrologists to independently address ACP, collaboration between nephrologists and PC specialists is recommended.

A longitudinal mixed methods study describing 4th year baccalaureate nursing students' perceptions of inclusive pedagogical strategies.

BACKGROUND: Creating inclusive learning environments-those in which all students thrive-is a priority as nursing educators are charged with preparing a diverse workforce to care for a diverse patient population. Yet, faculty are hindered by a dearth of evidence-based pedagogical strategies to promote inclusion. PURPOSE: This longitudinal mixed methods study uniquely addresses this evidence gap by describing relationships among inclusive pedagogical strategies and student outcomes in 81 4th-year baccalaureate nursing students. METHODS: Across the academic year, students participated in two focus groups and completed surveys at three timepoints on classroom and clinical belongingness, self-confidence and satisfaction with learning, and self-efficacy in the clinical setting. RESULTS: Students' reports of satisfaction and confidence in learning, clinical self-efficacy, and clinical belongingness were significantly higher when they characterized their learning environment as inclusive. Underrepresented students, however, reported significantly lower classroom and clinical belongingness at all three survey timepoints and shared examples of unaddressed breaches in inclusivity which undermined confidence and belongingness. Focus group participants evaluated pedagogical strategies and highlighted faculty's pivotal role in creating inclusive learning environments. CONCLUSION: Inclusive pedagogical strategies may increase students' sense of belongingness, satisfaction and confidence in learning, and self-efficacy. Study results may assist faculty and inform future interventions.

Fourth-Year Baccalaureate Nursing Students' Perceptions of Inclusive Learning Environments.

BACKGROUND: Creating inclusive learning environments is a priority in nursing education, yet faculty are hindered by a dearth of evidence-based inclusive pedagogical strategies. In addition, little is known about students' perceptions of inclusive learning environments. METHOD: Fourth-year baccalaureate nursing students from majority and underrepresented minority groups (n = 13) participated in focus groups at two time points across the academic year. Discussion topics included pedagogical strategies most strongly associated with inclusivity, facilitators and barriers to inclusivity, outcomes of inclusive learning experiences, and recommendations for promoting inclusivity in education and nursing practice. RESULTS: Qualitative content analysis resulted in three themes: 1) underrepresented minority and majority groups described inclusive learning environments differently, 2) every aspect of the learning community affects inclusivity but teachers are especially influential, and 3) the outcomes of an inclusive learning environment extend beyond the classroom. CONCLUSION: These findings may help create inclusive learning environments that support diversity and inclusive excellence in nursing education. [J Nurs Educ. 2020;59(5):256-262.].

Inclusivity in Baccalaureate Nursing Education: A Scoping Study.

BACKGROUND: Inclusivity, the intentional incorporation of practices that foster a sense of belonging by promoting meaningful interactions among persons and groups representing different traits, perceptions and experiences, is a prerequisite for excellence in nursing education. Nevertheless, many faculty struggle to create an inclusive learning experience for baccalaureate nursing students. PURPOSE: The purpose of this scoping study was to explore and summarize the extant literature on inclusivity, identify evidence-based strategies to promote inclusivity, and provide directions for further research on inclusivity in baccalaureate nursing education. RESULTS: Thirty studies, conducted in English-speaking countries, from 2001 through 2016, were included in the final analysis. Results from the mostly descriptive studies were organized into 3 themes. 1) Nursing students from underrepresented minority groups experience discrimination from peers, faculty, and clinicians in the classroom, the clinical setting and/or the larger institution. 2) The cumulative effect of discrimination is a lack of belongingness, which is associated with adverse outcomes. 3) All aspects of the undergraduate nursing students' learning community act as facilitators or barriers to inclusivity or a sense of belongingness. CONCLUSIONS: This study provided a deeper understanding of underrepresented minority nursing students' experiences and perspectives related to inclusivity. This, in turn, can inform future action.

Changing Patterns of Mental Health Care Use: The Role of Integrated Mental Health Services in Veteran Affairs Primary Care.

OBJECTIVE: Aiming to foster timely, high-quality mental health care for Veterans, VA's Primary Care-Mental Health Integration (PC-MHI) embeds mental health specialists in primary care and promotes care management for depression. PC-MHI and patient-centered medical home providers work together to provide the bulk of mental health care for primary care patients with low-to-moderate-complexity mental health conditions. This study examines whether increasing primary care clinic engagement in PC-MHI services is associated with changes in patient health care utilization and costs. METHODS: We performed a retrospective longitudinal cohort study of primary care patients with identified mental health needs in 29 Southern California VA clinics from October 1, 2008 to September 30, 2013, using electronic administrative data (n = 66,638). We calculated clinic PC-MHI engagement as the proportion of patients receiving PC-MHI services among all primary care clinic patients in each year. Capitalizing on variation in PC-MHI engagement across clinics, our multivariable regression models predicted annual patient use of 1) non-primary care based mental health specialty (MHS) visits, 2) total mental health visits (ie, the sum of MHS and PC-MHI visits), and 3) health care utilization and costs. We controlled for year- and clinic-fixed effects, other clinic interventions, and patient characteristics. RESULTS: Median clinic PC-MHI engagement increased by 8.2 percentage points over 5 years. At any given year, patients treated at a clinic with 1 percentage-point higher PC-MHI engagement was associated with 0.5% more total mental health visits (CI, 0.18% to 0.90%; P = .003) and 1.0% fewer MHS visits (CI, -1.6% to -0.3%; P = .002); this is a substitution rate, at the mean, of 1.5 PC-MHI visits for each MHS visit. There was no PC-MHI effect on other health care utilization and costs. CONCLUSIONS: As intended, greater clinic engagement in PC-MHI services seems to increase realized accessibility to mental health care for primary care patients, substituting PC-MHI for MHS visits, without increasing acute care use or total costs. Thus, PC-MHI services within primary care clinics may improve mental health care value at the patient population level. More research is needed to understand the relationship between clinic PC-MHI engagement and clinical quality of mental health care.

Process and impact of an advance care planning intervention evaluated by bereaved surrogate decision-makers of dialysis patients.

BACKGROUND: Few studies have examined the process and impact of an advance care planning intervention experienced by surrogate decision-makers of dialysis patients. AIM: To explore the perspectives of the bereaved surrogates of dialysis patients on the process and impact of an advance care planning intervention and to compare the perceived impacts of the intervention between African Americans and Whites. DESIGN: Qualitative interviews and thematic analysis. SETTING/PARTICIPANTS: 24 bereaved surrogates of patients from outpatient dialysis centers were interviewed. Both patients and surrogates had been participants in a larger efficacy study and had received an advance care planning intervention, SPIRIT (Sharing Patient's Illness Representations to Increase Trust). RESULTS: Two themes related to the process of SPIRIT were as follows: (1) SPIRIT provided a welcome opportunity to think about and discuss topics that had been avoided and (2) SPIRIT helped patients and surrogates to share their feelings. Four themes of the SPIRIT's impact were as follows: (1) SPIRIT was an eye-opening experience, acquiring knowledge and understanding of the patient's illness and end-of-life care, (2) SPIRIT helped strengthen relationships between patients and surrogates, (3) SPIRIT helped surrogates feel prepared during the time leading up to end-of-life decision-making, and (4) SPIRIT helped surrogates have peace of mind during and after actual end-of-life decision-making. Themes related to SPIRIT's impact on feeling prepared for end-of-life decision-making and the actual decision-making experience more frequently occurred in African Americans than in Whites. CONCLUSION: Our data may help explain the beneficial effects of SPIRIT on surrogates, but future trials should include data on control surrogates' perspectives.

Differences in Depression Care for Men and Women among Veterans with and without Psychiatric Comorbidities.

BACKGROUND: Depression is common among primary care patients, affecting more women than men. Women veterans are an extreme but growing minority among patients seeking care from the Department of Veterans Affairs (VA), an organization historically designed to serve men. Little is known about gender differences in depression care quality within the VA primary care population. PURPOSE: This works assesses the gender differences in depression care among veterans using longitudinal electronic measures. METHODS: We undertook a cross-sectional study of all veteran VA primary care users with a new episode of depression from federal fiscal year 2010, covering nine geographically diverse regions. We assessed the quality of depression care based on receipt of minimally appropriate depression treatment within 1 year of a new episode of depression and on receipt of depression-related follow-up visits within 180 days. Minimally appropriate treatment and follow-up were operationalized as meeting or exceeding a minimally appropriate threshold for care, based on national quality measures and expert panel consensus. Regression models were used to produce predicted probabilities for each process outcome accounting for the presence or absence of other psychiatric comorbidities. All models were adjusted for model covariates and clinic clusters (404 sites). MAIN FINDINGS: In 2010, 110,603 veterans with a primary care visit had a new episode of depression; 10,094 (9%) were women. In multivariate analyses, women had modest yet significantly higher rates of minimally appropriate depression treatment than men, whether patients had depression only (79% of women vs. 76% of men; p < .001) or depression along with other psychiatric comorbidities (92% of women vs. 91% or men; p < .001). There were no significant gender differences for rate of receipt of follow-up for depression at 180 days. Interactions between gender and other psychiatric comorbidities were not significant. CONCLUSIONS: Our findings suggest that the VA is achieving comparable depression care between genders at minimally appropriate thresholds.

LVAD patients' and surrogates' perspectives on SPIRIT-HF: An advance care planning discussion.

OBJECTIVES: To describe LVAD patients' and surrogates' experiences with, and perspectives on SPIRIT-HF, an advance care planning (ACP) intervention. BACKGROUND: ACP is important for patients with LVAD, yet little is known about their experiences or those of their surrogates who have participated in ACP discussions. METHODS: We used qualitative content analysis techniques to conduct a secondary analysis of 28 interviews with patients with LVAD (n = 14) and their surrogates (n = 14) who had participated in an RCT pilot study of SPIRIT-HF. RESULTS: Main themes from the data include: 1) sharing their HF stories was very beneficial; 2) participating in SPIRIT-HF led to greater peace of mind for patients and surrogates; 3) "one size does not fit all" when it comes to timing of ACP discussions. CONCLUSIONS: An understanding patient and surrogate perspectives may inform clinicians' approach to ACP discussions.

A randomized controlled pilot trial to improve advance care planning for LVAD patients and their surrogates.

OBJECTIVES: To examine feasibility, acceptability and preliminary effects of an advance care planning (ACP) intervention, SPIRIT-HF, in LVAD patients and their surrogates. BACKGROUND: LVADs may improve HF symptoms but they are not curative. Thus, ACP is needed to prepare patients and surrogates for end-of-life (EOL) decision-making. METHODS: Bridge to transplant and destination therapy LVAD patient-surrogate dyads were randomized to either SPIRIT-HF or usual care. Percentages of eligible dyads who were enrolled and completed the study determined feasibility. Analysis of interviews with SPIRIT dyads determined acceptability. Group comparisons of dyad congruence, patient's decisional conflict, and surrogate's decision-making confidence determined preliminary effects. RESULTS: Of 38 eligible dyads, 29 (76%) were enrolled, randomized, and completed the study. The 14 intervention dyads characterized SPIRIT-HF as beneficial. All dyads demonstrated improvement in outcomes. However, SPIRIT-HF dyads tended toward greater congruence on patient EOL treatment goals. CONCLUSIONS: SPIRIT-HF is feasible and acceptable. Results will inform future trials.

Depression Quality of Care: Measuring Quality over Time Using VA Electronic Medical Record Data.

BACKGROUND: The Veterans Health Administration (VA) has invested substantially in evidence-based mental health care. Yet no electronic performance measures for assessing the level at which the population of Veterans with depression receive appropriate care have proven robust enough to support rigorous evaluation of the VA's depression initiatives. OBJECTIVE: Our objectives were to develop prototype longitudinal electronic population-based measures of depression care quality, validate the measures using expert panel judgment by VA and non-VA experts, and examine detection, follow-up and treatment rates over a decade (2000-2010). We describe our development methodology and the challenges to creating measures that capture the longitudinal course of clinical care from detection to treatment. DESIGN AND PARTICIPANTS: Data come from the National Patient Care Database and Pharmacy Benefits Management Database for primary care patients from 1999 to 2011, from nine Veteran Integrated Service Networks. MEASURES: We developed four population-based quality metrics for depression care that incorporate a 6-month look back and 1-year follow-up: detection of a new episode of depression, 84 and 180 day follow-up, and minimum appropriate treatment 1-year post detection. Expert panel techniques were used to evaluate the measure development methodology and results. Key challenges to creating valid longitudinal measures are discussed. KEY RESULTS: Over the decade, the rates for detection of new episodes of depression remained stable at 7-8 %. Follow-up at 84 and 180 days were 37 % and 45 % in 2000 and increased to 56 % and 63 % by 2010. Minimum appropriate treatment remained relatively stable over the decade (82-84 %). CONCLUSIONS: The development of valid longitudinal, population-based quality measures for depression care is a complex process with numerous challenges. If the full spectrum of care from detection to follow-up and treatment is not captured, performance measures could actually mask the clinical areas in need of quality improvement efforts.

Determining Consistency of Surrogate Decisions and End-of-Life Care Received with Patient Goals-of-Care Preferences.

BACKGROUND: Care consistent with preferences is the goal of advance care planning (ACP). However, comparing written preferences to actual end-of-life care may not capture consistency of care with preferences. OBJECTIVE: We evaluated four additional types of consistency, using prospective data on written preferences and active clinical decision making by patients and their surrogates. METHODS: Secondary analysis of data was done from a trial of an ACP intervention for patient-surrogate dyads. Forty-five patients died during the trial and comprised the sample for the analysis. Sources of data included patients' preferences in a written goals-of-care tool, medical record reviews, and two-week postbereavement interviews with surrogates to complement medical record reviews. RESULTS: Twenty-four patients (53.3%) received care consistent with written preferences and 11 (24.4%) inconsistent with written preferences. The remaining 10 patients (22.2%) died suddenly with no opportunity for treatment decision making. Eleven (24.4%) were able to participate in decision making with their surrogates; of those, 9 (81.8%) received care consistent with their expressed preferences. Twenty-two patients were incapacitated and thus the surrogate made treatment decisions alone; of those, 18 (81.8%) made decisions consistent with the patient's written preference. CONCLUSIONS: Simply comparing documented preferences for end-of-life care and medical records of care delivered does not adequately reflect the process of ACP and treatment decision making at the end of life. To understand consistency between preferences and end-of-life care, investigators need data on written and real-time expressed preferences.