Evaluation of limitation-of-medical-treatment forms used in emergency medicine residency programs in the United States.

BACKGROUND: Patients are encouraged to complete limitation-of-medical-treatment forms (LMTFs), sometimes referred to as code status forms or do-not-resuscitate forms, before admission to hospitals or other health care facilities in the United States. OBJECTIVE: The purpose of this study was to review, evaluate, and to assess the LMTFs currently used in emergency medicine residency training programs throughout the United States. METHODS: In February 2009, researchers sent letters to all allopathic and osteopathic emergency medicine residency program directors (n = 193) requesting a copy of the LMTF used in their hospital. These forms were evaluated for content, consistency, and readability. RESULTS: Sixty-five responses were received (corrected response rate = 34%); 45 LMTFs were reviewed. Nineteen LMTFs required the signature of the patient, or the patient's appointed durable power of attorney for health care. The readability ranged from 11th to 17th grade (mean ± SD = 13.16 ± 1.77), greatly exceeding the average Americans' 8(th)-grade reading level. CONCLUSIONS: Our findings demonstrate that there is no standardization across LMTFs currently used in hospitals throughout the United States, and these forms are written above the literacy level of the average American adult. Therefore, there is a need to develop and disseminate an LMTF that is both consistent and better understood by the average American adult.

Hear all about it: nightly television news coverage of cervical cancer vaccination in the United States.

OBJECTIVE: To examine the content of human papillomavirus (HPV)-related vaccination information presented during nightly national television news broadcasts in the United States. MATERIALS AND METHODS: A retrospective content analysis of HPV vaccination coverage on 5 major nightly US television networks from 2002 to 2007. The Vanderbilt Television News Archive was searched for keywords "Gardasil," "cervical cancer vaccination," "human papillomavirus vaccine," and "HPV vaccination." Each television news broadcast was categorized as follows: segment length (in seconds), network (American Broadcasting Company, Columbia Broadcasting Company, National Broadcasting Company, Cable News Network, or Fox Broadcasting Company), year of broadcast (2002-2007), and (4) presentation type. Air dates were plotted on a timeline to depict trends and linkages to 5 seminal events surrounding the development, efficacy, and controversy regarding HPV vaccination. RESULTS: During the 6-year period, a total of 27 HPV-related vaccination news broadcasts aired. News broadcasts ranged from 10 to 250 seconds, lasting an average of close to 2 minutes (mean +/- SD, 127.0 +/- 66.1 seconds). Most broadcasts presented information pertaining to HPV and cervical cancer, information on vaccine labeling, impact of the vaccine, and raised issues or concerns about the vaccine. More than half (66.7%) of news broadcasts were directly related to 5 seminal events surrounding the development, efficacy, and controversy regarding HPV vaccination. CONCLUSION: All 5 networks included within the Vanderbilt Television News Archive aired HPV vaccination content, with National Broadcasting Company and Columbia Broadcasting Company broadcasting most of the news stories during this time period. As compared with other medical-related information presented on national nightly television news during this time period, HPV vaccination received a modest amount of coverage.

Human papillomavirus vaccination coverage on YouTube.

BACKGROUND: A large percentage of Internet users regularly search for health-related information. In recent years, participatory Internet sites such as YouTube have become increasingly popular, in part because individuals are able to both retrieve and post information. This study analyzed how human papillomavirus (HPV) vaccination was portrayed in videoclips and viewer-posted comments available on YouTube. METHODS: YouTube (www.youtube.com) was queried on February 8, 2008, using the search terms Gardasil, cervical cancer vaccination, and HPV vaccination to identify and download relevant videoclips. Videoclips were classified as either positively or negatively portraying HPV vaccination, and viewer-posted comments were enumerated. Data analyses were conducted immediately following videoclip retrieval. RESULTS: A total of 146 unique YouTube videoclips were located, using the three search keywords combined. Three quarters (n=109; 74.7%) of the videoclips portrayed HPV vaccination in a positive manner. One third (n=47; 32.2%) of the videoclips had generated at least one posted comment. CONCLUSIONS: These results demonstrate that there is a wide variety of information on YouTube regarding HPV vaccination and cervical cancer. As a result, public health and medical professionals need to be cognizant of the nature of the HPV-related information available, so that they are better equipped to respond to patients who acquire information posted on YouTube and other Internet sources.

Increasing inpatient hospice use versus patient preferences in the USA: are patients able to die in the setting of their choice?

BACKGROUND: Growth in hospice utilisation has been accompanied by an increase in the proportion of hospice patients who die in an inpatient hospice setting rather than at home. OBJECTIVE: To determine whether this increase in inpatient utilisation is consistent with patient preferences. DESIGN: Retrospective cohort study. SETTING: Seven hospices in the Coalition of Hospices Organised to Investigate Comparative Effectiveness (CHOICE) network. PATIENTS: 70 488 patients admitted between 1 July 2008 and 31 May 2012. MEASUREMENTS: We measured changes in patients' stated preferences at the time of admission regarding site of death, including weights to adjust for non-response bias. We also assessed patients' actual site of death and concordance with patients' preferences. RESULTS: More patients died receiving inpatient care in 2012 as compared to 2008 (1920 (32.7%), 2537 (18.5%); OR 1.21; 95% CI 1.19 to 1.22; p<0.001). However, patients also expressed an increasing preference for dying in inpatient settings (weighted preferences 27.5% in 2012 vs 7.9% in 2008; p<0.001). The overall proportion of patients who died in the setting of their choice (weighted preferences) increased from 74% in 2008 to 78% in 2012 (p<0.001). LIMITATIONS: This study included only seven hospices, and results may not be representative of the larger hospice population. CONCLUSIONS: Although more patients are dying while receiving inpatient care, these changes in site of death seem to reflect changing patient preferences. The net effect is that patients in this sample were more likely to die in the setting of their choice in 2012 than they were in 2008.

Does Continuous Hospice Care Help Patients Remain at Home?

CONTEXT: In the U. S., hospices sometimes provide high-intensity "continuous care" in patients' homes. However, little is known about the way that continuous care is used or what impact continuous care has on patient outcomes. OBJECTIVES: To describe patients who receive continuous care and determine whether continuous care reduces the likelihood that patients will die in an inpatient unit or hospital. METHODS: Data from 147,137 patients admitted to 11 U.S. hospices between 2008 and 2012 were extracted from the electronic medical records. The hospices are part of a research-focused collaboration. The study used a propensity score-matched cohort design. RESULTS: A total of 99,687 (67.8%) patients were in a private home or nursing home on the day before death, and of these, 10,140 (10.2%) received continuous care on the day before death. A propensity score-matched sample (n = 24,658) included 8524 patients who received continuous care and 16,134 patients who received routine care on the day before death. Using the two matched groups, patients who received continuous care on the day before death were significantly less likely to die in an inpatient hospice setting (350/8524 vs. 2030/16,134; 4.1% vs. 12.6%) (odds ratio [OR] 0.29; 95% CI 0.27-0.34; P < 0.001). When patients were cared for by a spouse, the use of continuous care was associated with a larger decrease in inpatient deaths (OR 0.12; 95% CI 0.09-0.16; P < 0.001) compared with those patients cared for by other family members (OR 0.37; 95% CI 0.32-0.42; P < 0.001). It is possible that unmeasured covariates were not included in the propensity score match. CONCLUSION: Use of continuous care on the day before death is associated with a significant reduction in the use of inpatient care on the last day of life, particularly when patients are cared for by a spouse.

Are advance directives associated with better hospice care?

OBJECTIVES: To describe individuals with advance directives at the time of hospice enrollment and to determine whether they have patterns of care and outcomes that are different from those of individuals without advance directives. DESIGN: Electronic health record-based retrospective cohort study with propensity score-adjusted analysis. SETTING: Three hospice programs in the United States. PARTICIPANTS: Individuals admitted to hospice between January 1, 2008, and May 15, 2012 (N = 49,370). MEASUREMENTS: Timing of hospice enrollment before death, rates of voluntary withdrawal from hospice, and site of death. RESULTS: Most participants (35,968, 73%) had advance directives at the time of hospice enrollment. These participants were enrolled in hospice longer (median 29 vs 15 days) and had longer survival times before death (adjusted hazard ratio = 0.62; 95% confidence interval (CI) 0.58-0.66; P < .001). They were less likely to die within the first week after hospice enrollment (24.3% vs 33.2%; adjusted odds ratio (aOR) = 0.83, 95% CI = 0.78-0.88; P < .001). Participants with advance directives were less likely to leave hospice voluntarily (2.2% vs 3.4%; aOR = 0.82, 95% CI = 0.74-0.90; P = .003) and more likely to die at home or in a nursing home than in an inpatient unit (15.3% vs 25.8%; aOR = 0.82, 95% CI = 0.77-0.87; P < .001). CONCLUSION: Participants with advance directives were enrolled in hospice for a longer period of time before death than those without and were more likely to die in the setting of their choice.

Hospice admissions for cancer in the final days of life: independent predictors and implications for quality measures.

PURPOSE: To define patient characteristics associated with hospice enrollment in the last 3 days of life, and to describe adjusted proportions of patients with late referrals among patient subgroups that could be considered patient-mix adjustment variables for this quality measure. METHODS: Electronic health record-based retrospective cohort study of patients with cancer admitted to 12 hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network. RESULTS: Of 64,264 patients admitted to hospice with cancer, 10,460 (16.3%) had a length of stay ≤ 3 days. There was significant variation among hospices (range, 11.4% to 24.5%). In multivariable analysis, among patients referred to hospice, patients who were admitted in the last 3 days of life were more likely to have a hematologic malignancy, were more likely to be male and married, and were younger (age < 65 years). Patients with Medicaid or self-insurance were less likely to be admitted to hospice within 3 days of death. CONCLUSION: Quality measures of hospice lengths of stay should include patient-mix adjustments for type of cancer and site of care. Patients with hematologic malignancies are at especially increased risk for late admission to hospice.

Can hospices predict which patients will die within six months?

OBJECTIVE: To determine whether it is possible to predict, at the time of hospice enrollment, which patients will die within 6 months. DESIGN: Electronic health record-based retrospective cohort study. SETTING: Patients admitted to 10 hospices in the CHOICE network (Coalition of Hospices Organized to Investigate Comparative Effectiveness). PARTICIPANTS: Hospice patients. MAIN OUTCOME MEASURES: Mortality at 6 months following hospice admission. RESULTS: Among 126,620 patients admitted to 10 hospices, 118,532 (93.6%) died within 6 months. In a multivariable logistic regression model, five characteristics were independent predictors of 6-month mortality. For instance, patients younger than 65 years were less likely to die within 6 months (odds ratio [OR] 0.64; 95% confidence interval [CI] 0.45-0.91; p=0.014). Conversely, male patients were more likely to die within 6 months (OR 1.47; 95% CI 1.05-2.02; p=;0.036). After adjusting for other variables in this model, there were several subgroups with a low probability of 6-month probability (e.g., stroke and Palliative Performance Scale [PPS] score=50; adjusted probability of 6-month mortality=39.4%; 95% CI: 13.9%-72.5%). However, 95% confidence intervals of these 6-month mortality predictions extended above 50%. CONCLUSIONS: Hospices might use several variables to identify patients with a relatively low risk for 6-month mortality and who therefore may become ineligible to continue hospice services if they fail to show significant disease progression.

A preliminary study comparing attitudes toward hospice referral between African American and white American primary care physicians.

UNLABELLED: End-of-life (EOL) decision making is an integral component of high-quality health care. Factors influencing individual primary care physicians (PCPs) can affect their perspectives and referral preferences for EOL care. Numerous barriers have been cited, including patient and family readiness, physicians' comfort with discussing death, and the pursuit of a cure. This study explores another barrier by examining physician ethnicity and comparing the attitudes toward hospice referral between African American and white American primary care providers (PCPs). Training PCPs to efficiently transition from a curative model of care to a palliative model of care has the potential to increase the level of appropriate EOL care, increase hospice referral, and enhance patient and provider satisfaction; it is also fiscally prudent. This preliminary study aims to compare attitudes toward hospice referral and physicians' personal experiences with hospice between African American and white American PCPs. METHODS: The survey tool was developed by PCPs at the Mayo Clinic Florida after a full literature review and consultation with hospice physicians, oncology specialists, and primary care colleagues from the residency programs at Mayo Minnesota and Mayo Arizona, with input from the Mayo Survey Office, and distributed to all physicians and residents in the departments of Family Medicine at via Mayo's intranet; Mayo's Midwest Regional Practices (245 physicians) received the survey via standard mail. The survey consisted of 17 questions regarding attitudes toward hospice referral and the one question regarding physicians' personal experience with hospice. The final sample size consisted of 167 white American physicians and 46 African American physicians. Responses were compared using a Wilcoxon rank sum test. P values ≤ 0.05 were considered statistically significant. All statistical analyses were performed using the SAS software package (SAS Institute, Cary, North Carolina). RESULTS: The distributions of physician age, specialty, board certification, and years practicing medicine were similar between African American and white American physicians, while male gender was more common in white American physicians than African American physicians. Statistically significant differences in attitudes toward hospice between African American and white American physicians were observed for five of the 17 survey questions. There was a dramatic difference in the distribution of patient race between African American and white American physicians, raising the possibility that any differences between white American and African American physicians could be attributed to patient race, rather than physician race. Due to survey limits, larger studies involving more African American physicians are needed to address this topic. CONCLUSION: The results of our preliminary study suggest that certain attitudes toward hospice referral may differ between African American and white American PCPs. If validated, further insight into this issue could lead to educational programs for PCPs that correct misperceptions.