Impact of a family support intervention on hospitalization costs and hospital readmissions among ICU patients at high risk of death or severe functional impairment.

BACKGROUND: Patients with advanced critical illness often receive more intensive treatment than they would choose for themselves, which contributes to high health care costs near the end of life. The purpose of this study was to determine whether a family support intervention delivered by the interprofessional ICU team decreases hospitalization costs and hospital readmissions among critically ill patients at high risk of death or severe functional impairment. RESULTS: We examined index hospitalization costs as well as post-discharge utilization of acute care hospitals, rehabilitation and skilled nursing facilities, and hospice services for the PARTNER trial, a multicenter, stepped-wedge, cluster randomized trial of an interprofessional ICU family support intervention. We determined patients' total controllable and direct variable costs using a computerized accounting system. We determined post-discharge resource utilization (as defined above) by structured telephone interview at 6-month follow-up. We used multiple variable regression modelling to compare outcomes between groups. Compared to usual care, the PARTNER intervention resulted in significantly lower total controllable costs (geometric mean: $26,529 vs $32,105; log-linear coefficient: - 0.30; 95% CI - 0.49, - 0.11) and direct variable costs ($3912 vs $6034; - 0.33; 95% CI - 0.56, - 0.10). A larger cost reduction occurred for decedents ($20,304 vs. $26,610; - 0.66; 95% CI - 1.01, - 0.31) compared to survivors ($31,353 vs. $35,015; - 0.15; 95% CI - 0.35,0.05). A lower proportion in the intervention arm were re-admitted to an acute care hospital (34.9% vs 45.1%; 0.66; 95% CI 0.56, 0.77) or skilled nursing facility (25.3% vs 31.6%; 0.63; 95% CI 0.47, 0.84). CONCLUSIONS: A family support intervention delivered by the interprofessional ICU team significantly decreased index hospitalization costs and readmission rates over 6-month follow-up. Trial registration Trial registration number: NCT01844492.

Equity in Using Artificial Intelligence Mortality Predictions to Target Goals of Care Documentation.

BACKGROUND: Artificial intelligence (AI) algorithms are increasingly used to target patients with elevated mortality risk scores for goals-of-care (GOC) conversations. OBJECTIVE: To evaluate the association between the presence or absence of AI-generated mortality risk scores with GOC documentation. DESIGN: Retrospective cross-sectional study at one large academic medical center between July 2021 and December 2022. PARTICIPANTS: Hospitalized adult patients with AI-defined Serious Illness Risk Indicator (SIRI) scores indicating > 30% 90-day mortality risk (defined as "elevated" SIRI) or no SIRI scores due to insufficient data. INTERVENTION: A targeted intervention to increase GOC documentation for patients with AI-generated scores predicting elevated risk of mortality. MAIN MEASURES: Odds ratios comparing GOC documentation for patients with elevated or no SIRI scores with similar severity of illness using propensity score matching and risk-adjusted mixed-effects logistic regression. KEY RESULTS: Among 13,710 patients with elevated (n = 3643, 27%) or no (n = 10,067, 73%) SIRI scores, the median age was 64 years (SD 18). Twenty-five percent were non-White, 18% had Medicaid, 43% were admitted to an intensive care unit, and 11% died during admission. Patients lacking SIRI scores were more likely to be younger (median 60 vs. 72 years, p < 0.0001), be non-White (29% vs. 13%, p < 0.0001), and have Medicaid (22% vs. 9%, p < 0.0001). Patients with elevated versus no SIRI scores were more likely to have GOC documentation in the unmatched (aOR 2.5, p < 0.0001) and propensity-matched cohorts (aOR 2.1, p < 0.0001). CONCLUSIONS: Using AI predictions of mortality to target GOC documentation may create differences in documentation prevalence between patients with and without AI mortality prediction scores with similar severity of illness. These finding suggest using AI to target GOC documentation may have the unintended consequence of disadvantaging severely ill patients lacking AI-generated scores from receiving targeted GOC documentation, including patients who are more likely to be non-White and have Medicaid insurance.

Rural Hospital Disparities in Goals of Care Documentation.

CONTEXT: Goals of care conversations for seriously ill hospitalized patients are associated with high-quality patient-centered care. OBJECTIVES: We aimed to assess the prevalence of documented goals of care conversations for rural hospitalized patients compared to nonrural hospitalized patients. METHODS: We retrospectively assessed goals of care documentation using a template note for adult patients with predicted 90-day mortality greater than 30% admitted to eight rural and nine nonrural community hospitals between July 2021 and April 2023. We compared predictors and prevalence of goals of care documentation among rural and nonrural hospitals. RESULTS: Of the 31,098 patients admitted during the study period, 21% were admitted to a rural hospital. Rural patients were more likely than nonrural patients to be >65 years old (89% vs. 86%, P = <.0001), more likely to live in a neighborhood classified in the highest quintile of socioeconomic disadvantage (40% vs. 16%, P = <.0001), and less likely to receive a palliative care consult (8% vs. 18%, P = <.0001). Goals of care documentation occurred less often for patients admitted to rural vs. nonrural community hospitals (2% vs. 7%, P < .0001). In the base multivariable logistic regression model adjusting for patient characteristics, the odds of goals care documentation were lower in rural vs. nonrural community hospitals (aOR 0.4, P = .0232). In a second multivariable logistic regression model including both patient characteristics and severity of illness, the odds of goals of care documentation in rural community hospitals were no longer statistically different than nonrural community hospitals (aOR 0.5, P = .1080). Patients who received a palliative care consult had a lower prevalence of goals of care documentation in rural vs. nonrural hospitals (16% vs. 37%, P = <.0001). CONCLUSION: In this study of 17 rural and nonrural community hospitals, we found low overall prevalence of goals of care documentation with particularly infrequent documentation occurring within rural hospitals. Future study is needed to assess barriers to goals of care documentation contributing to low prevalence of goals of care conversations in rural hospital settings.

Barriers of Acceptance to Hospice Care: a Randomized Vignette-Based Experiment.

BACKGROUND: The per diem financial structure of hospice care may lead agencies to consider patient-level factors when weighing admissions. OBJECTIVE: To investigate if treatment cost, disease complexity, and diagnosis are associated with hospice willingness to accept patients. DESIGN: In this 2019 online survey study, individuals involved in hospice admissions decisions were randomized to view one of six hypothetical patient vignettes: "high-cost, high-complexity," "low-cost, high-complexity," and "low-cost, low-complexity" within two diseases: heart failure and cystic fibrosis. Vignettes included demographics, prognoses, goals, and medications with costs. Respondents indicated their perceived likelihood of acceptance to their hospice; if likelihood was <100%, respondents were asked the barriers to acceptance. We used bivariate tests to examine associations between demographic, clinical, and organizational factors and likelihood of acceptance. PARTICIPANTS: Individuals involved in hospice admissions decisions MAIN MEASURES: Likelihood of acceptance to hospice care KEY RESULTS: N=495 (76% female, 53% age 45-64). Likelihoods of acceptance in cystic fibrosis were 79.8% (high-cost, high-complexity), 92.4% (low-cost, high-complexity), and 91.5% (low-cost, low-complexity), and in heart failure were 65.9% (high-cost, high-complexity), 87.3% (low-cost, high-complexity), and 96.6% (low-cost, low-complexity). For both heart failure and cystic fibrosis, respondents were less likely to accept the high-cost, high-complexity patient than the low-cost, high-complexity patient (65.9% vs. 87.3%, 79.8% vs. 92.4%, both p<0.001). For heart failure, respondents were less likely to accept the low-cost, high-complexity patient than the low-cost, low-complexity patient (87.3% vs. 96.6%, p=0.004). Treatment cost was the most common barrier for 5 of 6 vignettes. CONCLUSIONS: This study suggests that patients receiving expensive and/or complex treatments for palliation may have difficulty accessing hospice.

Low-Cost, Low-Resource Training Model to Enhance and Sustain Serious Illness Conversation Skills for Internal Medicine Residents.

Background: Funding and limited resources are barriers to required training of residents in serious illness conversation (SIC) skills. Objectives: To examine the effectiveness of a low-cost, low-resource (LCLR) SIC training embedded within a required palliative care rotation. Design: Pre-post prospective cohort study design. Setting/Subjects: Second year internal medicine (IM) residents received an LCLR three-hour training in the SIC Guide (SICG) with a single-faculty member and paired-participant practice replacing actors during a required two-week palliative medicine rotation. Measures: SIC competence checklist measured within simulated patient encounters longitudinally. Results: Twenty resident average SIC checklist scores improved from 11 (95% confidence interval [CI] 9-13) at the beginning of rotation to 19 (95% CI 17-20) at the end of rotation and 18 (95% CI 16-20) at six months after the rotation. Conclusions: LCLR SIC training for IM residents significantly increased the sustained use of basic SIC skills, but was less effective for more complex skills.

The Impact of Virtual Interviews on Recruitment in Hospice and Palliative Medicine Fellowship Training.

CONTEXT: The ongoing COVID-19 pandemic has led many leaders to reassess how recruitment into the medical field is conducted. In Hospice and Palliative Medicine, many training programs are moving to virtual recruitment as a more permanent strategy. However, virtual recruitment disproportionately affects smaller training programs as well as those in smaller cities or those whose location is less well-known. OBJECTIVES: To assess faculty perspective regarding the value of virtual vs. face-to-face recruitment methods in a well-established program located in a mid-sized city that is lesser known than many comparable programs. METHODS: After virtual recruitment season in 2020, we assessed our faculty regarding the process of virtual interviews. Survey items were based on results of the 2020 NRMP Internal Medicine Program Director Survey to include the most highly cited factors used to rank internal medicine applicants. Faculty was asked whether virtual or face-to-face interviews were more effective and were asked to make an overall choice between face to face and virtual recruitment formats and to explain the reason behind their decision. RESULTS: Twenty-three faculty received the survey and 17 completed. Although more faculty felt that in-person interviews allowed for better ability to recruit the most qualified trainees than virtual interviews, nine out of the 17 faculty chose virtual as their preferred format. CONCLUSION: While acknowledging benefits that can only be achieved in-person, our faculty believe that virtual interviews for future Hospice and Palliative Medicine fellows is an effective and potentially advantageous way to recruit the future work force of Hospice and Palliative Medicine.

Associations between demographic characteristics and unmet supportive care needs in adults with cystic fibrosis.

CONTEXT: Patients living with cystic fibrosis (CF) report impaired quality of life. Little is known about unmet supportive care needs among adults living with CF and how they are associated with demographic characteristics. OBJECTIVES: The primary objective of this study was to identify associations between demographic variables and unmet supportive care needs regarding anxiety, sadness, pain and uncertainty about the future of living with CF. METHODS: We recruited 165 adults with CF from a single academic medical centre to complete a brief demographic survey and the Supportive Care Needs Survey (SCNS-34), a validated self-reported needs assessment that measures the prevalence of and preferences for support for 34 needs that commonly occur in patients with serious illness. RESULTS: Approximately half of the participant sample was male, with a median age of 29 years, varying income levels and a range of lung disease severity. We found statistically significant associations between insufficient income and increased odds of reporting need for support regarding anxiety (OR: 6.48; 95% CI 2.08 to 20.2), sadness (OR: 6.15; 95% CI 2.04 to 18.5), pain (OR: 7.06; 95% CI 2.22 to 22.4) and worries surrounding uncertainty about the future (OR: 3.43; 95% CI 1.18 to 9.99). CONCLUSION: Adults with CF report significant unmet needs for support in several physical and emotional domains. Many of these domains were associated with demographic characteristics, most notably, income. Our findings underscore the importance of developing treatment approaches that are sensitive to patient demographics when addressing unmet supportive care needs among adults with CF.

Effect of an Oncology Nurse-Led Primary Palliative Care Intervention on Patients With Advanced Cancer: The CONNECT Cluster Randomized Clinical Trial.

Importance: Guidelines recommend early specialty palliative care for all patients with advanced cancer, but most patients lack access to such services. Objective: To assess the effect of CONNECT (Care Management by Oncology Nurses to Address Supportive Care Needs), a primary palliative care intervention delivered by oncology nurses, on patient outcomes. Design, Setting, and Participants: This cluster randomized clinical trial of the CONNECT intervention vs standard care was conducted from July 25, 2016, to October 6, 2020. Participants were adult patients with metastatic solid tumors who were undergoing oncological care and for whom an oncologist would agree with the statement "would not be surprised if the patient died in the next year." The trial was conducted at 17 community oncology practices in western Pennsylvania. Data analyses adhered to the intention-to-treat principle. Interventions: The CONNECT intervention included 3 monthly visits with an existing infusion room nurse who was trained to address symptoms, provide emotional support, engage in advance care planning, and coordinate care. Main Outcomes and Measures: The primary outcome was quality of life. At baseline and 3 months, participants completed assessments of quality of life (Functional Assessment of Chronic Illness Therapy-Palliative care: score range, 0-184, with higher scores indicating better quality of life), symptom burden (Edmonton Symptom Assessment Scale: score range, 0-90, with higher scores indicating greater symptom burden), and mood symptoms (Hospital Anxiety and Depression Scale [HADS]: score range, 0-21, with higher scores indicating substantial anxiety and depression). Linear mixed-effects models were used to estimate adjusted mean differences in 3-month outcomes. Preplanned, intensity-adjusted analyses were conducted. Results: A total of 672 patients were enrolled (mean [SD] age, 69.3 [10.2] years; 360 women [53.6%]). The mean (SD) number of CONNECT visits completed was 2.2 (1.0). At 3 months, no difference in mean (SD) quality-of-life score was found between the CONNECT and standard care groups (130.7 [28.2] vs 134.1 [28.1]; adjusted mean difference, 1.20; 95% CI, -2.75 to 5.15; P = .55). Similarly, there was no difference between groups in 3-month mean (SD) symptom burden (23.2 [16.6] vs 24.0 [16.1]; adjusted mean difference, -2.64; 95% CI, -5.85 to 0.58; P = .11) or mood symptoms (HADS depression subscale score: 5.1 [3.4] vs 4.8 [3.7], adjusted mean difference, -0.08 [95% CI, -0.71 to 0.57], P = .82; HADS anxiety subscale score: 5.7 [3.9] vs 5.4 [4.2], adjusted mean difference, -0.31 [95% CI, -0.96 to 0.33], P = .34). Intensity-adjusted analyses revealed a larger estimated treatment effect for patients who received a full dose (3 visits) of the CONNECT intervention. Conclusions and Relevance: This cluster randomized clinical trial found that a primary palliative care intervention that was delivered by oncology nurses did not improve patient-reported outcomes at 3 months. Primary palliative care interventions with a higher dose intensity may be beneficial for most patients with advanced cancer who lack access to palliative care specialists. Trial Registration: ClinicalTrials.gov Identifier: NCT02712229.

Evaluation of a Home-Based, Nurse Practitioner-led Advanced Illness Care Program.

OBJECTIVES: In the United States, people with serious illness often experience gaps and discontinuity in care. Gaps are frequently exacerbated by limited mobility, need for social support, and challenges managing multiple comorbidities. The Advanced Illness Care (AIC) Program provides nurse practitioner-led, home-based care for people with serious or complex chronic illnesses that specifically targets palliative care needs and coordinates with patients' primary care and specialty health care providers. We sought to investigate the effect of the AIC Program on hospital encounters [hospitalizations and emergency department (ED) visits], hospice conversion, and mortality. DESIGN: Retrospective nearest-neighbor matching. SETTING AND PARTICIPANTS: Patients in AIC who had ≥1 inpatient stay within the 60 days prior to AIC enrollment to fee-for-service Medicare controls at 9 hospitals within one health system. METHODS: We matched on demographic characteristics and comorbidities, with exact matches for diagnosis-related group and home health enrollment. Outcomes were hospital encounters (30- and 90-day ED visits and hospitalizations), hospice conversion, and 30- and 90-day mortality. RESULTS: We included 110 patients enrolled in the AIC Program matched to 371 controls. AIC enrollees were mean age 77.0, 40.9% male, and 79.1% white. Compared with controls, AIC enrollees had a higher likelihood of ED visits at 30 [15.1 percentage points, confidence interval (CI) 4.9, 25.3; P = .004] and 90 days (27.8 percentage points, CI 16.0, 39.6; P < .001); decreased likelihood of hospitalization at 30 days (11.4 percentage points, CI -17.7, -5.0; P < .001); and a higher likelihood of converting to hospice (22.4 percentage points, CI 11.4, 33.3; P < .001). CONCLUSIONS: The AIC Program provides care and coordination that the home-based serious illness population may not otherwise receive. IMPLICATIONS: By identifying and addressing care needs and gaps in care early, patients may avoid unnecessary hospitalizations and receive timely hospice services as they approach the end of life.

Associations between Reason for Inpatient Palliative Care Consultation, Timing, and Cost Savings.

Background: Specialty palliative care (SPC) provides patient-centered care to people with serious illness and may reduce costs. Specific cost-saving functions of SPC remain unclear. Objectives: (1) To assess the effect of SPC on inpatient costs and length of stay (LOS) and (2) to evaluate differences in costs by indication and timing of SPC. Design: Case-control with in patients who received an SPC consultation and propensity matched controls. Setting: One large U.S. integrated delivery finance system. Measurements: Using administrative data, we assessed costs associated with inpatient stays, a subset of whom received an SPC consultation. Consultations were stratified by reasons based on physician discretion: goals of care, pain management, hospice evaluation, nonpain symptom management, or support. The primary outcome was total operating costs and the secondary outcome was hospital LOS. Results: In total, 1404 patients with SPC consultations associated with unique hospital encounters were matched with 2806 controls. Total operating costs were lower for patients who received an SPC consultation when the consultation was within 0 to 1 days of admission ($6,924 vs. $7,635, p = 0.002). Likewise, LOS was shorter (4.3 vs. 4.7 days, p < 0.001). Upon stratification by reason, goals-of-care consultations early in the hospital stay (days 0-1) were associated with reduced total operating costs ($7,205 vs. $8,677, p < 0.001). Costs were higher for pain management consultations ($7,727 vs. $6,914, p = 0.047). Consultation for hospice evaluation was associated with lower costs, particularly when early (hospital days 0-1: $4,125 vs. $7,415, p < 0.001). Conclusions: SPC was associated with significant cost saving and decreased LOS when occurring early in a hospitalization and used for goals-of-care and hospice evaluation.

NephroTalk Multimodal Conservative Care Curriculum for Nephrology Fellows.

Conservative care, a comprehensive treatment path for advanced kidney disease most suitable for individuals unlikely to benefit from dialysis, is underutilized in the United States. One reason is an absence of robust education about this approach and how to discuss it with potential candidates. To address this need, we developed a multimodal conservative care curriculum for nephrology fellows. This curriculum consists of four online modules that address essential concepts and communication skills related to conservative care. It is followed by an in-person, interactive, "flipped classroom" session facilitated by designated nephrology educators at participating Accreditation Council for Graduate Medical Education nephrology training programs. Curriculum effect was assessed using surveys completed by participating fellows immediately before and following the curriculum and for participating nephrology educators following flipped classroom teaching; 148 nephrology trainees from 19 programs participated, with 108 completing both pre- and postcurriculum surveys. Mean self-reported preparedness (measured on a five-point Likert scale) increased significantly for all ten concepts taught in the curriculum. The mean correct score on eight knowledge questions increased from 69% to 82% following the curriculum (P<0.001). Fellows rated the curriculum highly and reported that they plan to practice skills learned. For the 19 nephrology program educators, the mean perceived preparedness to teach all curriculum domains increased after, compared with before, facilitating the flipped classroom, reaching significance for seven of the ten concepts measured. Data suggest that fellows' participation in a multimodal curriculum increased knowledge and preparation for fundamental conservative care concepts and communication skills. Fellows rated the curriculum highly. Educator participation appears to have increased preparedness for teaching the curriculum concepts, making it likely that future education in conservative care will become more widespread. Herein, we describe the curriculum content, which we have made publicly available in order to encourage broader implementation, and its effect on participating fellows and the nephrology educators who facilitated it.

Poor patient health is associated with higher caregiver burden for older adults with advanced cancer.

OBJECTIVES: Family caregiver burden among older adults with advanced cancer remains poorly understood. We sought to (1) identify patient factors associated with caregiver burden and (2) examine how amount of time caregiving modifies these relationships. METHODS: Cross-sectional analysis of baseline data from a cluster-randomized palliative care intervention trial including patients with advanced cancer and their family caregivers, recruited from 17 oncology practices in Pennsylvania. Caregiver burden was measured using Zarit Burden Interview (ZBI-12; range 0-48). Patient factors included functional status (Eastern Cooperative Oncology Group), symptom burden (Edmonton Symptom Assessment Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and quality of life (Functional Assessment of Chronic Illness Therapy - Palliative Care). Using adjusted multivariable regression, we analyzed (1) independent associations between patient factors and caregiver burden and (2) how weekly caregiving hours modified these relationships. RESULTS: Among 441 patient-caregiver dyads, mean patient age was 70 ± 10 and caregiver age was 62 ± 13 years. Most caregivers (59%) were patients' partners. Caregivers reported 44.5 ± 53.5 average hours spent caregiving weekly; mean ZBI-12 scores were 10.3 ± 7.3. Worse patient functional status (ß = 4.20, p < 0.01), poorer quality of life (ß = -0.07, p < 0.01), more anxiety (ß = 0.33, p < 0.01) and depression (ß = 0.33, p < 0.01) were associated with higher caregiver burden; caregiving hours did not affect these relationships. CONCLUSIONS: In advanced cancer, poor patient physical and mental health is associated with higher caregiver burden regardless of hours caregiving; future studies should examine interventions tailored to alleviate caregiver burden for this group.

Launching the Next Steps to Improve Hospice and Palliative Medicine Fellow Performance Assessment: A Look Back to the Initial Toolkit of Assessment Methods.

Education leaders in hospice and palliative medicine (HPM) have long acknowledged the challenge of fellow performance assessment and the need for HPM-specific fellow assessment tools. In 2010, and in alignment with the Accreditation Council for Graduate Medical Education's (ACGME's) directive toward competency-based medical education, the national HPM Competencies Workgroup curated a set of assessment tools, the HPM Toolkit of Assessment Methods. The Toolkit has been a resource for HPM fellowship directors in evolving practical, multifaceted fellow assessment strategies. Now, as American Academy of Hospice and Palliative Medicine plans for a national workgroup in 2020 to define current HPM fellow assessment methods and to propose strategies to strengthen and standardize future assessment, the Toolkit provides a strong base from which to launch. However, the field learned important lessons from the 2010 Workgroup about the consensus process, gaps in areas of assessment, opportunities to address gaps with new or adapted tools, and limitations in implementing the Toolkit over time in terms of tracking, accessibility, and dissemination. This article describes the development of the Toolkit, including recommended tools and methods for assessment within each ACGME competency domain, and links the lessons learned to recommendations for the 2020 workgroup to consider in creating the next HPM assessment strategy and toolkit. Effective implementation will be crucial in supporting fellows to reach independent practice, which will further strengthen the field and workforce to provide the highest quality patient and family-centered care in serious illness. This will require an inspired, committed effort from the HPM community, which we enthusiastically anticipate.

Lack of Exposure to Palliative Care Training for Black Residents: A Study of Schools With Highest and Lowest Percentages of Black Enrollment.

CONTEXT: The palliative medicine workforce lacks racial diversity with <5% of specialty Hospice and Palliative Medicine (HPM) fellows identifying as black. Little is known about black trainees' exposure to palliative care during their medical education. OBJECTIVES: To describe palliative care training for black students during medical school, residency, and fellowship training. METHODS: We conducted a cross-sectional descriptive study using Internet searches and phone communication in September 2019. We evaluated 24 medical schools in three predetermined categories: historically black colleges and universities (HBCUs; N = 4) and non-under-represented minority-serving institutions with the highest (N = 10) and lowest (N = 10) percentages of black medical students. Training opportunities were determined based on the presence of a course, clerkship, or rotation in the medical school and residency curricula, a specialty HPM fellowship program, and specialty palliative care consult service at affiliated teaching hospitals. RESULTS: None of the four HBCUs with a medical school offered a palliative care course or clerkship, rotation during residency, or specialty HPM fellowship program. Three of four HBCUs were affiliated with a hospital that had a palliative care consult service. Institutions with the highest black enrollment were less likely to offer palliative care rotations during internal medicine (P = 0.046) or family medicine (P = 0.019) residency training than those with the lowest black enrollment. CONCLUSION: Residents at schools with the highest black medical student enrollment lack access to palliative care training opportunities. Efforts to reduce health disparities and underrepresentation in palliative care must begin with providing palliative-focused training to physicians from under-represented minority backgrounds.