Patient perspectives of care and process and outcome quality measures for heart failure admissions in US hospitals: how are they related in the era of public reporting?

IMPORTANCE: Process quality measure performance has improved significantly with public reporting, requiring reevaluation of process-outcome relationships and the emerging role of patient perspectives on care. OBJECTIVE: To evaluate associations between heart failure patient perspectives of care and publicly reported processes and outcomes. DESIGN: Cross-sectional study, July 2008-June 2011. SETTING: US hospitals in the Press Ganey database. PARTICIPANTS: Heart failure inpatients. MEASURES: Outcomes were Hospital Compare hospital-level risk-adjusted 30-day heart failure mortality and readmissions. Predictors included Hospital Compare heart failure processes of care, a weighted process composite and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains for heart failure. Hospital characteristics included volume of heart failure patients and race, health status and education. RESULTS: Among 895 included hospitals, performance on process measures was high (median by hospital for composite, 95.6%); the median HCAHPS overall rating was 86.9. Median mortality was 11.3% and readmissions was 24.8%. No process measures were statistically significantly associated with lower mortality or readmissions in adjusted analyses. Higher ratings on HCAHPS patient perspectives of care were significantly correlated with lower readmissions in adjusted analyses, particularly those publicly reported domains conceptually related to readmissions. The magnitude was small (1.8 points higher on a 100-point scale between the highest and lowest quartiles of hospital readmissions). CONCLUSIONS: Publicly reported process quality measures were no longer associated with outcomes, but higher patient perspectives of care were associated with lower heart failure readmissions. These associations support continued reevaluation of these measures and increased emphasis on patient experience and outcomes, as planned for Value-Based Purchasing.

Association of goals of care meetings for hospitalized cancer patients at risk for critical care with patient outcomes.

BACKGROUND: Caring for cancer patients with advanced and refractory disease requires communication about care preferences, particularly when patients become ill enough to be at risk for critical care interventions potentially inconsistent with their preferences. AIM: To describe the use of goals of care discussions in patients with advanced/refractory cancer at risk for critical care interventions and evaluate associations between these discussions and outcomes. DESIGN: Cohort study describing patients/families' perceptions of goals of care meetings and comparing health care utilization outcomes of patients who did and did not have discussions. SETTING/PARTICIPANTS: Inpatient units of an academic cancer center. Included patients had metastatic solid tumors or relapsed/refractory lymphoma or leukemia and were at risk for critical care, defined as requiring supplemental oxygen and/or cardiac monitor. RESULTS: Of 86 patients enrolled, 34 (39%) had a reported goals of care discussion (study group). Patients/families reported their needs and goals were addressed moderately to quite a bit during the meetings. Patients in the study group were less likely to receive critical care (0% vs 22%, p = 0.003) and more likely to be discharged to hospice (48% vs 30%, p = 0.04) than the control group. Only one patient in the study group died during the index hospitalization (on comfort care) (3%) compared with 9(17%) in the control group (p = 0.08). CONCLUSION: Goals of care meetings for advanced/refractory cancer inpatients at risk for critical care interventions can address patient and family goals and needs and improve health care utilization. These meetings should be part of routine care for these patients.

Defining Clinical Excellence for Palliative Care Specialists: A Concept Whose Time Has Come.

Experts in the field of palliative care in the United States (U.S.) have defined competence, or "good," mainly for programs, trainees, or providers of primary palliative care. Our interprofessional workgroup of palliative care specialists proposes that setting a standard for clinical excellence, or "great," applicable to palliative care specialists of all professions will elevate the field in the U.S. by providing an aspirational target usable for individual assessment and self-assessment, highlighting the common ground between team roles, and promoting a deeper understanding of teamwork, utilization, and productivity. We call for research that utilizes inclusive methods and broad representation of diverse voices to design a vivid, practical, and evidence-based definition of clinical excellence for palliative care specialists.

Implementation of Patient Safety Structures and Processes in the Patient-Centered Medical Home.

ABSTRACT: Although most patient-clinician interactions occur in ambulatory care, little research has addressed measuring ambulatory patient safety or how primary care redesign such as the patient-centered medical home (PCMH) addresses patient safety. Our objectives were to identify PCMH standards relevant to patient safety, construct a measure of patient safety activity implementation, and examine differences in adoptions of these activities by practice and community characteristics. Using a consensus process, we selected elements among a widely adopted, nationally representative PCMH program representing activities that, according to a physician panel, represented patient safety overall and in four domains (diagnosis, treatment delays, medications, and communication and coordination) and generated a score for each. We then evaluated this score among 5,007 practices with the highest PCMH recognition level. Implementation of patient safety activities varied; the few military practices (2.4%) had the highest, and community clinics the lowest, patient safety score, both overall (82.0 and 72.0, respectively, p < .001) and across specific domains. Other practice and community characteristics were not associated with the patient safety score. Understanding better what factors are associated with implementation of patient safety activities may be a key step in improving ambulatory patient safety.

Narrative Approach to Goals of Care Discussions: Adapting the 3-Act Model Training to an Online Format.

CONTEXT: The three-Act Model, a narrative approach to goals of care (GOC) discussions centered on patients' individual stories, has proven to be effective as measured by objective skill improvement among medical trainees. This study describes the adaptation of the in-person curriculum to a streamlined, online format, in the setting of the Covid19 pandemic. We hypothesized that high levels of skill proficiency and learner satisfaction observed in previous in-person cohorts would be sustained amongst trainees in the online setting. OBJECTIVE: Our primary aim was to assess the skills proficiency of a cohort of internal medicine interns undergoing online training for GOC discussions with the three-Act Model. Our secondary goal was to assess learners' satisfaction with the prerecorded didactic video and online role plays. METHODS: Our team used REDCap for the data collection, and as the user-facing hub for learners to access didactic video content and for submitting surveys. We used Zoom to host synchronous discussions and role-play sessions. Trainers used the previously validated Goals of Care Assessment Tool (GCAT) to objectively rate intern proficiency in two role plays each. RESULTS: Twenty-one internal medicine interns began the training; 20 completed the training and were assessed using the GCAT. All but one intern who completed the training (19 of 20, 95%) achieved proficiency in leading a GOC discussion as measured objectively using the GCAT. Learner satisfaction was high: 1) 100% of respondents recommended the training to others as a "good" (26.7%) or "outstanding" experience (73.3%); 2) 93.3% were "satisfied" or "very satisfied" using a online, distance-learning format for the prerecorded didactic component; 3) 80% were "satisfied" or "very satisfied" using an online, distance-learning format for the role-play component; and 4) 93.3% were content with the number of role plays. The amount of time dedicated to this training decreased compared to prior years when done in person (six hours) - to four hours and 40 minutes for learners and under four hours for trainers. CONCLUSION: After completing the adapted online three-Act Model training, nearly all learners were scored to be proficient in GOC communication skills and reported high satisfaction with the online curriculum. Achieving high quality more efficiently represents genuine educational value. Further, these online teaching results show that the three-Act Model training can be delivered to geographically distanced learners.

Measure Scan and Synthesis of Palliative and End-of-Life Process Quality Measures for Advanced Cancer.

PURPOSE: Monitoring and improving the quality of palliative and end-of-life cancer care remain pressing needs in the United States. Among existing measures that assess the quality of palliative and end-of-life care, many operationalize similar concepts. We identified existing palliative care process measures and synthesized these measures to aid stakeholder prioritization that will facilitate health system implementation in patients with advanced cancer. METHODS: We reviewed MEDLINE/PubMed-indexed articles for process quality measures related to palliative and end-of-life care for patients with advanced cancer, supplemented by expert input. Measures were inductively grouped into "measure concepts" and higher-level groups. RESULTS: Literature review identified 226 unique measures from 23 measure sources, which we grouped into 64 measure concepts within 12 groups. Groups were advance care planning (11 measure concepts), pain (7), dyspnea (9), palliative care-specific issues (6), other specific symptoms (17), comprehensive assessment (2), symptom assessment (1), hospice/palliative care referral (1), spiritual care (2), mental health (5), information provision (2), and culturally appropriate care (1). CONCLUSION: Measure concepts covered the spectrum of care from acute symptom management to advance care planning and psychosocial needs, with variability in the number of measure concepts per group. This taxonomy of process quality measure concepts can be used by health systems seeking stakeholder input to prioritize targets for improving palliative and end-of-life care quality in patients with advanced cancer.

Narrative Approach to Goals of Care Discussions: Assessing the Use of the 3-Act Model in the Clinical Setting.

CONTEXT: The 3-Act Model is an innovative narrative approach to goals of care (GOC) discussions centered on patients' unique stories. Previous studies have demonstrated the effectiveness of the 3-Act Model training in enhancing trainees' skills objectively in role-plays with standardized patients. This study moves beyond the classroom to the clinical setting to assess whether learners preferred this approach, believed it to be clinically effective, and demonstrated proficiency objectively. OBJECTIVE: Our primary objective was to describe internal medicine interns' preferred approach to leading GOC discussions and their view of its efficacy, before vs. after training. Our secondary objective was to assess the proficiency of interns in leading GOC discussions with hospitalized patients. METHODS: We sent online surveys to a cohort of 22 interns both before (pretest) and mid-year after (posttest) training in the 3-Act Model. In addition, trainers objectively assessed GOC discussions led by a subset of trainees in the inpatient setting using a previously described rubric congruent with the 3-Act Model. RESULTS: In the posttest survey, many more interns reported using a narrative approach to GOC discussions most often (pretest, 1 of 22 [5%] vs. posttest, 16 of 18 [89%]). The percentage of interns reporting their preferred approach worked "very well" or "extremely well" increased from pretest to posttest (32%-89%, P = 0.002). Trainers assessed 13 completed GOC discussions led by 4 trainees (18% of original cohort) in the hospital setting and found all 13 to be proficient. CONCLUSION: The vast majority of interns reported preferential use and effectiveness of the 3-Act Model several months after training, and trainers found a subset to be proficient in GOC discussions with hospitalized patients. This study contributes evidence that training in the 3-Act Model positively impacted intern behavior in the clinical setting.

Narrative Approach to Goals of Care Discussions: A Novel Curriculum.

CONTEXT: Innovative patient-centered approaches to goals of care (GOC) communication training are needed. Teaching a narrative approach, centered on the patient's unique story, is conceptually sound but has not been evaluated with respect to objective skills attainment. We developed a curriculum based on a novel, easily-remembered narrative approach to GOC, the 3-Act Model, and piloted it with a cohort of internal medicine (IM) interns. OBJECTIVES: To describe the development of the 3-Act Model curriculum and to assess its impact on the GOC communication skills of IM interns. METHODS: The curriculum was developed with input from multidisciplinary experts, IM residents, and patient/family representative. Notable elements included instrument development with validity evidence established, determination of proficiency standards, and creation of role-play scenarios. In two three-hour workshops, interns participated in role-plays as both providers and patients, before and after teaching (which included narrative reflection, didactics, and video demonstration). RESULTS: 22 interns played the role of provider in five unique scenarios; 106 proficiency ratings were analyzable. Interns objectively rated as proficient increased from 30% (pretest) to 100% (final role-play). By the end of the training, 96% of interns strongly agreed or agreed that they felt ready to independently lead basic GOC discussions and the percentage who strongly agreed increased with successive role-plays. All interns indicated they would recommend the training. CONCLUSION: This pilot demonstrates that the 3-Act Model is teachable and appreciated by learners. This GOC curriculum is the first based on a narrative approach to demonstrate objective skills improvement.

Is patients' insurance coverage associated with prescribing after hospitalization for severe, poorly controlled hypertension?

High medication costs may be a significant cause of nonadherence and threaten recent gains in hypertension treatment. It is unclear whether prescribing patterns differ with patients' insurance coverage. The objective of this study was to determine whether insurance coverage, reported difficulty affording medications, or nonadherence were associated with antihypertensive prescribing in a high-risk population. The authors conducted a cross-sectional survey of 189 patients admitted to an inner-city academic hospital with severe, poorly controlled hypertension. Patients' poor medication access (one-third lacked insurance and half reported difficulty affording medications) was not associated with admission or discharge regimen costs. Substituting the least expensive drug within each class would have reduced costs by 42%, and reducing calcium channel blocker use would have significantly reduced costs. In conclusion, markers of poor medication access were not associated with prescribing patterns. Further research is needed to explore these patterns and their impact on vulnerable populations' financial burden and adherence.

Associations between home remedy use and a validated self-reported adherence measure in an urban African-American population with poorly controlled hypertension.

OBJECTIVE: To determine associations between home remedy use and self-reported adherence among urban African Americans with poorly controlled hypertension. METHODS: A cross-sectional structured interview of African Americans admitted to medical units for uncontrolled hypertension at an urban academic hospital from 1999-2004. Logistic regression was used to test associations between home remedy use and self-reported adherence. RESULTS: One-hundred-eighty-three of 272 participants completed the study (67%); 39 (21%) reported using home remedies for hypertension. In a multivariate model, home remedy use was independently associated with greater medication adherence (OR for nonadherence=0.32, 95% CI: 0.14-0.75; p<0.01) and dietary adherence (OR for changing diet=3.28, 95% CI: 1.10-9.81; p=0.03), but not lifestyle or appointment adherence. These associations remained strong while controlling for age; sex; employment status; and key covariates, including greater medication side effects (OR=4.31; 95% CI: 1.64-11.3; p<0.01), greater difficulty paying for medications (OR=2.94, 95% CI: 1.25-6.92; p=0.01) and longer duration of diagnosis (OR for log years=1.53; 95% CI: 1.02-2.33; p=0.045). CONCLUSION: Home remedy use may be a marker of positive self-care for some hypertensive African Americans and not a promoter of nonadherence.

Instruments for evaluating shared medical decision making: a structured literature review.

The author conducted a structured literature review of instruments for evaluating shared medical decision making. She included relevant instruments that were generalizable beyond specific situations and had been formally evaluated and organized them by domains of values or preferences, information and communication in decision making, and other aspects of decision making. For values or preferences, the author identified 11 instruments, mostly on preferences for roles and information. For information and communication, she found a systematic review of instruments for observational assessment of decision making, 3 additional observational instruments, and 3 questionnaires. For other aspects of decision making, the author identified 3 instruments in domains such as decision self-efficacy and 4 multidimensional instruments. Although instrument development tended to cluster in several areas and there were clear gaps in the literature, the diversity of instruments demonstrates the broad range of constructs involved in assessing shared decision making.

Enteral and parenteral nutrition in terminally ill cancer patients: a review of the literature.

Many terminally ill patients who are able to eat appear to be eating less than they should, losing weight, and becoming malnourished, and many others develop difficulties with eating. These symptoms and signs are usually a marker of advanced cancer, rather than the cause of decreasing functional status, and providing supplemental nutrition rarely changes the course of the disease. This article reviews evidence on issues relevant to enteral and parenteral nutrition in patients with advanced cancer, including benefits, risks, and discomforts; how these types of nutrition are used and perceived, and how decisions are made; and how decision-making might be improved.

Patient Safety and End-of-Life Care: Common Issues, Perspectives, and Strategies for Improving Care.

The current state of the science in the fields of patient safety and palliative and end-of-life care have many issues in common. This article synthesizes recent systematic reviews and additional research on improving patient safety and end-of-life care and compares each field's perspective on common issues, both in traditional patient safety frameworks and in other areas, and how current approaches in each field can inform the other. The article then applies these overlapping concepts to a key example area: improving documentation of patient preferences for life-sustaining treatment. The synthesis demonstrates how end-of-life issues should be incorporated into patient safety initiatives. In addition, evaluating overlap and comparable issues between patient safety and end-of-life care and comparing different perspectives and improvement strategies can benefit both fields.

Palliative Care Education in Emergency Medicine Residency Training: A Survey of Program Directors, Associate Program Directors, and Assistant Program Directors.

CONTEXT: Emergency medicine (EM) residents perceive palliative care (PC) skills as important and want training, yet there is a general lack of formal PC training in EM residency programs. A clearer definition of the PC educational needs of EM trainees is a research priority. OBJECTIVES: To assess PC competency education in EM residency programs. METHODS: This was a mixed-mode survey of residency program directors, associate program directors, and assistant program directors at accredited EM residency programs, evaluating four educational domains: 1) importance of specific competencies for senior EM residents, 2) senior resident skills in PC competencies, 3) effectiveness of educational methods, and 4) barriers to training. RESULTS: Response rate was 50% from more than 100 residency programs. Most respondents (64%) identified PC competencies as important for residents to learn, and 59% reported that they teach7 PC skills in their residency program. In Domains 1 and 2, crucial conversations, management of pain, and management of the imminently dying had the highest scores for importance and residents' skill. In Domain 3, bedside teaching, mentoring from hospice and palliative medicine faculty, and case-based simulation were the most effective educational methods. In Domain 4, lack of PC expertise among faculty and lack of interest by faculty and residents were the greatest barriers. There were differences between competency importance and senior resident skill level for management of the dying child, withdrawal/withholding of nonbeneficial interventions, and ethical/legal issues. CONCLUSION: There are specific barriers and opportunities for PC competency training and gaps in resident skill level. Specifically, there are discrepancies in competency importance and residency skill in the management of the dying child, nonbeneficial interventions, and ethical and legal issues that could be a focus for educational interventions in PC competency training in EM residencies.

Methodological Research Priorities in Palliative Care and Hospice Quality Measurement.

Quality measurement is a critical tool for improving palliative care and hospice, but significant research is needed to improve the application of quality indicators. We defined methodological priorities for advancing the science of quality measurement in this field based on discussions of the Technical Advisory Panel of the Measuring What Matters consensus project of the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association and a subsequent strategy meeting to better clarify research challenges, priorities, and quality measurement implementation strategies. In this article, we describe three key priorities: 1) defining the denominator(s) (or the population of interest) for palliative care quality indicators, 2) developing methods to measure quality from different data sources, and 3) conducting research to advance the development of patient/family-reported indicators. We then apply these concepts to the key quality domain of advance care planning and address relevance to implementation of indicators in improving care. Developing the science of quality measurement in these key areas of palliative care and hospice will facilitate improved quality measurement across all populations with serious illness and care for patients and families.

Why do patients and families request transfers to tertiary care? a qualitative study.

Interhospital transfers comprise a significant and increasing proportion of admissions to tertiary care centers. Patient dissatisfaction with the quality of hospital care may play an important role in these trends. The objective of this study was to describe why and how patients and surrogates request transfers to tertiary care. We interviewed 32 patients transferred to the Johns Hopkins Hospital, a US tertiary care center, or their surrogate decision-makers using a semi-structured, open-ended, iterative protocol. We used ethnographic decision modeling to develop an influence diagram of the decision. We contrasted subjects' perceptions of situations where patients did and did not request transfer to describe the threshold for requesting transfer. Subjects reported three major influences on the request to transfer to tertiary care: the quality of care at the community hospital compared to the tertiary center; the severity and potential consequences of the current illness; and their relationship with community hospitals, physicians, and tertiary care. Subjects' perceptions of the quality differential between community hospitals and tertiary centers focused on communication and medical errors rather than specialized care, hospital volume, or teaching status. Thresholds for when patients requested transfers were influenced by relationships with community hospitals and physicians and previous experience with tertiary care. This model provides a framework for understanding requests to transfer to tertiary care. Further investigation into the elements we have described might provide insights into improvements in the quality of care at community hospitals that might reduce the rates of requests for transfer. Our results also highlight the importance of including patient or surrogate perspectives in evaluations of the appropriateness of care.

Access to Care, Treatment Ambivalence, Medication Nonadherence, and Long-Term Mortality Among Severely Hypertensive African Americans: A Prospective Cohort Study.

African Americans living in poor neighborhoods bear a high burden of illness and early mortality. Nonadherence may contribute to this burden. In a prospective cohort study of urban African Americans with poorly controlled hypertension, mortality was 47.6% over a median follow-up of 6.1 years. Patients with pill-taking nonadherence were more likely to die (hazard ratio, 1.80; 95% confidence interval [CI], 1.18-2.76) after adjustment for potential confounders. With regard to factors related to nonadherence, poor access to care such as difficulty paying for medications was associated with prescription refill nonadherence (odds ratio [OR], 4.12; 95% CI, 1.88-9.03). Pill-taking nonadherence was not associated with poor access to care; however, it was associated with factors related to treatment ambivalence including lower hypertension knowledge (OR, 2.97; 95% CI, 1.39-6.32), side effects (OR, 3.44; 95% CI, 1.47-8.03), forgetfulness (OR, 3.62; 95% CI, 1.78-7.34), and feeling that the medications do not help (OR, 2.78; 95% CI, 1.09-7.09). These data suggest that greater access to care is a necessary but insufficient remedy to the disparities experienced by urban African Americans with hypertension. To achieve its full promise, health reform must also address treatment ambivalence.

Measuring what matters: top-ranked quality indicators for hospice and palliative care from the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association.

CONTEXT: Measuring quality of hospice and palliative care is critical for evaluating and improving care, but no standard U.S. quality indicator set exists. OBJECTIVES: The Measuring What Matters (MWM) project aimed to recommend a concise portfolio of valid, clinically relevant, cross-cutting indicators for internal measurement of hospice and palliative care. METHODS: The MWM process was a sequential consensus project of the American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA). We identified candidate indicators mapped to National Consensus Project (NCP) Palliative Care Guidelines domains. We narrowed the list through a modified Delphi rating process by a Technical Advisory Panel and Clinical User Panel and ratings from AAHPM and HPNA membership and key organizations. RESULTS: We narrowed the initial 75 indicators to a final list of 10. These include one in the NCP domain Structure and Process (Comprehensive Assessment), three in Physical Aspects (Screening for Physical Symptoms, Pain Treatment, and Dyspnea Screening and Management), one in Psychological and Psychiatric Aspects (Discussion of Emotional or Psychological Needs), one in Spiritual and Existential Aspects (Discussion of Spiritual/Religious Concerns), and three in Ethical and Legal Aspects (Documentation of Surrogate, Treatment Preferences, and Care Consistency with Documented Care Preferences). The list also recommends a global indicator of patient/family perceptions of care, but does not endorse a specific survey instrument. CONCLUSION: This consensus set of hospice and palliative care quality indicators is a foundation for standard, valid internal quality measurement for U.S. SETTINGS: Further development will assemble implementation tools for quality measurement and benchmarking.

Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension.

BACKGROUND: Missed appointments are associated with an increased risk of hospitalization and mortality. Despite its widespread prevalence, little data exists regarding factors related to appointment non-adherence among hypertensive African-Americans. OBJECTIVE: To investigate factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension. DESIGN AND PARTICIPANTS: A cross-sectional survey of 185 African-Americans admitted to an urban medical center in Maryland, with severe, poorly controlled hypertension from 1999-2004. Categorical and continuous variables were compared using chi-square and t-tests. Adjusted multivariable logistic regression was used to assess correlates of appointment non-adherence. MAIN OUTCOME MEASURES: Appointment non-adherence was the primary outcome and was defined as patient-report of missing greater than 3 appointments out of 10 during their lifetime. RESULTS: Twenty percent of participants (n = 37) reported missing more than 30% of their appointments. Patient characteristics independently associated with a higher odds of appointment non-adherence included not finishing high school (Odds ratio [OR]  = 3.23 95% confidence interval [CI] (1.33-7.69), hypertension knowledge ([OR]  = 1.20 95% CI: 1.01-1.42), lack of insurance ([OR]  = 6.02 95% CI: 1.83-19.88), insurance with no medication coverage ([OR]  = 5.08 95% CI: 1.05-24.63), cost of discharge medications ([OR]  = 1.20 95% CI: 1.01-1.42), belief that anti-hypertensive medications do not work ([OR]  = 3.67 95% CI: 1.16-11.7), experience of side effects ([OR]  = 3.63 95% CI: 1.24-10.62), medication non-adherence ([OR]  = 11.31 95% CI: 3.87-33.10). Substance abuse was not associated with appointment non-adherence ([OR]  = 1.05 95% CI: 0.43-2.57). CONCLUSIONS: Appointment non-adherence among African-Americans with poorly controlled hypertension was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.