Triadic treatment decision-making in advanced cancer: a pilot study of the roles and perceptions of patients, caregivers, and oncologists.

PURPOSE: The research on cancer treatment decision-making focuses on dyads; the full "triad" of patients, oncologists, and caregivers remains largely unstudied. We investigated how all members of this triad perceive and experience decisions related to treatment for advanced cancer. METHODS: At an academic cancer center, we enrolled adult patients with advanced gastrointestinal or hematological malignancies, their caregivers, and their oncologists. Triad members completed a semi-structured qualitative interview and a survey measuring decisional conflict and perceived influence of the other triad members on treatment decisions. RESULTS: Seventeen patients, 14 caregivers, and 10 oncologists completed the study. Patients and caregivers reported little decisional regret and voiced high satisfaction with their decisions, but levels of decisional conflict were high. We found sizeable disagreement among triad members' perceptions and preferences. For example, patients and oncologists disagreed about the caregiver's influence on the decision 56% of the time. In addition, many patients and caregivers preferred to defer to their oncologist about treatment decisions, felt like no true decision existed, and disagreed with their oncologist about how many treatment options had been presented. CONCLUSIONS: Patients, caregivers, and oncologists have discordant perceptions of the cancer treatment decision-making process, and bring different preferences about how they want to make decisions. These data suggest that oncologists should assess patients' and caregivers' decisional preferences, explicitly signal that a decision needs to be made whenever approaching an important crossroads in treatment and ensure that patients and caregivers understand the full range of presented options.

Modern Management Practices and Hospital Admissions.

We investigate whether the modern management practices and publicly reported performance measures are associated with choice of hospital for patients with acute myocardial infarction (AMI). We define and measure management practices at approximately half of US cardiac care units using a novel survey approach. A patient's choice of a hospital is modeled as a function of the hospital's performance on publicly reported quality measures and the quality of its management. The estimates, based on a grouped conditional logit specification, reveal that higher management scores and better performance on publicly reported quality measures are positively associated with hospital choice. Management practices appear to have a direct correlation with admissions for AMI--potentially through reputational effects--and indirect association, through better performance on publicly reported measures. Overall, a one standard deviation change in management practice scores is associated with an 8% increase in AMI admissions.

Racial Disparities in Health Care With Timing to Amputation Following Diabetic Foot Ulcer.

OBJECTIVE: To examine variations in timing of lower-limb amputation (LLA) across race/ethnicity and sex among older adults with a diabetic foot ulcer (DFU). It was hypothesized Black/African Americans were more likely to have LLA post-DFU earlier compared with non-Hispanic/Whites, and more men would receive LLA earlier post-DFU compared with women. RESEARCH DESIGN AND METHODS: This was a retrospective cohort analysis of enrolled Medicare fee-for-service (FFS) beneficiaries with a diagnosis of DFU during the study period (2012-2017), allowing up to 5 years post-DFU. Final analytic sample contained 643,287 individuals; the subsample consisted of 68,633 individuals with LLA only. The primary outcome was mutually exclusive groups based on timing of LLA. Multinomial logistic regression was applied to assess likelihood of membership into a group post-DFU based on characteristics such as sex and race/ethnicity. RESULTS: Black/African American beneficiaries had 1.98 (95% CI 1.93-2.03) times the odds of receiving an LLA within 1 year of DFU diagnosis compared with non-Hispanic/White beneficiaries relative to no amputation. Female beneficiaries had increased odds (odds ratio [OR] 1.07, 95% CI 1.02-1.11] between 1 and 3 years and OR 1.08 [95% CI 1.03-1.12] in ≥3 years) of a delayed LLA compared with men among those that underwent LLA. CONCLUSIONS: Notably, these results present novel evidence on timing of LLA between racial groups and sex for Medicare FFS beneficiaries post-DFU. Results may be generalizable to individuals with Medicare FFS and DFU. Clinically more targeted, evidence-based decision making informs care decisions with opportunities to address inequities related to the social determinants of health that may lead to LLA.

Triadic agreement about advanced cancer treatment decisions: Perceptions among patients, families, and oncologists.

OBJECTIVES: When patients make cancer treatment decisions, they consider the needs and preferences of family caregivers and clinicians. We examined how much all three triad members agreed about goals of treatment and caregivers' influence on decision-making. METHODS: We surveyed 70 triads of patients, caregivers, and oncologists who had recently made an advanced cancer treatment decision. We assessed each triad member's perception of the goal of treatment and the caregiver's influence on the decision. Participants also completed scales related to decisional conflict, satisfaction, and regret. RESULTS: In only 28/70 triads (40%), all three agreed on the goal of treatment with the most common goal being to live longer (n = 22). Whereas patients and caregivers tended to think the goal was to cure or live longer, oncologists were less optimistic. In only 22 triads (31%), all three agreed on how much influence the caregiver had on decision-making. Oncologists tended to underestimate caregiver influence. Patients and caregivers had low decisional conflict (M=15.40, SD=4.51; M=17.09, SD=6.34, respectively). CONCLUSIONS: Advanced cancer treatment decision-making occurs amid incomplete understanding among patients, caregivers, and oncologists. PRACTICE IMPLICATIONS: Confirming agreement about goals of care and influence on treatment decision-making may increase the likelihood of goal-concordant care throughout the illness trajectory.

Management practices and the quality of care in cardiac units.

IMPORTANCE: To improve the quality of health care, many researchers have suggested that health care institutions adopt management approaches that have been successful in the manufacturing and technology sectors. However, relatively little information exists about how these practices are disseminated in hospitals and whether they are associated with better performance. OBJECTIVES: To describe the variation in management practices among a large sample of hospital cardiac care units; assess association of these practices with processes of care, readmissions, and mortality for patients with acute myocardial infarction (AMI); and suggest specific directions for the testing and dissemination of health care management approaches. DESIGN: We adapted an approach used to measure management and organizational practices in manufacturing to collect management data on cardiac units. We scored performance in 18 practices using the following 4 dimensions: standardizing care, tracking of key performance indicators, setting targets, and incentivizing employees. We used multivariate analyses to assess the relationship of management practices with process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for acute myocardial infarction (AMI). SETTING: Cardiac units in US hospitals. PARTICIPANTS: Five hundred ninety-seven cardiac units, representing 51.5% of hospitals with interventional cardiac catheterization laboratories and at least 25 annual AMI discharges. MAIN OUTCOME MEASURES: Process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for AMI. RESULTS: We found a wide distribution in management practices, with fewer than 20% of hospitals scoring a 4 or a 5 (best practice) on more than 9 measures. In multivariate analyses, management practices were significantly correlated with mortality (P = .01) and 6 of 6 process measures (P < .05). No statistically significant association was found between management and 30-day readmissions. CONCLUSIONS AND RELEVANCE: The use of management practices adopted from manufacturing sectors is associated with higher process-of-care measures and lower 30-day AMI mortality. Given the wide differences in management practices across hospitals, dissemination of these practices may be beneficial in achieving high-quality outcomes.