Interactions with the healthcare system influence advance care planning activities: results from a representative survey in 11 developed countries.

Aim: To identify factors associated with completion of Advance Care Planning (ACP) by patients seen in primary care in developed countries. We hypothesized that the quality of primary care is associated. Method: We analysed respondent reported individual and healthcare utilization factors associated with the completion of ACP activities from the 2014 Commonwealth Fund International Health Policy Survey of Older Adults in 11 Countries. The primary outcome is the combined number of ACP activities completed. ACP activities included discussion of treatment preferences, documentation of healthcare wishes, or documentation of a surrogate decision maker. A quality of primary care index was calculated. Results: Respondents averaged 69 years old. Most were women, graduated high school, rated their income as average or higher, and rated their health as good or better. A minority reported multimorbidity, accessed the emergency department or hospital, or were informal caregivers. Out of 25530 survey respondents, 13409 (53%) reported completion of any ACP activity; 11579 (45%) had discussed treatment preferences. Generalized linear mixed model results suggest that hospitalization (rate ratio [RR] 1.18), multimorbidity (RR 1.16), informal caregiving (RR 1.13), higher education level (RR 1.14), income (RR 1.05), access to higher quality primary care (RR 1.04) and ED visits (RR 1.04) were associated with higher rates of ACP activities. Male gender (RR 0.85) and higher perceived health status (RR 0.96) were associated with lower rates. Conclusions: In this international study, individuals with greater interaction with the healthcare system through hospitalization, multimorbidity, access to quality primary care and informal caregiving reported more ACP activities.

A Report on the Innovative University of Colorado Community Hospice and Palliative Medicine Fellowship.

Background: Predictive health services modeling signals a shortage of board-certified Hospice and Palliative Medicine (HPM) physicians. Methods: This article introduces the Community Hospice and Palliative Medicine (CHPM) Fellowship, an Accreditation Council for Graduate Medical Education (ACGME) Advancing Innovation in Residency Education (AIRE) project designed to enable mid-career physicians (at least five years out from residency or fellowship) to achieve eligibility for board certification in HPM. Results: From 2020 to 2023, 24 fellows have completed or are currently participating in the CHPM fellowship which is evaluated using the Kirkpatrick model. Conclusion: This program shows promise in addressing the impending HPM workforce shortage by allowing physicians to complete a fellowship in their local communities.

Characteristics of international primary care practices and physicians related to advance care planning: a cross-sectional survey study.

BACKGROUND: Primary care providers (PCPs) are well-situated to delivery primary palliative care such as advance care planning (ACP). The aim of this work is to identify practice characteristics, including features found in advanced primary care models (APCMs), that predict PCP engagement of patients in ACP. METHODS: We analyzed characteristics of physician respondents and their practices associated with ACP conversations in older and sicker patients using data from 11 countries who participated in the 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. The primary outcome was how routinely these ACP conversations are reported. We used a validated measure to describe practice-level characteristics of advanced primary care models. We conducted bivariate and multivariable analyses to determine PCP and practice characteristics associated with routinely engaging patients in ACP and with documenting patient preferences in medical records. RESULTS: Respondents (N = 12,049) predominantly were older than 45 and did not view their jobs as high stress. PCPs reported routinely engaging patients in ACP work in practices with more APCM features. They are more likely to view their jobs as high stress, to work more hours, to practice in rural areas, and to work in smaller practices. Multivariable analyses showed that older PCP age, higher perceived stress of the job, practice location in rural areas, and increased number of APCM features were associated with more ACP conversations. Increased number of APCM features was also associated with higher odds of routinely recording patient preferences in their medical records. CONCLUSIONS: In this international survey, physician and practice characteristics, including having features associated with APCMs, were associated with whether physicians routinely discuss ACP with patients who are older and sicker. Many features of APCMs may facilitate ACP discussions between PCPs and patients.

Features of U.S. Primary Care Physicians and Their Practices Associated with Advance Care Planning Conversations.

INTRODUCTION: Primary care practices are essential settings for Advance Care Planning (ACP) conversations with patients. We hypothesized that such conversations occur more routinely in Advanced Primary Care/Patient Centered Medical Home (APCP/PCMH) Practices using practice transformation strategies. METHODS: We analyzed characteristics of physician respondents and their practices associated with ACP discussions in older and sicker patients using US data from the 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. The primary outcome was how routinely these ACP conversations are reported. We developed an index of APCP/PCMH features as a practice covariable. RESULTS: Respondents (N = 1001) were predominantly male (60%) and ≥45 years old (74%). Multivariable analyses showed that suburban practice location was associated with fewer ACP conversations; working in a practice commonly seeing patients with multiple chronic conditions or who have palliative care needs, and working in a practice from which home visits are made, were associated with more ACP conversations. Physicians compensated in part by capitation were more likely to report ACP conversations. No association was found between a single item asking if the practice was an APCP/PCMH and having ACP conversations. However, higher scores on an index of APCP/PCMH features were associated with more ACP conversations. CONCLUSIONS: In this sample of US primary care physicians, the types of patients seen, practice location, and physician compensation influenced whether physicians routinely discuss ACP with patients who are older and sicker. Practices demonstrating more features of APCP/PCMH models of primary care are also associated with ACP discussions.

New "Core Quality Measures": Only a Beginning.

A plethora of quality measures are used in health care for quality improvement, accountability (including reimbursement), and research. The Core Quality Measures Collaborative, with input from the American Association of Family Physicians, recently released several groups of reduced core measure sets, including one for primary care. The proposed measures are less helpful for the increasing proportion patients with multiple morbidities or advancing illness. Going forward, the development of quality measures that assess multidimensional patient experiences and how closely the health care patients receive matches their goals in the face of multiple morbidities and advancing illness should be the focus.

Advance Care Planning: Understanding Clinical Routines and Experiences of Interprofessional Team Members in Diverse Health Care Settings.

BACKGROUND: Interprofessional health care team members consider advance care planning (ACP) to be important, yet gaps remain in systematic clinical routines to support ACP. A clearer understanding of the interprofessional team members' perspectives on ACP clinical routines in diverse settings is needed. METHODS: One hundred eighteen health care team members from community-based clinics, long-term care facilities, academic clinics, federally qualified health centers, and hospitals participated in a 35-question, cross-sectional online survey to assess clinical routines, workflow processes, and policies relating to ACP. RESULTS: Respondents were 53% physicians, 18% advanced practice nurses, 11% nurses, and 18% other interprofessional team members including administrators, chaplains, social workers, and others. Regarding clinical routines, respondents reported that several interprofessional team members play a role in facilitating ACP (ie, physician, social worker, nurse, others). Most (62%) settings did not have, or did not know of, policies related to ACP documentation. Only 14% of settings had a patient education program. Two-thirds of the respondents said that addressing ACP is a high priority and 85% felt that nonphysicians could have ACP conversations with appropriate training. The clinical resources needed to improve clinical routines included training for providers and staff, dedicated staff to facilitate ACP, and availability of patient/family educational materials. CONCLUSION: Although interprofessional health care team members consider ACP a priority and several team members may be involved, clinical settings lack systematic clinical routines to support ACP. Patient educational materials, interprofessional team training, and policies to support ACP clinical workflows that do not rely solely on physicians could improve ACP across diverse clinical settings.

Perspectives of Primary Care Providers Toward Palliative Care for Their Patients.

PURPOSE: The need for all providers to deliver basic palliative care has emerged as patients' needs outstrip the capacity of specialty palliative care. Many patients with complex illnesses have unmet needs and are seen in primary care more than other settings. We explore primary care providers' willingness and perceived capacity to provide basic palliative care, and their concerns and perceived barriers. METHODS: We performed semistructured telephone interviews with 20 primary care providers about their perceptions of palliative care, including needs, practices, experiences, access, and what would be helpful for their practices to systematically provide basic palliative care. RESULTS: We identified 3 major themes: (1) Participants recognize palliative needs in patients with complex problems. (2) They reactively respond to those needs using practice and community resources, believing that meeting those needs at a basic level is within the scope of primary care. (3) They can identify opportunities to improve the delivery of a basic palliative approach in primary care through practice change and redesign strategies used in enhanced primary care environments. CONCLUSIONS: Systematic attention along the multidimensional domains of basic palliative care might allow practices to address unmet needs in patients with complex illnesses by using existing practice improvement models, strategies, and prioritization.

Outcomes and characteristics of patients discharged alive from hospice.

OBJECTIVES: To describe outcomes and characteristics of patients discharged alive from hospice. DESIGN: Prospective cohort study using a telephone survey. SETTING: Hospices (n=18) participating in the Population-Based Palliative Care Research Network during the 1-year study period. PARTICIPANTS: English-speaking adults (n=164) who were discharged alive from participating hospices during the 1-year study period. MEASUREMENTS: Mortality within 6 months of hospice discharge. RESULTS: Thirty-five percent (n=48) of the 139 patients with known outcomes died within 6 months of hospice discharge, 15 of whom (31%) died without hospice readmission. There were no significant associations between sex (P=.77), length of hospice service (P=.99), diagnosis (P=.73), discharge disposition (P=.54), admission evidence of prognosis of less than 6 months to live (P=.22-.95), Karnofsky score at admission or change between admission and discharge (P=.39, P=.38, respectively), or duration of hospice care after stabilization (P=.83) and mortality within 6 months after hospice discharge. Age (P=.11), discharge Karnofsky score (P=.17), and reason for discharge being improved or stabilized condition (P=.13) trended toward statistical significance. The strongest predictor of mortality after hospice discharge was a report that the patient's condition had worsened (hazard ratio=10.2, 95% confidence interval 4.5-23.4). CONCLUSION: One-third of patients who were discharged from hospice died within 6 months of hospice discharge, indicating ongoing eligibility for hospice care even under the strictest interpretation of hospice eligibility criteria. Patients who are discharged from hospice care should be evaluated frequently, especially within the first weeks to months after discharge, for changes in status, unmet needs, and potential hospice readmission.

Estimation of confusion prevalence in hospice patients.

BACKGROUND: Confusion is common among ill patients and has broad consequences for their care and well-being. The prevalence of confusion in hospice patients is unknown. OBJECTIVES: Describe the prevalence, severity, and manifestations of nurse-identified confusion and estimate the prevalence of delirium in hospice patients. DESIGN: Cross-sectional descriptive study. SETTING: Nineteen hospices in the Population-based Palliative Care Research Network (PoPCRN). PATIENTS: Adult patients receiving care from participating hospices, February 15 to April 1, 2000. MEASUREMENT/ANALYSIS: Hospice nurses estimated prevalence, severity, behavioral manifestations, and consequences of confusion during the preceding week. Confused and nonconfused patients were compared using standard bivariate and stratification techniques. Logistic regression identified manifestations associated with problematic confusion. RESULTS: Median age of the 299 patients was 78 years; 59% were female, 52% lived at home, and cancer was the most common diagnosis (54%). Fifty percent were confused during the preceding week, 36% of those were severely confused or disabled by confusion. Compared with nonconfused patients, confused patients were less likely to have cancer (64% vs. 43%, p < or = 0.001) and more likely to live in nursing home/assisted living (21% vs. 33%, p < or = 0.01). Disorientation to time or place, impaired short-term memory, drowsiness, and easy distractibility were common manifestations of confusion. When present, confusion caused a problem for the patient, someone else, or both 79% of the time. Inappropriate mood, cancer diagnosis, agitation, and age were the variables predicting problematic confusion. Only 14% of confused patients met criteria for delirium. CONCLUSIONS: Confusion among hospice patients was common, frequently severe, and usually problematic.

Hospice pharmaceutical cost trends.

Hospices are required to provide pharmaceuticals under the Medicare Hospice Benefit. Since there are no data describing these costs for hospice programs, this study analyzes data from a cross-sectional survey of 34 hospices concerning their pharmaceutical cost trends. Most respondents reported higher pharmaceutical-related costs between 1998 and 2002, but a significant minority reported that their costs had decreased. Pharmaceutical costs varied by patient setting, but long-acting opioids and continuous-infusion delivery systems were the two most significant contributors. A variety of mechanisms were employed to control drug costs.

Validation of the EQ-5D quality of life instrument in patients after myocardial infarction.

BACKGROUND: We assessed cross-sectional validity of EQ-5D after myocardial infarction (MI). METHODS: We compared EQ-5D, SF-36, quality of life After MI (QLMI), and Canadian Cardiovascular Society Anginal Classification (CCSG) scores. Correlation and regression techniques were used to assess convergent validity. SF-36 and alternate Rand-36 scoring were compared. CCSG class was used to evaluate discriminative validity and clinical difference in health state scores. RESULTS: Of 99 patients: mean age 64; median 176.5 days post-MI; 80% had one MI; 74% were CCSG I. 1/3 to 1/2 reported mobility, self-care, pain, and emotional difficulties on EQ-5D. Median health state was 0.73. EQ-5D and SF-36 (or Rand-36) strongly correlate in overall health (0.75), emotional health (0.75), pain (0.68), and activity/functional (0.5-0.63). EQ-5D and QLMI strongly correlate in activities/self esteem (0.56), emotional health (0.64), anxiety/ depression--restriction (0.53), and overall health (0.5-0.57). EQ-5D self-care correlates weakly with all domains. Domain scores from each general instrument contributed to each other's overall health score (adjusted R2 0.61-0.69) and to disease specific score (0.45 adjusted R2). EQ-5D discriminates among CCSG classes (p < 0.000). Physicians detected a 0.16 difference in health state scores. CONCLUSION: The EQ-5D provides valid general HrQOL measurement post-MI.

Confirmation of the "disability paradox" among hospice patients: preservation of quality of life despite physical ailments and psychosocial concerns.

OBJECTIVE: The purpose of this study was to describe quality of life (QOL) and psychosocial and spiritual issues among patients receiving hospice care. METHODS: A questionnaire addressing QOL, spirituality, optimism, loss, fears about the terminal process and death anxiety was administered to 66 adults receiving care from 14 hospices. The physical components of QOL (physical symptoms and physical well-being) were rated lower than the psychosocial and spiritual aspects (support, existential well-being, psychological symptoms). RESULTS: Respondents had a strong spiritual connection and a strong sense of hope. Although these individuals did not express anxiety or fear about death, there were concerns about the dying process itself. Also, although most felt at ease with their current situation, respondents were concerned about how their illness was affecting their family. Financial and legal issues did not concern most of these individuals. SIGNIFICANCE OF RESULTS: There were few significant associations between patient characteristics and the QOL or other psychosocial or spiritual issues addressed. Among this older terminally ill population receiving hospice care, whose functional status was fair and for whom physical symptoms were troublesome, QOL persisted and a positive outlook prevailed.