Relationships among clinicians are crucial to successful palliative care integration: a qualitative study in lung cancer.

Aims: Palliative care integration improves quality of life among patients with lung cancer and their families. Despite these benefits, significant barriers persist and patients do not receive timely integration. This study sought to identify facilitators of and barriers to integration in lung cancer care. Materials & methods: Semistructured qualitative interviews were conducted with palliative care and lung cancer clinicians and analyzed using traditional content analysis. 23 clinicians were interviewed from geographically dispersed hospitals within a national healthcare system. Results: Palliative care integration improved over time, enhanced by several facilitators stratified at four levels (patient/clinician/hospital/organization). Most important among these was multidisciplinary care delivered in outpatient settings, fostering trust and relationships among clinicians which were pivotal to successful integration. Workforce shortages and limited use of primary palliative care among lung cancer clinicians need to be addressed for continued growth in the field. Conclusion: Relationships among clinicians are crucial to successful palliative care integration in lung cancer care.

Palliative care is a form of supportive care for patients with a serious illness that improves quality of life among patients with lung cancer and their families. Unfortunately, many patients do not receive this care until they are near the end of life. This study sought to explore clinicians' perspectives regarding ways to enhance the use of palliative care among patients with lung cancer. Using interviews of clinicians from geographically dispersed hospitals within a national healthcare system, the authors explored reasons and potential solutions to improve palliative care delivery. One of the most important factors in enhancing palliative care use was fostering trust and relationships among palliative care and lung cancer clinicians. Workforce shortages also need to be addressed for continued growth in the field of palliative care. Relationships among clinicians are crucial to successful palliative care integration in lung cancer care.

Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey.

OBJECTIVES: Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN: Cross-sectional survey using four validated instruments. SETTING: Sixty-two sites in Canada and the United States. SUBJECTS: Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS: Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.

Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic.

OBJECTIVES: The coronavirus disease 2019 pandemic has strained many healthcare systems. In response, U.S. hospitals altered their care delivery systems, but there are few data regarding specific structural changes. Understanding these changes is important to guide interpretation of outcomes and inform pandemic preparedness. We sought to characterize emergency responses across hospitals in the United States over time and in the context of local case rates early in the coronavirus disease 2019 pandemic. DESIGN: We surveyed hospitals from a national acute care trials group regarding operational and structural changes made in response to the coronavirus disease 2019 pandemic from January to August 2020. We collected prepandemic characteristics and changes to hospital system, space, staffing, and equipment during the pandemic. We compared the timing of these changes with county-level coronavirus disease 2019 case rates. SETTING AND PARTICIPANTS: U.S. hospitals participating in the Prevention and Early Treatment of Acute Lung Injury Network Coronavirus Disease 2019 Observational study. Site investigators at each hospital collected local data. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-five sites participated (94% response rate). System-level changes (incident command activation and elective procedure cancellation) occurred at nearly all sites, preceding rises in local case rates. The peak inpatient census during the pandemic was greater than the prior hospital bed capacity in 57% of sites with notable regional variation. Nearly half (49%) expanded ward capacity, and 63% expanded ICU capacity, with nearly all bed expansion achieved through repurposing of clinical spaces. Two-thirds of sites adapted staffing to care for patients with coronavirus disease 2019, with 48% implementing tiered staffing models, 49% adding temporary physicians, nurses, or respiratory therapists, and 30% changing the ratios of physicians or nurses to patients. CONCLUSIONS: The coronavirus disease 2019 pandemic prompted widespread system-level changes, but front-line clinical care varied widely according to specific hospital needs and infrastructure. Linking operational changes to care delivery processes is a necessary step to understand the impact of the coronavirus disease 2019 pandemic on patient outcomes.

Gender Differences in Authorship of Critical Care Literature.

Rationale: Gender gaps exist in academic leadership positions in critical care. Peer-reviewed publications are crucial to career advancement, and yet little is known regarding gender differences in authorship of critical care research.Objectives: To evaluate gender differences in authorship of critical care literature.Methods: We used a validated database of author gender to analyze authorship of critical care articles indexed in PubMed between 2008 and 2018 in 40 frequently cited journals. High-impact journals were defined as those in the top 5% of all journals. We used mixed-effects logistic regression to evaluate the association of senior author gender with first and middle author gender, as well as association of first author gender with journal impact factor.Measurements and Main Results: Among 18,483 studies, 30.8% had female first authors, and 19.5% had female senior authors. Female authorship rose slightly over the last decade (average annual increases of 0.44% [P < 0.01] and 0.51% [P < 0.01] for female first and senior authors, respectively). When the senior author was female, the odds of female coauthorship rose substantially (first author adjusted odds ratio [aOR], 1.93; 95% confidence interval [CI], 1.71-2.17; middle author aOR, 1.48; 95% CI, 1.29-1.69). Female first authors had higher odds than men of publishing in lower-impact journals (aOR, 1.30; 95% CI, 1.16-1.45).Conclusions: Women comprise less than one-third of first authors and one-fourth of senior authors of critical care research, with minimal increase over the past decade. When the senior author was female, the odds of female coauthorship rose substantially. However, female first authors tend to publish in lower-impact journals. These findings may help explain the underrepresentation of women in critical care academic leadership positions and identify targets for improvement.

The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department.

STUDY OBJECTIVE: Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). METHODS: This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. RESULTS: A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). CONCLUSION: Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.

Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life.

Importance: Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. Objectives: To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. Design, Setting, and Participants: Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. Exposures: POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. Main Outcomes and Measures: The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. Results: Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). Conclusions and Relevance: Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying.

OBJECTIVE: Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This hypothesis was based on two possibilities: 1) high-acuity ICUs may have a culture of aggressive therapy that could lead to potentially avoidable complications and 2) high-acuity ICUs may focus attention toward the many sicker patients and away from the fewer low-risk patients. DESIGN: Retrospective cohort study. SETTING: Three hundred twenty-two ICUs in 199 hospitals in the Philips eICU database between 2010 and 2015. PATIENTS: Adult ICU patients at low risk of dying, defined as an Acute Physiology and Chronic Health Evaluation-IVa-predicted mortality of 3% or less. EXPOSURE: ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. MEASUREMENTS AND MAIN RESULTS: We used generalized estimating equations to test whether ICU acuity is independently associated with a primary outcome of ICU length of stay and secondary outcomes of hospital length of stay, hospital mortality, and discharge destination. The study included 381,997 low-risk patients. Mean ICU and hospital length of stay were 1.8 ± 2.1 and 5.2 ± 5.0 days, respectively. Mean Acute Physiology and Chronic Health Evaluation IVa-predicted hospital mortality was 1.6% ± 0.8%; actual hospital mortality was 0.7%. In adjusted analyses, admission to low-acuity ICUs was associated with worse outcomes compared with higher-acuity ICUs. Specifically, compared with the highest-acuity quartile, ICU length of stay in low-acuity ICUs was increased by 0.24 days; in medium-acuity ICUs by 0.16 days; and in high-acuity ICUs by 0.09 days (all p < 0.001). Similar patterns existed for hospital length of stay. Patients in lower-acuity ICUs had significantly higher hospital mortality (odds ratio, 1.28 [95% CI, 1.10-1.49] for low-; 1.24 [95% CI, 1.07-1.42] for medium-, and 1.14 [95% CI, 0.99-1.31] for high-acuity ICUs) and lower likelihood of discharge home (odds ratio, 0.86 [95% CI, 0.82-0.90] for low-, 0.88 [95% CI, 0.85-0.92] for medium-, and 0.95 [95% CI, 0.92-0.99] for high-acuity ICUs). CONCLUSIONS: Admission to high-acuity ICUs is associated with better outcomes among low mortality-risk patients. Future research should aim to understand factors that confer benefit to patients with different risk profiles.

Identifying Distinct Subgroups of ICU Patients: A Machine Learning Approach.

OBJECTIVES: Identifying subgroups of ICU patients with similar clinical needs and trajectories may provide a framework for more efficient ICU care through the design of care platforms tailored around patients' shared needs. However, objective methods for identifying these ICU patient subgroups are lacking. We used a machine learning approach to empirically identify ICU patient subgroups through clustering analysis and evaluate whether these groups might represent appropriate targets for care redesign efforts. DESIGN: We performed clustering analysis using data from patients' hospital stays to retrospectively identify patient subgroups from a large, heterogeneous ICU population. SETTING: Kaiser Permanente Northern California, a healthcare delivery system serving 3.9 million members. PATIENTS: ICU patients 18 years old or older with an ICU admission between January 1, 2012, and December 31, 2012, at one of 21 Kaiser Permanente Northern California hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used clustering analysis to identify putative clusters among 5,000 patients randomly selected from 24,884 ICU patients. To assess cluster validity, we evaluated the distribution and frequency of patient characteristics and the need for invasive therapies. We then applied a classifier built from the sample cohort to the remaining 19,884 patients to compare the derivation and validation clusters. Clustering analysis successfully identified six clinically recognizable subgroups that differed significantly in all baseline characteristics and clinical trajectories, despite sharing common diagnoses. In the validation cohort, the proportion of patients assigned to each cluster was similar and demonstrated significant differences across clusters for all variables. CONCLUSIONS: A machine learning approach revealed important differences between empirically derived subgroups of ICU patients that are not typically revealed by admitting diagnosis or severity of illness alone. Similar data-driven approaches may provide a framework for future organizational innovations in ICU care tailored around patients' shared needs.

The Association of Pregnancy With Outcomes Among Critically Ill Reproductive-Aged Women: A Propensity Score-Matched Retrospective Cohort Analysis.

BACKGROUND: The maternal mortality rate in the United States is unacceptably high. However, the relative contribution of pregnancy to these outcomes is unknown. Studies comparing outcomes among pregnant vs nonpregnant critically ill patients show mixed results and are limited by small sample sizes. RESEARCH QUESTION: What is the association of pregnancy with critical illness outcomes? STUDY DESIGN AND METHODS: We performed a retrospective cohort study of women 18 to 55 years of age who received invasive mechanical ventilation (MV) on hospital day 0 or 1 or who demonstrated sepsis on admission (infection with organ failure) discharged from Premier Healthcare Database hospitals from 2008 through 2021. The exposure was pregnancy. The primary outcome was in-hospital mortality. We created propensity scores for pregnancy (using patient and hospital characteristics) and performed 1:1 propensity score matching without replacement within age strata (to ensure exact age matching). We performed multilevel multivariable mixed-effects logistic regression for propensity-matched pairs with pair as a random effect. RESULTS: Three thousand ninety-three pairs were included in the matched MV cohort, and 13,002 pairs were included in the sepsis cohort. The characteristics of both cohorts were well balanced (all standard mean differences, < 0.1). Among matched pairs, unadjusted mortality was 8.0% vs 13.8% for MV and 1.4% vs 2.3% for sepsis among pregnant and nonpregnant patients, respectively. In adjusted regression, pregnancy was associated with lower odds of in-hospital mortality (MV: OR, 0.50; 95% CI, 0.41-0.60; P < .001; sepsis: OR, 0.52; 95% CI, 0.40-0.67; P < .001). INTERPRETATION: In this large US cohort, critically ill pregnant women receiving MV or with sepsis showed better survival than propensity score-matched nonpregnant women. These findings must be interpreted in the context of likely residual confounding.

Interhospital Transfer of Patients With Acute Respiratory Failure in the United States: A Scoping Review.

OBJECTIVES: Interhospital transfer of patients with acute respiratory failure (ARF) is relevant in the current landscape of critical care delivery. However, current transfer practices for patients with ARF are highly variable, poorly formalized, and lack evidence. We aim to synthesize the existing evidence, identify knowledge gaps, and highlight persisting questions related to interhospital transfer of patients with ARF. DATA SOURCES: Ovid Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Embase, CINAHL Plus, and American Psychological Association. STUDY SELECTION: We included studies that evaluated or described hospital transfers of adult (age > 18) patients with ARF between January 2020 and 2024 conducted in the United States. Using predetermined search terms and strategies, a total of 3369 articles were found across all databases. After deduplication, 1748 abstracts were screened by authors with 45 articles that advanced to full-text review. This yielded 16 studies that fit our inclusion criteria. DATA EXTRACTION: The studies were reviewed in accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews by three authors. DATA SYNTHESIS: Included studies were mostly retrospective analyses of heterogeneous patients with various etiologies and severity of ARF. Overall, transferred patients were younger, had high severity of illness, and were more likely to have commercial insurance compared with nontransferred cohorts. There is a paucity of data examining why patients get transferred. Studies that retrospectively evaluated outcomes between transferred and nontransferred cohorts found no differences in mortality, although transferred patients have a longer length of stay. There is limited evidence to suggest that patients transferred early in their course have improved outcomes. CONCLUSIONS: Our scoping review highlights the sparse evidence and the urgent need for further research into understanding the complexity behind ARF transfers. Future studies should focus on defining best practices to inform clinical decision-making and improve downstream outcomes.

Association of Patient-Centered Elements of Care and Palliative Care Among Patients With Advanced Lung Cancer.

CONTEXT: Palliative care (PC) is associated with improved quality of life, survival, and decreased healthcare use at the end of life among lung cancer patients. However, the specific elements of palliative care that may contribute to these benefits are unclear. OBJECTIVES: To evaluate the associations of PC and its setting of delivery with prescriptions of symptom management medications, advance care planning (ACP), hospice enrollment, and home health care (HHC) receipt. METHODS: Retrospective, cohort study of patients with advanced stage (IIIB/IV) lung cancer in the Veterans Health Administration (VA) diagnosed from 2007-2013; with follow-up through 2017. Propensity score methods were used with inverse probability of treatment weighting and logistic regression modeling, adjusting for patient and tumor characteristics. RESULTS: Among 23 142 patients, 57% received PC. Compared to non-receipt of PC, PC in any setting (inpatient or outpatient) was associated with increased prescriptions of pain medications (Adjusted Odds Ratio (aOR) = 1.63, 95% CI: 1.45-1.83), constipation regimen with pain medications (aOR = 2.04, 95% CI: 1.63-2.54), and antidepressants (aOR = 1.78, 95% CI: 1.52-2.09). PC was also associated with increased ACP (aOR = 1.52, 95% CI: 1.37-1.67) and hospice enrollment (aOR = 1.39, 95% CI:1.31-1.47), and decreased HHC (aOR = 0.79, 95% CI: 0.70-.90) compared to non-receipt of PC. Receipt of PC in outpatient settings was associated with increased prescriptions of pain medications (aOR = 2.54, 95% CI: 2.13-3.04) and antidepressants (aOR = 1.76, 95% CI: 1.46-2.12), and hospice enrollment (aOR = 2.09, 95% CI: 1.90-2.31) compared to receipt of PC in inpatient settings. CONCLUSIONS: PC is associated with increased use of symptom management medications, ACP, and hospice enrollment, especially when delivered in outpatient settings. These elements of care elucidate potential mechanisms for improved outcomes associated with PC and provide a framework for a primary palliative care approach among non-palliative care clinicians.

"You're Socially Distant and Trying Not to Be Emotionally Distant." Physicians' Perspectives of Communication and Therapeutic Relationships in the ICU During the COVID-19 Pandemic: A Qualitative Study.

To: 1) characterize how COVID-19-related policies influence patient-clinician communication and relationships in the ICU, with attention to race and ethnicity as factors and 2) identify interventions that may facilitate patient-clinician communication. DESIGN: We conducted a qualitative study between September 2020 and February 2021 that explored facilitators and barriers to patient-clinician communication and the formation of therapeutic relationships. We used thematic analysis to develop findings describing patient-communication and therapeutic relationships within the ICU early in the COVID-19 pandemic. SETTING: We purposively selected hospital dyads from regions in the United States that experienced early and/or large surges of patients hospitalized with COVID-19. SUBJECTS: We recruited a national sample of ICU physicians from Veteran Affairs (VA) Health Care Systems and their associated academic affiliate hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty-four intensivists from seven VA hospitals and six academic-affiliate hospitals participated. Intensivists noted the disproportionate impact of the pandemic on among people holding minoritized racial and ethnic identities, describing how language barriers and restrictive visitation policies exacerbated institutional mistrust and compromised physicians' ability to develop therapeutic relationships. We also identified several perceived influences on patient-clinician communication and the establishment of therapeutic relationships. Barriers included physicians' fear of becoming infected with COVID-19 and use of personal protective equipment, which created obstacles to effective physical and verbal interactions. Facilitators included the presence of on-site interpreters, use of web-based technology to interact with family members outside the ICU, and designation of a care team member or specialist service to provide routine updates to families. CONCLUSIONS: The COVID-19 pandemic has threatened patient-clinician communication and the development of therapeutic relationships in the ICU, particularly among people holding minoritized racial and ethnic identities and their families. We identified several facilitators to improve patient-clinician communication as perceived by intensivists that may help improve trust and foster therapeutic alliances.

Influence of the COVID-19 Pandemic on Author Sex and Manuscript Acceptance Rates among Pulmonary and Critical Care Journals.

Rationale: The coronavirus disease (COVID-19) pandemic has negatively affected women more than men and may influence the publication of non-COVID-19 research. Objectives: To evaluate whether the COVID-19 pandemic is associated with changes in manuscript acceptance rates among pulmonary/critical care journals and sex-based disparities in these rates. Methods: We analyzed first, senior, and corresponding author sex (female vs. male, identified by matching first names in a validated Genderize database) of manuscripts submitted to four pulmonary/critical care journals between January 1, 2018 and December 31, 2020. We constructed interrupted time series regression models to evaluate whether the proportion of female first and senior authors of non-COVID-19 original research manuscripts changed with the pandemic. Next, we performed multivariable logistic regressions to evaluate the association of author sex with acceptance of original research manuscripts. Results: Among 8,332 original research submissions, women represented 39.9% and 28.3% of first and senior authors, respectively. We found no change in the proportion of female first or senior authors of non-COVID-19 or COVID-19 submitted research manuscripts during the COVID-19 era. Non-COVID-19 manuscripts submitted during the COVID-19 era had reduced odds of acceptance, regardless of author sex (first author adjusted OR [aOR], 0.46 [95% confidence interval (CI), 0.36-0.59]; senior author aOR, 0.46 [95% CI, 0.37-0.57]). Female senior authorship was associated with decreased acceptance of non-COVID-19 research manuscripts (crude rates, 14.4% [male] vs. 13.2% [female]; aOR, 0.84 [95% CI, 0.71-0.99]). Conclusions: Although female author submissions were not disproportionately influenced by COVID-19, we found evidence suggesting sex disparities in manuscript acceptance rates. Journals may need to consider strategies to reduce this disparity, and academic institutions may need to factor our findings, including lower acceptance rates for non-COVID-19 manuscripts, into promotion decisions.

Intersection of Palliative Care and Hospice Use Among Patients With Advanced Lung Cancer.

Background: Hospice and palliative care (PC) are important components of lung cancer care and independently provide benefits to patients and their families. Objective: To better understand the relationship between hospice and PC and factors that influence this relationship. Methods: A retrospective cohort study of patients diagnosed with advanced lung cancer (stage IIIB/IV) within the U.S. Veterans Health Administration (VA) from 2007 to 2013 with follow-up through 2017 (n = 22,907). Mixed logistic regression models with a random effect for site, adjustment for patient variables, and propensity score weighting were used to examine whether the association between PC and hospice use varied by U.S. region and PC team characteristics. Results: Overall, 57% of patients with lung cancer received PC, 69% received hospice, and 16% received neither. Of those who received hospice, 60% were already enrolled in PC. Patients who received PC had higher odds of hospice enrollment than patients who did not receive PC (adjusted odds ratio = 3.25, 95% confidence interval: 2.43-4.36). There were regional differences among patients who received PC; the predicted probability of hospice enrollment was 85% and 73% in the Southeast and Northeast, respectively. PC team and facility characteristics influenced hospice use in addition to PC; teams with the shortest duration of existence, with formal team training, and at lower hospital complexity were more likely to use hospice (all p < 0.05). Conclusions: Among patients with advanced lung cancer, PC was associated with hospice enrollment. However, this relationship varied by geographic region, and PC team and facility characteristics. Our findings suggest that regional PC resource availability may contribute to substitution effects between PC and hospice for end-of-life care.

Perspectives on advance care planning needs of persons with advanced dementia from their surrogates and clinicians.

Objectives: This study was designed to understand the experience and needs surrounding advance care planning (ACP) discussions for surrogate decision-makers of persons with advanced dementia (PWAD). Methods: Semi-structured qualitative interviews based on end-of-life communication models with a convenience sample of 17 clinicians, and 15 surrogates of PWAD. We used a hybrid approach of deductive and inductive thematic analysis. Results: Two main themes emerged. 1)Deficits in communication: Often surrogates did not fully comprehend the disease trajectory or medical treatments, like the likelihood of pneumonia and use of mechanical ventilation, nor concepts related to ACP, particularly legal documents and orders such as Do Not Hospitalize, which made decision-making challenging as perceived by clinicians. 2)Decision-making conflicts: Clinicians perceived a disconnect between surrogates' understanding of their loved one's preferences and knowing how or when to operationalize them. Conclusions: Significant gaps in knowledge surrounding disease trajectory and complications, such as pneumonia, and aspects of ACP, exist. These gaps create decision-making challenges for surrogates and clinicians alike. Innovation: This study assessed both clinicians and surrogate decision-makers' perspectives on communication and decision-making concerning care preferences, goals, and ACP. The study findings from a national cohort can inform decision-support interventions for clinicians and surrogate decision-makers of PWAD.

Clinician Perspectives on Barriers and Enablers to Implementing an Inpatient Oncology Early Warning System: A Mixed-Methods Study.

PURPOSE: To elicit end-user and stakeholder perceptions regarding design and implementation of an inpatient clinical deterioration early warning system (EWS) for oncology patients to better fit routine clinical practices and enhance clinical impact. METHODS: In an explanatory-sequential mixed-methods study, we evaluated a stakeholder-informed oncology early warning system (OncEWS) using surveys and semistructured interviews. Stakeholders were physicians, advanced practice providers (APPs), and nurses. For qualitative data, we used grounded theory and thematic content analysis via the constant comparative method to identify determinants of OncEWS implementation. RESULTS: Survey respondents generally agreed that an oncology-focused EWS could add value beyond clinical judgment, with nurses endorsing this notion significantly more strongly than other clinicians (nurse: median 5 on a 6-point scale [6 = strongly agree], interquartile range 4-5; doctors/advanced practice providers: 4 [4-5]; P = .005). However, some respondents would not trust an EWS to identify risk accurately (n = 36 [42%] somewhat or very concerned), while others were concerned that institutional culture would not embrace such an EWS (n = 17 [28%]).Interviews highlighted important aspects of the EWS and the local context that might facilitate implementation, including (1) a model tailored to the subtleties of oncology patients, (2) transparent model information, and (3) nursing-centric workflows. Interviewees raised the importance of sepsis as a common and high-risk deterioration syndrome. CONCLUSION: Stakeholders prioritized maximizing the degree to which the OncEWS is understandable, informative, actionable, and workflow-complementary, and perceived these factors to be key for translation into clinical benefit.

Assessment of Symptom, Disability, and Financial Trajectories in Patients Hospitalized for COVID-19 at 6 Months.

Importance: Individuals who survived COVID-19 often report persistent symptoms, disabilities, and financial consequences. However, national longitudinal estimates of symptom burden remain limited. Objective: To measure the incidence and changes over time in symptoms, disability, and financial status after COVID-19-related hospitalization. Design, Setting, and Participants: A national US multicenter prospective cohort study with 1-, 3-, and 6-month postdischarge visits was conducted at 44 sites participating in the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Network's Biology and Longitudinal Epidemiology: COVID-19 Observational (BLUE CORAL) study. Participants included hospitalized English- or Spanish-speaking adults without severe prehospitalization disabilities or cognitive impairment. Participants were enrolled between August 24, 2020, and July 20, 2021, with follow-up occurring through March 30, 2022. Exposure: Hospitalization for COVID-19 as identified with a positive SARS-CoV-2 molecular test. Main Outcomes and Measures: New or worsened cardiopulmonary symptoms, financial problems, functional impairments, perceived return to baseline health, and quality of life. Logistic regression was used to identify factors associated with new cardiopulmonary symptoms or financial problems at 6 months. Results: A total of 825 adults (444 [54.0%] were male, and 379 [46.0%] were female) met eligibility criteria and completed at least 1 follow-up survey. Median age was 56 (IQR, 43-66) years; 253 (30.7%) participants were Hispanic, 145 (17.6%) were non-Hispanic Black, and 360 (43.6%) were non-Hispanic White. Symptoms, disabilities, and financial problems remained highly prevalent among hospitalization survivors at month 6. Rates increased between months 1 and 6 for cardiopulmonary symptoms (from 67.3% to 75.4%; P = .001) and fatigue (from 40.7% to 50.8%; P < .001). Decreases were noted over the same interval for prevalent financial problems (from 66.1% to 56.4%; P < .001) and functional limitations (from 55.3% to 47.3%; P = .004). Participants not reporting problems at month 1 often reported new symptoms (60.0%), financial problems (23.7%), disabilities (23.8%), or fatigue (41.4%) at month 6. Conclusions and Relevance: The findings of this cohort study of people discharged after COVID-19 hospitalization suggest that recovery in symptoms, functional status, and fatigue was limited at 6 months, and some participants reported new problems 6 months after hospital discharge.

Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State.

Importance: The COVID-19 pandemic prompted health care institutions worldwide to develop plans for allocation of scarce resources in crisis capacity settings. These plans frequently rely on rapid deployment of institutional triage teams that would be responsible for prioritizing patients to receive scarce resources; however, little is known about how these teams function or how to support team members participating in this unique task. Objective: To identify themes illuminating triage team members' perspectives and experiences pertaining to the triage process. Design, Setting, and Participants: This qualitative study was conducted using inductive thematic analysis of observations of Washington state triage team simulations and semistructured interviews with participants during the COVID-19 pandemic from December 2020 to February 2021. Participants included clinician and ethicist triage team members. Data were analyzed from December 2020 through November 2021. Main Outcomes and Measures: Emergent themes describing the triage process and experience of triage team members. Results: Among 41 triage team members (mean [SD] age, 50.3 [11.4] years; 21 [51.2%] women) who participated in 12 simulations and 21 follow-up interviews, there were 5 Asian individuals (12.2%) and 35 White individuals (85.4%); most participants worked in urban hospital settings (32 individuals [78.0%]). Three interrelated themes emerged from qualitative analysis: (1) understanding the broader approach to resource allocation: participants strove to understand operational and ethical foundations of the triage process, which was necessary to appreciate their team's specific role; (2) contending with uncertainty: team members could find it difficult or feel irresponsible making consequential decisions based on limited clinical and contextual patient information, and they grappled with ethically ambiguous features of individual cases and of the triage process as a whole; and (3) transforming mindset: participants struggled to disentangle narrow determinations about patients' likelihood of survival to discharge from implicit biases and other ethically relevant factors, such as quality of life. They cited the team's open deliberative process, as well as practice and personal experience with triage as important in helping to reshape their usual cognitive approach to align with this unique task. Conclusions and Relevance: This study found that there were challenges in adapting clinical intuition and training to a distinctive role in the process of scarce resource allocation. These findings suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training, such as triage simulations, may help prepare clinicians for this difficult role.

Show me the roads and give me a road map: Development of a patient conversation tool to improve lung cancer treatment decision-making.

Objective: Evidence-based decision support resources do not exist for persons with lung cancer. We sought to develop and refine a treatment decision support, or conversation tool, to improve shared decision-making (SDM). Methods: We conducted a multi-site study among patients with stage I-IV non-small cell lung cancer (NSCLC) who completed or had ongoing lung cancer treatment using semi-structured, cognitive qualitative interviews to assess participant understanding of content. We used an integrated approach of deductive and inductive thematic analysis. Results: Twenty-seven patients with NSCLC participated. Participants with prior cancer experiences or those with family members with prior cancer experiences reported better preparedness for cancer treatment decision-making. All participants agreed the conversation tool would be helpful to clarify their thinking about values, comparisons, and goals of treatment, and to help patients communicate more effectively with their clinicians. Conclusion: Participants reported that the tool may empower them with confidence and agency to actively participate in cancer treatment SDM. The conversation tool was acceptable, comprehensible, and usable. Next steps will test effectiveness on patient-centered and decisional outcomes. Innovation: A personalized conversation tool using consequence tables and core SDM components is novel in that it can encourage a tailored, conversational dynamic and includes patient-centered values along with traditional decisional outcomes.

The Influence of the COVID-19 Pandemic on Intensivists' Well-Being: A Qualitative Study.

BACKGROUND: The COVID-19 pandemic has strained health care systems and has resulted in widespread critical care staffing shortages, negatively impacting the quality of care delivered. RESEARCH QUESTION: How have hospitals' emergency responses to the pandemic influenced the well-being of frontline intensivists, and do any potential strategies exist to improve their well-being and to help preserve the critical care workforce? STUDY DESIGN AND METHODS: We conducted semistructured interviews of intensivists at clusters of tertiary and community hospitals located in six regions across the United States between August and November 2020 using the "four S" framework of acute surge planning (ie, space, staff, stuff, and system) to organize the interview guide. We then used inductive thematic analysis to identify themes describing the influence of hospitals' emergency responses on intensivists' well-being. RESULTS: Thirty-three intensivists from seven tertiary and six community hospitals participated. Intensivists reported experiencing substantial moral distress, particularly because of restricted visitor policies and their perceived negative impacts on patients, families, and staff. Intensivists also frequently reported burnout symptoms as a result of their experiences with patient death, exhaustion over the pandemic's duration, and perceived lack of support from colleagues and hospitals. We identified several potentially modifiable factors perceived to improve morale, including the proactive provision of mental health resources, establishment of formal backup schedules for physicians, and clear actions demonstrating that clinicians are valued by their institutions. INTERPRETATION: Restrictive visitation policies contributed to moral distress as reported by intensivists, highlighting the need to reconsider the risks and benefits of these policies. We also identified several interventions as perceived by intensivists that may help to mitigate moral distress and to improve burnout as part of efforts to preserve the critical care workforce.