Goals, Values, and Priorities of Hospitalized Patients: Using a Structured Communication Tool to Engage Medical Students in Serious Illness Communication.

Background: To build third-year medical students' serious illness communication skills, we implemented a structured communication tool-the VALUES tool-focused on patients' goals, values, and priorities and described students' experiences using this tool. Methods: Medical students participated in a social worker-led VALUES didactic and discussion with a patient on the palliative care consult service and, subsequently, completed an anonymous survey about their comfort with the VALUES tool and its usefulness for learning (5-point Likert scales). Results: Of the 142 medical students who participated in the VALUES didactic, 37 completed the survey (26%). The VALUES tool was rated highly in terms of usefulness (mean 4.5; standard deviation [SD] 0.7) and rated lower in terms of overall comfort (mean 3.7; SD 0.7). Conclusion: Our project explored the integration of a VALUES tool into medical student education, and we show that the tool is well rated by learners in terms of comfort and usefulness.

Perceptions of Palliative Care Program Viability During the Pandemic: Qualitative Results From a National Survey.

Background: Palliative care programs have played a significant role during the COVID-19 pandemic. However, the financial impact of the pandemic and operational challenges for palliative care programs have raised concerns for their future viability. Objectives: To explore palliative care program leaders' perceptions of the future viability of their programs in the context of the pandemic and inform future educational and program development. Methods: Surveys were sent to 1430 specialist palliative care program leaders, identified through the Center to Advance Palliative Care's contact lists, via email in May 2020 and January 2021. Leaders were asked why they were or were not concerned about the viability of their palliative care programs. Qualitative content analysis was applied to determine themes. Results: We received 440 responses. Most programs served hospital settings and were geographically located across all US regions. We identified four themes: 1) The importance of being valued by organizational leadership and peers, 2) The importance of adequate and supported palliative care staff, 3) The pandemic validated and accelerated the need for palliative care, and 4) The pandemic perpetuated organizational financial concerns. Conclusion: Findings provide insights about palliative care program viability from the perspective of program leaders during a global pandemic. Technical assistance to support palliative care teams and their relationships with stakeholders, methods to measure the impact of peer support, efforts to educate administrators about the value of palliative care, and efforts to reduce burnout are needed to sustain palliative care programs into the future.

An Update: National Institutes of Health Research Funding for Palliative Medicine 2016-2020.

Background: The evidence base to support palliative care clinical practice is inadequate and opportunities to improve the evidence base remain despite the field's rapid growth. Objective: The aim of this study was to examine current National Institutes of Health (NIH) funding of palliative medicine research and trends over time. Design: We sought to identify NIH funding of palliative medicine (2016-2020) in two stages: (1) we searched the NIH grant database, RePORTER, for grants with the keywords, "palliative care," "end-of-life care," "hospice," and "end of life," and (2) identified palliative care researchers likely to have secured NIH funding using three strategies. Methods: We abstracted (1) the first and last authors' names from original investigations published in major palliative medicine journals from 2016 to 2018; (2) names from a PubMed-generated list of original articles published in major medicine, nursing, and subspecialty journals using the above keywords; and (3) palliative medicine journal editorial board members and members of key palliative medicine initiatives. We cross-matched the pooled names against NIH grants funded from 2016 to 2021. Results: A crosswalk analysis of the author search and NIH RePORTER search identified 1658 grants. Of those, 541 were categorized as relevant to palliative medicine, which represented 419 unique principal investigators (mean of 1.34 grants per investigator). Compared with 2011-2015, the number of NIH-funded grants increased by 25%, NIH dollars increased by 35%, and the distribution of grant types remained stable. Conclusions: Despite the challenging NIH funding climate, the number of NIH grants and funding to palliative care have increased. Given the increased funding allocation toward Alzheimer's dementia and related dementia research at the congressional level, this increase in funding reflects this funding allocation and does not represent overall growth. Dedicated federal funding for palliative care research remains critical to grow the evidence base for persons living with serious illnesses and their families.

Virtual Geritalk: Does Intensive Virtual Communication Skills Training Improve Use of Serious Illness Communication Skills?

Background: The COVID-19 pandemic presented a unique opportunity to adapt in-person communication skills training to a virtual format. Objective: Examine use of serious illness communication skills by learners after participating in an intensive virtual communication skills training. Design: Prospective cohort study. Setting/Subjects: Icahn School of Medicine at Mount Sinai, Clinical Fellows. Measurements: Family Meeting Communication Assessment Tool (FAMCAT) assessed fundamental and advanced communication skills. Results: As compared to a historical benchmark obtained after a prior in-person course, the virtual course showed equivalent or better use of communication skills across fundamental skills and advanced skills. Conclusions: Our findings suggest that a virtual communication skills training is associated with the use of serious illness communication skills in the clinical setting by learners.

Characterizing delayed care among US older adults by self-rated health during the COVID-19 pandemic.

OBJECTIVES: Previous studies showed that older adults with fair or poor self-rated health (SRH) were more likely to experience delayed care during the COVID-19 pandemic. We aim to understand delayed care patterns by SRH during the COVID-19 pandemic among US older adults. METHODS: Using a nationally representative sample of older adults (≥ 70 years old) from the National Health and Aging Trends Study (NHATS), we assessed the patterns of delayed care by good, fair, or poor SRH. RESULTS: Nearly one in five of the survey-weighted population of 9,465,117 older adults who experienced delayed care during the pandemic reported fair or poor SRH. The overall distributions of the numbers of types of delayed care (p = 0.16) and the numbers of reasons for delayed care (p = 0.12) did not differ significantly by SRH status. Older adults with good, fair, or poor SRH shared the four most common types of delayed care and three most common reasons for delayed care but differed in ranking. Older adults with poor SRH mostly delayed seeing a specialist (good vs. fair vs. poor SRH: 40.1%, 46.7%, 73%, p = 0.01). CONCLUSIONS: The results suggest that utilizing SRH as a simple indicator may help researchers and clinicians understand similarities and differences in care needs for older adults during the pandemic. Targeted interventions that address differences in healthcare needs among older adults by SRH during the evolving pandemic may mitigate the negative impacts of delayed care.

Use of hospitals in the New York City Metropolitan Region, by race: how separate? How equal in resources and quality?

BACKGROUND: Although racial and ethnic minorities disproportionately use some hospitals, hospital-based racial and ethnic composition relative to geographic region and its association with quality indicators has not been systematically analyzed. METHODS: We used four race and ethnicity categories: non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and Asian/Pacific Islander/Alaskan Native/American Indian (API/AIAN), as well as a combined non-NHW category, from the 2010 (latest year publicly available) Medicare Institutional Provider & Beneficiary Summary public use file for 84 hospitals in the New York City region. We assessed the relative distribution of race and ethnicity across hospitals grouped at different geographic levels (region, county, hospital referral region [HRR], or hospital service areas [HSA]) using the dissimilarity index. Hospital characteristics included quality star ratings, essential professional services and diagnostic/treatment equipment, bed size, total expenses, and patients with dual Medicare and Medicaid enrollment. We assessed Spearman's rank correlation between hospital-based racial and ethnic composition and quality/structural measures. RESULTS: Dissimilarity Index decreases from region (range 30.3-40.1%) to county (range 13.7-23.5%), HRR (range 10.5-27.5%), and HSA (range 12.0-16.9%) levels. Hospitals with larger non-NHW patients tended to have lower hospital ratings and higher proportions of dually-enrolled patients. They were also more likely to be safety net hospitals and non-federal governmental hospitals. CONCLUSIONS: In the NYC metropolitan region, there is considerable hospital-based racial and ethnic segregation of Medicare patients among non-NHW populations, extending previous research limited to NHB. Availability of data on racial and ethnic composition of hospitals should be made publicly available for researchers and consumers.

Characteristics Associated With Disparities Among Older Adults in Coronavirus Disease 2019 Outcomes in an Academic Health Care System.

BACKGROUND: An improved understanding of the coronavirus disease 2019 (COVID-19) pandemic is needed to identify predictors of outcomes among older adults with COVID-19. OBJECTIVE: The objective of this study was to examine patient and health system factors predictive of in-hospital mortality, intensive care unit (ICU) admission, and readmission among patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS: A cohort study of patients aged 18 years and older with COVID-19 discharged from 5 New York hospitals within the Mount Sinai Health System (March 1, 2020-June 30, 2020). MEASURES: Patient-level characteristics (age, sex, race/ethnicity, comorbidities/serious illness, transfer from skilled nursing facility, severe acute respiratory syndrome coronavirus 2 viral load, Sequential Organ Failure Assessment score, treatments); hospital characteristics. OUTCOMES: All-cause in-hospital mortality; ICU admission; 30-day readmission. RESULTS: Among 7556 subjects, mean age 61.1 (62.0) years; 1556 (20.6%) died, 949 (12.6%) had an ICU admission, and 227 (9.1%) had a 30-day readmission. Increased age [aged 55-64: odds ratio (OR), 3.28; 95% confidence interval (CI), 2.41-4.46; aged 65-74: OR, 4.67; 95% CI, 3.43-6.35; aged 75-84: OR, 10.73; 95% CI, 7.77-14.81; aged 85 y and older: OR, 20.57; 95% CI, 14.46-29.25] and comorbidities (OR, 1.11; 95% CI, 1.16, 2.13) were independent risk factors for in-hospital mortality. Yet older adults (aged 55-64 y: OR, 0.56; 95% CI, 0.40-0.77; aged 65-74: OR, 0.46; 95% CI, 0.33-0.65; aged 75-84: OR, 0.27; 95% CI, 0.18-0.40; aged above 85 y: OR, 0.21; 95% CI, 0.13-0.34) and those with Medicaid (OR, 0.74; 95% CI, 0.56-0.99) were less likely to be admitted to the ICU. Race/ethnicity, crowding, population density, and health system census were not associated with study outcomes. CONCLUSIONS: Increased age was the single greatest independent risk factor for mortality. Comorbidities and serious illness were independently associated with mortality. Understanding these risk factors can guide medical decision-making for older adults with COVID-19. Older adults and those admitted from a skilled nursing facility were half as likely to be admitted to the ICU. This finding requires further investigation to understand how age and treatment preferences factored into resource allocation.

Telemedicine Utilization in the Ambulatory Palliative Care Setting: Are There Disparities?

CONTEXT: Given a shortage of specialty palliative care clinicians and geographic variation in availability, telemedicine has been proposed as one way to improve access to palliative care services for patients with cancer. However, the enduring digital divide raises questions about whether unequal access will exacerbate healthcare disparities. OBJECTIVES: To examine factors associated with utilization of telemedicine as compared to in-person visits by patients with cancer in the ambulatory palliative care setting. METHODS: We collected data on patients seen in Supportive Oncology clinic by palliative care clinicians with an in-person or telemedicine visit from March 1 to December 30, 2020. A logistic regression with generalized estimating equation was fit to assess the association between visit type and patient characteristics. RESULTS: A total of 491 patients and 1783 visits were identified, including 1061 (60%) in-person visits and 722 (40%) telemedicine visits. Female patients were significantly more likely to utilize telemedicine than male patients (OR 1.46; 95% CI 1.11-1.90). Spanish-speaking patients (OR 0.32, 95% CI 0.17-0.61), those without insurance (OR 0.28, 95% CI 0.15-0.52), and those without an activated patient portal (Inactivated: OR 0.46, 95% CI 0.26-0.82; Pending Activation: OR 0.29, 95% CI 0.18-0.48) were less likely to utilize telemedicine. CONCLUSION: Our study reveals disparities in telemedicine utilization in the ambulatory palliative care setting for patients with cancer who are male, Spanish-speaking, uninsured, or do not have an activated patient portal. In the wake of the COVID-19 pandemic, we can better meet the palliative care needs of patients with cancer through telemedicine only if equity is kept at the forefront of our discussions.

Access to Palliative Care Consultation for Hospitalized Adults with COVID-19 in an Urban Health System: Were There Disparities at the Peak of the Pandemic?

Background: Palliative care (PC) services expanded rapidly to meet the needs of coronavirus disease 2019 (COVID-19) patients, yet little is known about which patients were referred for PC consultation during the pandemic. Objective: Examine factors predictive of PC consultation for COVID-19 patients. Design: Retrospective cohort study of COVID-19 patients discharged from four hospitals (March 1-June 30, 2020). Exposures: Patient demographic, socioeconomic, and clinical factors and hospital-level characteristics. Outcome Measurement: Inpatient PC consultation. Results: Of 4319 hospitalized COVID-19 patients, 581 (14%) received PC consultation. Increasing age, serious illness (cancer, chronic obstructive pulmonary disease, and dementia), greater illness severity, and admission to the quaternary hospital were associated with receipt of PC consultation. There was no association between PC consultation and race/ethnicity, household crowding, insurance status, or hospital-factors, including inpatient, emergency department, and intensive care unit census. Conclusions: Although site variation existed, the highest acuity patients were most likely to receive PC consultation without racial/ethnic or socioeconomic disparities.

Virtual Geritalk: Improving Serious Illness Communication of Clinicians Who Care for Older Adults.

CONTEXT: High quality communication is essential to older adults' medical decision-making, quality of life, and adjustment to serious illness. Studies have demonstrated that Geritalk, a two day (16 hours total) in-person communication skills training improves self-assessed preparedness, skill acquisition, and sustained practice of communication skills. Due to the COVID-19 pandemic, Geritalk was adapted to a virtual format (four days, 10 hours total). OBJECTIVES: Our study evaluated the change in participants' self-assessed preparedness for serious illness communication before and after the virtual course and satisfaction with the course, and compared these findings to responses from a prior in-person Geritalk course. METHODS: Geriatrics and Palliative Medicine fellows at three urban academic medical centers completed surveys, which employed five-point Likert scales, before and after the virtual course to assess satisfaction with the course and preparedness for serious illness communication. RESULTS: Of the 20 virtual Geritalk participants, 17 (85%) completed the pre-course assessment, and 14 (70%) completed the post-course assessment. Overall, satisfaction with the course was high (mean 4.9 on a 5-point scale). Compared to in-person Geritalk participants, virtual course participants reported comparable and significant (P < 0.01) improvements in mean self-reported preparedness across all surveyed communication skills. CONCLUSION: We show that a virtual communication skills training is feasible and effective. Our findings suggest that the innovative virtual Geritalk course has the potential to increase access to communication skills training, improve serious illness communication skills, and in improve the quality of care received by older adults with serious illness.

Improving the Care of Patients With Serious Illness: What Are the Palliative Care Education Needs of Internal Medicine Residents?

BACKGROUND: Hospitalized patients with serious illness have significant symptom burden and face complex medical decisions that often require goals of care discussions. Given the shortage of specialty palliative care providers, there is a pressing need to improve the palliative care skills of internal medicine (IM) residents, who have a central role in the care of seriously ill patients hospitalized at academic medical centers. METHODS: We conducted an anonymous survey of IM residents at a large, urban, academic medical center to identify which aspects of palliative care trainees find most important and their knowledge gaps in palliative care. The survey measured trainees' self-assessed degree of importance and knowledge of core palliative care skills and evaluated frequency of completing advance care planning documentation. RESULTS: Overall, 51 (23%) IM residents completed the survey. The majority of trainees considered multiple palliative care skills to be "very important/important": symptom management, prognostication, introducing the palliative care approach, discussing code status, and breaking serious news. Across these same skills, trainees reported variable levels of knowledge. In our sample, trainees reported completing healthcare proxy forms and Medical Orders for Life-Sustaining Treatment infrequently. CONCLUSIONS: IM trainees rated core palliative care skills as important to their practice. Yet, they reported knowledge gaps across multiple core palliative care skills that should be addressed given their role as frontline providers for patients with serious illness.

A Descriptive Analysis of an Ambulatory Kidney Palliative Care Program.

Background: Many patients with serious kidney disease have an elevated symptom burden, high mortality, and poor quality of life. Palliative care has the potential to address these problems, yet nephrology patients frequently lack access to this specialty. Objectives: We describe patient demographics and clinical activities of the first 13 months of an ambulatory kidney palliative care (KPC) program that is integrated within a nephrology practice. Design/Measurements: Utilizing chart abstractions, we characterize the clinic population served, clinical service utilization, visit activities, and symptom burden as assessed using the Integrated Palliative Care Outcome Scale-Renal (IPOS-R), and patient satisfaction. Results: Among the 55 patients served, mean patient age was 72.0 years (standard deviation [SD] = 16.7), 95% had chronic kidney disease stage IV or V, and 46% had a Charlson Comorbidity Index >8. The mean IPOS-R score at initial visit was 16 (range = 0-60; SD = 9.1), with a mean of 7.5 (SD = 3.7) individual physical symptoms (range = 0-15) per patient. Eighty-seven percent of initial visits included an advance care planning conversation, 55.4% included a medication change for symptoms, and 35.5% included a dialysis decision-making conversation. Overall, 96% of patients who returned satisfaction surveys were satisfied with the care they received and viewed the KPC program positively. Conclusions: A model of care that integrates palliative care with nephrology care in the ambulatory setting serves high-risk patients with serious kidney disease. This KPC program can potentially meet documented gaps in care while achieving patient satisfaction. Early findings from this program evaluation indicate opportunities for enhanced patient-centered palliative nephrology care.