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Development and Validation of a Questionnaire to Detect Behavior Change in Multiple Advance Care Planning Behaviors (SA522-A)
Vol. 47 No. 2 February 2014
Schedule With Abstracts
2. Explore care challenges for patients with mechanical circulatory support in the outpatient setting (home, nursing home, hospice). 3. Discuss end-of-life management of mechanical circulatory support across the care continuum. Mechanical circulatory support (MCS) is being utilized with increasing prevalence for patients with advanced heart failure. The use of MCS (eg, ventricular assist devices and total artificial hearts) presents opportunities for hospice and palliative medicine (PM) providers to optimize care. The goal of this session is to demonstrate how PM providers can support patients receiving MCS across the care spectrumdfrom preimplantation to patients living with MCS and those endoflife. In the preimplantation period (often in the inpatient setting), PM consultation is recommended. Determination of patients’ goals and preferences is important before they make the decision for MCS. Additionally, PM providers can help with preparedness planningdan advance care plan specific to MCS recipients. Although many PM providers are familiar with this concept, details regarding how to approach this or how to utilize models are not well known. We will discuss approaches to MCS candidates and recipients in the inpatient setting, with emphasis on how to complete a preparedness plan and how to document this in the chart. Patients with MCS also face unique challenges as outpatients. After their initial discharge, most patients will live months to years with their device as outpatients, although frequent inpatient stays are not uncommon. We will discuss the role of PM in supporting these patients as outpatients, at home, and during transitions. Lastly, nursing homes and hospices are often uncomfortable with managing patients with MCS, or lack providers certified to provide care for these patients. This can lead to significant disparities in care for these patients, particularly when approaching the end of life. Inpatient and home hospices are often asked to care for patients with MCS, but may not have protocols in place to provide optimal care. We will discuss end-of-life management with emphasis on hospice and nursing home-based protocols for deactivation and comfort care.
459
Paper Sessions Development and Validation of a Questionnaire to Detect Behavior Change in Multiple Advance Care Planning Behaviors (SA522-A) Rebecca Sudore, MD, University of California, San Francisco and VA Medical Center, San Francisco, CA. Sara Knight, PhD, Department of Veterans Affairs, Woodside, CA. Anita Stewart, PhD, University of California, San Francisco, San Francisco, CA. Ryan McMahan, BS BA, University of California, San Francisco, San Francisco, CA. Deborah Barnes University of California, San Francisco, San Francisco, CA. Mari Feuz University of California, San Francisco, San Francisco, CA. (All authors listed above had no relevant financial relationships to disclose with the following exception: Barnes is a study design consultant and receives research support from UCB Pharma.) Objectives 1. Describe the development of a survey to detect behavior change in multiple advance care planning behaviors. 2. Describe the validity and reliability of a new Advance Care Planning Engagement Survey. Background. Advance directive completion has traditionally been considered the gold standard for successful advance care planning (ACP). However, recent evidence suggests that ACP involves multiple discrete behaviors for which people are in varying stages of behavior change. Research Objectives. To develop and validate a survey to measure behavior change for a full range of ACP behaviors. Methods. The ACP Engagement Survey assesses ‘‘Process Measures’’ of factors known from Behavior Change Theory to affect behavior (knowledge, contemplation, self-efficacy, and readiness, using 5-point Likert scales) and ‘‘Action Measures’’ (yes/no) of multiple ACP behaviors related to surrogates, values and quality of life, flexibility for surrogate decision making, and informed decision making. We administered surveys at baseline and after 1 week to 50 diverse, older adults from San Francisco hospitals. Internal consistency reliability of Process Measures was assessed using Cronbach’s alpha (only
460
Schedule With Abstracts
continuous variables) and test-retest reliability of Process and Action Measures was examined using intraclass correlations. For discriminant validity, we compared Process and Action Measure scores between this cohort and 20 healthy college students (mean age 23.2 years [SD, 2.7]) using t-tests. Results. Mean age was 69.3 years (SD, 10.5) and 42% were non-White. The survey took a mean of 21.4 minutes ( 6.2) to administer. The survey had good internal consistency (Process Measures Cronbach alpha, 0.94) and testretest reliability (Process Measures intraclass correlation, 0.70; Action Measures, 0.87). Both Process and Action Measures had good discriminant validity with higher scores in the older than younger group, P<.001. Conclusions. A new ACP Engagement Survey that measures both behavior change factors and multiple ACP actions demonstrates good reliability and validity.
Implications for research, policy, or practice. Successful ACP is more than advance directive completion. Studies should also assess behavior change for a full range of ACP behaviors. Further research is needed to assess whether ACP Engagement Survey scores improve in response to ACP interventions.
Professionals’ Self-Assessment of Quality Care at the End of Life: Implications for Clinicians and Educators (SA522-B) Marilyn Bookbinder, RN, Beth Israel Medical Center, New York, NY. Myra Glajchen, DSW, Beth Israel Medical Center, New York, NY. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Share pilot data from 60 tracer end-of-life care reviews evaluating the quality of a patients’ death in the last 2 days of life in an inpatient setting. 2. Identify areas of concordance and discordance among physicians, physician trainees, nurses, and family caregivers related to patients’ deaths. Background. The care provided to dying patients and their families in the hospital is often inconsistent with best practices in palliative care. Quality improvement (QI) in end-of-life (EoL) care requires the development of a feasible and valid measurement strategy for key indicators of care in multiple domains.
Vol. 47 No. 2 February 2014
Optimally, this measurement strategy should apply the ‘‘tracer’’ method, the approach familiar in institutions to capture source data (through interviews of key personnel and chart review) for judging quality in real time. Research Objectives. The purpose of this study was to develop a brief measure of the quality of care given in the last days of life to dying inpatients. Methods. The initial tools for professional caregivers, physicians, and chart audit tool were based on the Palliative Care Consensus Guidelines and piloted following 45 patient deaths. After several item reiterations and cognitive debriefing with staff, a field-test using the revised tools was done after 100 patient deaths. A total of 455 interviews with professional caregivers (including nurses, social workers, chaplains, and physicians)and 145 patient records were analyzed. Results. The 51-item professional caregiver tool was subjected to statistical analyses, including factor analysis, yielding a 3-factor solution (symptom management, communication and decision making, and care of the imminently dying. Alpha coefficient of .89. The result is a 10-item tracer for end-of-life care. Conclusions. We have completed encouraging developmental work indicating the feasibility and initial validity of a tracer-based measurement strategy focused on care related to symptom control, communication and decision making, and care for the imminently dying.
Implications for research, policy, or practice. This tool has the potential to confirm that effective measurement leads to quality improvement and establish the utility of a simple tracer-based measurement approach for inpatient care at the end of life.
Communicating with Dying Patients and Their Families: Multimedia Training in End-of-Life Care (SA522-C) Phylliss Chappell, MD, University of Texas Health Science Center at San Antonio, San Antonio, TX. Shuko Lee, MS, South Texas Veterans Health Care System, San Antonio, TX. Jeanette Ross, MD, South Texas Veterans Health Care System and University of Texas Health Science Center at San Antonio, San Antonio, TX. Jennifer Healy, DO, University of Texas Health Science Center, San Antonio, TX. Sandra Sanchez-Reilly, MD FAAHPM, University of Texas Health
Schedule With Abstracts
2. Explore care challenges for patients with mechanical circulatory support in the outpatient setting (home, nursing home, hospice). 3. Discuss end-of-life management of mechanical circulatory support across the care continuum. Mechanical circulatory support (MCS) is being utilized with increasing prevalence for patients with advanced heart failure. The use of MCS (eg, ventricular assist devices and total artificial hearts) presents opportunities for hospice and palliative medicine (PM) providers to optimize care. The goal of this session is to demonstrate how PM providers can support patients receiving MCS across the care spectrumdfrom preimplantation to patients living with MCS and those endoflife. In the preimplantation period (often in the inpatient setting), PM consultation is recommended. Determination of patients’ goals and preferences is important before they make the decision for MCS. Additionally, PM providers can help with preparedness planningdan advance care plan specific to MCS recipients. Although many PM providers are familiar with this concept, details regarding how to approach this or how to utilize models are not well known. We will discuss approaches to MCS candidates and recipients in the inpatient setting, with emphasis on how to complete a preparedness plan and how to document this in the chart. Patients with MCS also face unique challenges as outpatients. After their initial discharge, most patients will live months to years with their device as outpatients, although frequent inpatient stays are not uncommon. We will discuss the role of PM in supporting these patients as outpatients, at home, and during transitions. Lastly, nursing homes and hospices are often uncomfortable with managing patients with MCS, or lack providers certified to provide care for these patients. This can lead to significant disparities in care for these patients, particularly when approaching the end of life. Inpatient and home hospices are often asked to care for patients with MCS, but may not have protocols in place to provide optimal care. We will discuss end-of-life management with emphasis on hospice and nursing home-based protocols for deactivation and comfort care.
459
Paper Sessions Development and Validation of a Questionnaire to Detect Behavior Change in Multiple Advance Care Planning Behaviors (SA522-A) Rebecca Sudore, MD, University of California, San Francisco and VA Medical Center, San Francisco, CA. Sara Knight, PhD, Department of Veterans Affairs, Woodside, CA. Anita Stewart, PhD, University of California, San Francisco, San Francisco, CA. Ryan McMahan, BS BA, University of California, San Francisco, San Francisco, CA. Deborah Barnes University of California, San Francisco, San Francisco, CA. Mari Feuz University of California, San Francisco, San Francisco, CA. (All authors listed above had no relevant financial relationships to disclose with the following exception: Barnes is a study design consultant and receives research support from UCB Pharma.) Objectives 1. Describe the development of a survey to detect behavior change in multiple advance care planning behaviors. 2. Describe the validity and reliability of a new Advance Care Planning Engagement Survey. Background. Advance directive completion has traditionally been considered the gold standard for successful advance care planning (ACP). However, recent evidence suggests that ACP involves multiple discrete behaviors for which people are in varying stages of behavior change. Research Objectives. To develop and validate a survey to measure behavior change for a full range of ACP behaviors. Methods. The ACP Engagement Survey assesses ‘‘Process Measures’’ of factors known from Behavior Change Theory to affect behavior (knowledge, contemplation, self-efficacy, and readiness, using 5-point Likert scales) and ‘‘Action Measures’’ (yes/no) of multiple ACP behaviors related to surrogates, values and quality of life, flexibility for surrogate decision making, and informed decision making. We administered surveys at baseline and after 1 week to 50 diverse, older adults from San Francisco hospitals. Internal consistency reliability of Process Measures was assessed using Cronbach’s alpha (only
460
Schedule With Abstracts
continuous variables) and test-retest reliability of Process and Action Measures was examined using intraclass correlations. For discriminant validity, we compared Process and Action Measure scores between this cohort and 20 healthy college students (mean age 23.2 years [SD, 2.7]) using t-tests. Results. Mean age was 69.3 years (SD, 10.5) and 42% were non-White. The survey took a mean of 21.4 minutes ( 6.2) to administer. The survey had good internal consistency (Process Measures Cronbach alpha, 0.94) and testretest reliability (Process Measures intraclass correlation, 0.70; Action Measures, 0.87). Both Process and Action Measures had good discriminant validity with higher scores in the older than younger group, P<.001. Conclusions. A new ACP Engagement Survey that measures both behavior change factors and multiple ACP actions demonstrates good reliability and validity.
Implications for research, policy, or practice. Successful ACP is more than advance directive completion. Studies should also assess behavior change for a full range of ACP behaviors. Further research is needed to assess whether ACP Engagement Survey scores improve in response to ACP interventions.
Professionals’ Self-Assessment of Quality Care at the End of Life: Implications for Clinicians and Educators (SA522-B) Marilyn Bookbinder, RN, Beth Israel Medical Center, New York, NY. Myra Glajchen, DSW, Beth Israel Medical Center, New York, NY. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Share pilot data from 60 tracer end-of-life care reviews evaluating the quality of a patients’ death in the last 2 days of life in an inpatient setting. 2. Identify areas of concordance and discordance among physicians, physician trainees, nurses, and family caregivers related to patients’ deaths. Background. The care provided to dying patients and their families in the hospital is often inconsistent with best practices in palliative care. Quality improvement (QI) in end-of-life (EoL) care requires the development of a feasible and valid measurement strategy for key indicators of care in multiple domains.
Vol. 47 No. 2 February 2014
Optimally, this measurement strategy should apply the ‘‘tracer’’ method, the approach familiar in institutions to capture source data (through interviews of key personnel and chart review) for judging quality in real time. Research Objectives. The purpose of this study was to develop a brief measure of the quality of care given in the last days of life to dying inpatients. Methods. The initial tools for professional caregivers, physicians, and chart audit tool were based on the Palliative Care Consensus Guidelines and piloted following 45 patient deaths. After several item reiterations and cognitive debriefing with staff, a field-test using the revised tools was done after 100 patient deaths. A total of 455 interviews with professional caregivers (including nurses, social workers, chaplains, and physicians)and 145 patient records were analyzed. Results. The 51-item professional caregiver tool was subjected to statistical analyses, including factor analysis, yielding a 3-factor solution (symptom management, communication and decision making, and care of the imminently dying. Alpha coefficient of .89. The result is a 10-item tracer for end-of-life care. Conclusions. We have completed encouraging developmental work indicating the feasibility and initial validity of a tracer-based measurement strategy focused on care related to symptom control, communication and decision making, and care for the imminently dying.
Implications for research, policy, or practice. This tool has the potential to confirm that effective measurement leads to quality improvement and establish the utility of a simple tracer-based measurement approach for inpatient care at the end of life.
Communicating with Dying Patients and Their Families: Multimedia Training in End-of-Life Care (SA522-C) Phylliss Chappell, MD, University of Texas Health Science Center at San Antonio, San Antonio, TX. Shuko Lee, MS, South Texas Veterans Health Care System, San Antonio, TX. Jeanette Ross, MD, South Texas Veterans Health Care System and University of Texas Health Science Center at San Antonio, San Antonio, TX. Jennifer Healy, DO, University of Texas Health Science Center, San Antonio, TX. Sandra Sanchez-Reilly, MD FAAHPM, University of Texas Health