- Email: [email protected]
Six-Month Natural History of Hospitalized Medicare Beneficiaries With Heart Failure Referred for Hospice Care (S709)
Vol. 45 No. 2 February 2013
Poster Abstracts
2. Identify opportunities to influence, initiate, maintain, and advance the practice and sustainability of palliative care within the changing healthcare environment. Background. In general, medical education in the US inadequately addresses end-of-life (EOL) care and palliative care. After a shift of focus post-Katrina, Tulane is placing a renewed emphasis on these important but difficult topics. Research Objectives. (1) Assess the current state of Tulane medical student interest in EOL education, (2) teach medical students basic EOL care competencies with an emphasis on confidence-building for addressing these topics, and (3) measure the impact of this pilot elective. Method. We designed an elective course open to 25 first-year medical students for approximately 9 total hours and implemented it in both the 2010-2011 and the 2011-2012 academic years. The elective utilized the expertise of Tulane’s palliative care specialist and other multidisciplinary specialists to combine creative, active-learning modules with published tools and techniques to explore the basics of hospice and palliative medicine. A survey was conducted to compare knowledge and confidence gained by participants compared to other first-year students. Result. Elective students showed a significant difference in their perceived knowledge of palliative care, hospice, and healthcare advanced directives (average score of 10.2 out of 15 for elective students vs. 8.8 for non-elective students; p < .01); this difference has been evident for 2 consecutive years. Additionally, participants indicated that their preparation to speak with a patient or their family about these topics increased more than non-participants (4.23 vs. 3.26; range from 1 ‘‘I’m now less prepared’’ to 5 ‘‘I am now much more prepared’’; p < .01). Conclusion. Well-timed, creative, and interactive teaching sessions can draw upon the energy and excitement of entering the first year of medical school to stimulate educational opportunities in EOL care.
Implications for Research, Policy, or Practice. This student-initiated and low-cost elective opens the door to the complex ethical, social, and psychological situations that doctors will face with an aging population. The
421
elective also increases students’ confidence to address these situations.
Six-Month Natural History of Hospitalized Medicare Beneficiaries With Heart Failure Referred for Hospice Care (S709) Donna Bearden, MD MPH, University of Alabama at Birmingham, Birmingham, AL. Kanan Patel, MBBS MPH, University of Alabama at Birmingham, Birmingham, AL. Rodney Tucker, MD MMM FAAHPM, University of Alabama Center for Palliative and Supportive Care, Birmingham, AL. Colin Wozencraft, MD, University of Alabama at Birmingham, Birmingham, AL. Richard Allman, MD, University of Alabama and Birmingham VA Medical Center, Birmingham, AL. Ali Ahmed, MD MPH, University of Alabama and VA Medical Center, Birmingham, AL. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Briefly review the hospice Medicare benefit. 2. Recognize the difficulties in determining when heart failure patients are appropriate candidates for hospice referral. 3. Review the 6-month natural history of heart failure patients referred to hospice, after a hospitalization for heart failure. Background. Medicare hospice eligibility requires a life expectancy of # 6 months. Unlike cancer, life expectancy of heart failure (HF) patients is difficult to predict. However, little is known about 6-month natural history of older HF patients receiving hospice care. Research Objectives. This study was conducted to identify predictors of hospice referral among HF patients and compare 6-month outcomes of those who received referral versus those who did not. Method. Charts of 8049 hospitalized Medicare beneficiaries discharged with a primary diagnosis of HF from 106 Alabama hospitals during 1998e2001 were abstracted; 182 (2%) patients were discharged to hospice care. Patients were followed up at 6 months post discharge. Chi square testing was used to compare demographic and clinical characteristics, six-month mortality, all-cause hospital readmission and HF hospital readmission between patients receiving and not receiving hospice care. (P values < 0.05).
422
Poster Abstracts
Result. Hospitalized HF patients receiving discharge referral for hospice care were older, white, had a prior history of HF, higher comorbidities, and were more likely to receive diuretics and digoxin. During 6 month post-discharge follow-up, all-cause mortality occurred in 74% and 21% of patients receiving and not receiving hospice care (p # .001). All-cause hospitalization occurred in 18% and 53% of patients receiving and not receiving hospice care (p # .001). HF hospitalization occurred in 8% and 24% of patients receiving and not receiving hospice care (p # .001). Conclusion. Several patient and care characteristics were associated with hospice referral. The hospice referral process seems to have identified most patients who died within 6 months of referral. Further, hospice referral was associated with lower hospital readmission rates.
Implications for Research, Policy, or Practice. Extending hospice care to the 20% of patients not receiving referral who died within 6 months of hospital discharge may improve their quality of life and further reduce hospital readmission, a CMS target for Medicare cost reduction.
Unmet Quality Indicators of Care for Metastatic Cancer Patients Admitted to ICU in Last 2 Weeks of Life (S710) Jennifer Blechman, MD, Stanford University, Bend, OR. VJ Periyakoil, MD, Stanford University School of Medicine, Stanford, CA. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Understand the current quality of end-of-life care provided to patients with advanced cancer admitted to the ICU at our academic medical center. 2. Discuss mechanisms to improve end-of-life care for patients with advanced cancer. 3. Evaluate what barriers prevented palliative care consultation to significantly improve the quality of end-of-life care metastatic cancer patients receive. Background. Evidence indicates that terminally ill cancer patients are subjected to ineffective treatments and do not receive quality care at the end of life. Research Objectives. We wanted to gain a better understanding of the quality of end of life
Vol. 45 No. 2 February 2013
care (EOLC) received by terminally ill cancer patients admitted to the Intensive Care Unit (ICU) in the last 2 weeks of life. The established UK Quality Indicators were used to evaluate quality of care. Method. Design: A retrospective chart review of the electronic medical records (EMR) of patients admitted to the ICU from January-August 2011 was completed. Six UK quality indicators (prognostication, advanced care planning, goals of care, caregiver needs, coordinated care across organizational boundaries, and standardized care pathway implementation) were used to assess quality of EOLC. Setting: Tertiary academic medical center with 663 beds and 66 adult ICU beds in Northern California, USA. Patients: 2498 patients were admitted to the ICU, 232 died within two weeks of admission; 69 of these patients died of metastatic cancer. 58% patients were male; average age 59.8 years (range 25-91). Result. Quality indicators were met in a relatively small percentage of patients (prognostication 67%, advanced care planning 32%, goals of care 42%, caregiver needs 0%, coordination of care across organizational boundaries 7%, standardized care pathway implementation 58%) admitted to the ICU in the last 2 weeks of life. Palliative care consultations occurred in 28 of the 69 patients and resulted in increased POLST documentation. Conclusion. Quality indicators for EOLC were not met for majority of patients with advanced cancer admitted to the ICU. Earlier discussions with patients and families regarding their goals of care and preferred venue of death may help improve quality of care at EOL.
Implications for Research, Policy, or Practice. Create triggers for earlier palliative care consultation. Identify markers to measure the quality of care patients receive at EOL.
Attitudes and Barriers of Prognostication Across the Internal Medicine Learner Hierarchy in an Academic Medical Center (S711) Jane Broxterman, MD, University of Kansas, Kansas City, KS. Michael Brimacombe, PhD, University of Kansas Medical Center, Kansas City, KS. Lindy Landzaat, DO, University of Kansas Medical Center, Kansas City, KS. (All authors listed above had no relevant financial relationships to disclose.)
Poster Abstracts
2. Identify opportunities to influence, initiate, maintain, and advance the practice and sustainability of palliative care within the changing healthcare environment. Background. In general, medical education in the US inadequately addresses end-of-life (EOL) care and palliative care. After a shift of focus post-Katrina, Tulane is placing a renewed emphasis on these important but difficult topics. Research Objectives. (1) Assess the current state of Tulane medical student interest in EOL education, (2) teach medical students basic EOL care competencies with an emphasis on confidence-building for addressing these topics, and (3) measure the impact of this pilot elective. Method. We designed an elective course open to 25 first-year medical students for approximately 9 total hours and implemented it in both the 2010-2011 and the 2011-2012 academic years. The elective utilized the expertise of Tulane’s palliative care specialist and other multidisciplinary specialists to combine creative, active-learning modules with published tools and techniques to explore the basics of hospice and palliative medicine. A survey was conducted to compare knowledge and confidence gained by participants compared to other first-year students. Result. Elective students showed a significant difference in their perceived knowledge of palliative care, hospice, and healthcare advanced directives (average score of 10.2 out of 15 for elective students vs. 8.8 for non-elective students; p < .01); this difference has been evident for 2 consecutive years. Additionally, participants indicated that their preparation to speak with a patient or their family about these topics increased more than non-participants (4.23 vs. 3.26; range from 1 ‘‘I’m now less prepared’’ to 5 ‘‘I am now much more prepared’’; p < .01). Conclusion. Well-timed, creative, and interactive teaching sessions can draw upon the energy and excitement of entering the first year of medical school to stimulate educational opportunities in EOL care.
Implications for Research, Policy, or Practice. This student-initiated and low-cost elective opens the door to the complex ethical, social, and psychological situations that doctors will face with an aging population. The
421
elective also increases students’ confidence to address these situations.
Six-Month Natural History of Hospitalized Medicare Beneficiaries With Heart Failure Referred for Hospice Care (S709) Donna Bearden, MD MPH, University of Alabama at Birmingham, Birmingham, AL. Kanan Patel, MBBS MPH, University of Alabama at Birmingham, Birmingham, AL. Rodney Tucker, MD MMM FAAHPM, University of Alabama Center for Palliative and Supportive Care, Birmingham, AL. Colin Wozencraft, MD, University of Alabama at Birmingham, Birmingham, AL. Richard Allman, MD, University of Alabama and Birmingham VA Medical Center, Birmingham, AL. Ali Ahmed, MD MPH, University of Alabama and VA Medical Center, Birmingham, AL. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Briefly review the hospice Medicare benefit. 2. Recognize the difficulties in determining when heart failure patients are appropriate candidates for hospice referral. 3. Review the 6-month natural history of heart failure patients referred to hospice, after a hospitalization for heart failure. Background. Medicare hospice eligibility requires a life expectancy of # 6 months. Unlike cancer, life expectancy of heart failure (HF) patients is difficult to predict. However, little is known about 6-month natural history of older HF patients receiving hospice care. Research Objectives. This study was conducted to identify predictors of hospice referral among HF patients and compare 6-month outcomes of those who received referral versus those who did not. Method. Charts of 8049 hospitalized Medicare beneficiaries discharged with a primary diagnosis of HF from 106 Alabama hospitals during 1998e2001 were abstracted; 182 (2%) patients were discharged to hospice care. Patients were followed up at 6 months post discharge. Chi square testing was used to compare demographic and clinical characteristics, six-month mortality, all-cause hospital readmission and HF hospital readmission between patients receiving and not receiving hospice care. (P values < 0.05).
422
Poster Abstracts
Result. Hospitalized HF patients receiving discharge referral for hospice care were older, white, had a prior history of HF, higher comorbidities, and were more likely to receive diuretics and digoxin. During 6 month post-discharge follow-up, all-cause mortality occurred in 74% and 21% of patients receiving and not receiving hospice care (p # .001). All-cause hospitalization occurred in 18% and 53% of patients receiving and not receiving hospice care (p # .001). HF hospitalization occurred in 8% and 24% of patients receiving and not receiving hospice care (p # .001). Conclusion. Several patient and care characteristics were associated with hospice referral. The hospice referral process seems to have identified most patients who died within 6 months of referral. Further, hospice referral was associated with lower hospital readmission rates.
Implications for Research, Policy, or Practice. Extending hospice care to the 20% of patients not receiving referral who died within 6 months of hospital discharge may improve their quality of life and further reduce hospital readmission, a CMS target for Medicare cost reduction.
Unmet Quality Indicators of Care for Metastatic Cancer Patients Admitted to ICU in Last 2 Weeks of Life (S710) Jennifer Blechman, MD, Stanford University, Bend, OR. VJ Periyakoil, MD, Stanford University School of Medicine, Stanford, CA. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Understand the current quality of end-of-life care provided to patients with advanced cancer admitted to the ICU at our academic medical center. 2. Discuss mechanisms to improve end-of-life care for patients with advanced cancer. 3. Evaluate what barriers prevented palliative care consultation to significantly improve the quality of end-of-life care metastatic cancer patients receive. Background. Evidence indicates that terminally ill cancer patients are subjected to ineffective treatments and do not receive quality care at the end of life. Research Objectives. We wanted to gain a better understanding of the quality of end of life
Vol. 45 No. 2 February 2013
care (EOLC) received by terminally ill cancer patients admitted to the Intensive Care Unit (ICU) in the last 2 weeks of life. The established UK Quality Indicators were used to evaluate quality of care. Method. Design: A retrospective chart review of the electronic medical records (EMR) of patients admitted to the ICU from January-August 2011 was completed. Six UK quality indicators (prognostication, advanced care planning, goals of care, caregiver needs, coordinated care across organizational boundaries, and standardized care pathway implementation) were used to assess quality of EOLC. Setting: Tertiary academic medical center with 663 beds and 66 adult ICU beds in Northern California, USA. Patients: 2498 patients were admitted to the ICU, 232 died within two weeks of admission; 69 of these patients died of metastatic cancer. 58% patients were male; average age 59.8 years (range 25-91). Result. Quality indicators were met in a relatively small percentage of patients (prognostication 67%, advanced care planning 32%, goals of care 42%, caregiver needs 0%, coordination of care across organizational boundaries 7%, standardized care pathway implementation 58%) admitted to the ICU in the last 2 weeks of life. Palliative care consultations occurred in 28 of the 69 patients and resulted in increased POLST documentation. Conclusion. Quality indicators for EOLC were not met for majority of patients with advanced cancer admitted to the ICU. Earlier discussions with patients and families regarding their goals of care and preferred venue of death may help improve quality of care at EOL.
Implications for Research, Policy, or Practice. Create triggers for earlier palliative care consultation. Identify markers to measure the quality of care patients receive at EOL.
Attitudes and Barriers of Prognostication Across the Internal Medicine Learner Hierarchy in an Academic Medical Center (S711) Jane Broxterman, MD, University of Kansas, Kansas City, KS. Michael Brimacombe, PhD, University of Kansas Medical Center, Kansas City, KS. Lindy Landzaat, DO, University of Kansas Medical Center, Kansas City, KS. (All authors listed above had no relevant financial relationships to disclose.)