Dataset Information

Preferences on advance care planning and end-of-life care in patients hospitalized for heart failure.

ABSTRACT:

Aims

Early engagement in advance care planning (ACP) is recommended in heart failure (HF) management. We investigated the preferences of patients with HF regarding ACP and end-of-life (EOL) care, including their desired timing of ACP initiation.

Methods and results

Data were collected using a 92-item questionnaire survey, which was directly distributed to hospitalized patients by dedicated physicians and nurses in a university hospital setting. One-hundred eighty-seven patients agreed to participate (response rate: 92.6%), and 171 completed the survey [valid response rate: 84.7%; men: 67.3%; median age: 73.0 (63.0-81.0) years]. Logistic regression analyses were conducted to identify the predictors of positive attitudes towards ACP. Most recognized ACP as important for their care (n = 127, 74.3%), 48.1% stated that ACP should be initiated after repeated HF hospitalizations in the past year, and 29.0% preferred ACP to begin during the first or second HF hospitalization. Only 21.7% of patients had previously engaged in ACP conversations during HF management. Positive attitudes towards ACP were associated with lower depressive symptoms [two-item Patient Health Questionnaire; odds ratio (OR): 0.75, 95% confidence interval (CI): 0.61-0.92, P-value: 0.006], marriage (OR: 2.53, 95% CI: 1.25-5.12, P-value: 0.010), and a high educational level (OR: 2.66, 95% CI: 1.28-5.56, P-value: 0.009), but not with severity of HF (represented by Seattle Heart Failure Model risk score). Regarding EOL care, while 'Saying what one wants to tell loved ones' (83.4%), 'Dying a natural death' (81.8%), and 'Being able to stay at one's favorite place' (75.6%) were the three most important factors for patients, preferences for 'Receiving sufficient treatment' (56.5%) and 'Knowing what to expect about future condition' (50.3%) were divergent.

Conclusions

Despite patients' preferences for ACP conversations, there was a discrepancy between preference and engagement in ACP among patients hospitalized for HF. Patients' preferences regarding EOL care may differ; physicians need to consider the appropriate ACP approach to align with patients' care goals.

SUBMITTER: Kitakata H

PROVIDER: S-EPMC8712895 | biostudies-literature | 2021 Dec

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Preferences on advance care planning and end-of-life care in patients hospitalized for heart failure.

Kitakata Hiroki H Kohno Takashi T Kohsaka Shun S Fujisawa Daisuke D Nakano Naomi N Shiraishi Yasuyuki Y Katsumata Yoshinori Y Nagatomo Yuji Y Yuasa Shinsuke S Fukuda Keiichi K

ESC heart failure 20210904 6

<h4>Aims</h4>Early engagement in advance care planning (ACP) is recommended in heart failure (HF) management. We investigated the preferences of patients with HF regarding ACP and end-of-life (EOL) care, including their desired timing of ACP initiation.<h4>Methods and results</h4>Data were collected using a 92-item questionnaire survey, which was directly distributed to hospitalized patients by dedicated physicians and nurses in a university hospital setting. One-hundred eighty-seven patients ag ...[more]

PMID: 34480526

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Project description:ImportancePrimary care is a key setting for advance care planning (ACP).ObjectiveTo test the effects of a multicomponent primary care-based ACP intervention (SHARING Choices) on documented end-of-life preferences and potentially burdensome care at end of life.Design, setting, and participantsThis pragmatic cluster randomized clinical trial in primary care practices from 2 health systems was conducted between March 2021 and April 2022. Adults 65 years and older with a scheduled in-person or telehealth visit with clinicians from participating practices were eligible for inclusion.InterventionsThe treatment protocol encompassed an introductory letter from the clinic, access to a designated facilitator trained in ACP, a person-family agenda-setting checklist, shared access to the patient portal, a mailed advance directive, and print education. The control protocol encompassed usual care.Main outcomes and measuresPrimary outcomes included (1) new electronic health record-documented end-of-life preferences (advance directive or medical orders for life-sustaining treatment) at 12 months among those without documentation at baseline and (2) receipt of potentially burdensome care within 6 months of death among a subsample of Maryland residents with serious illness who died within 18 months of study entry from health information exchange data.ResultsThere were 19 practices in the intervention arm and 32 practices in the control arm. The study included 22 949 patients in the intervention group (13 575 women [59.2%]; mean [SD] age, 73.9 [7.2] years; 1674 [7.3%] with diagnosed dementia) and 41 966 in the control group (25 057 women [59.7%]; mean [SD] age, 74.0 [7.1] years; 3223 [7.9%] with diagnosed dementia). A total of 17 907 patients (27.6%) were Black, 1373 (2.1%) were Hispanic, 40 345 (62.2%) were White, and 5290 (8.2%) were another race (including American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander, and missing race). Grant-funded facilitators initiated 17 931 outreach attempts by phone (13 963 [77.9%]) and through the patient portal (3968 [22.1%]) to patients from intervention practices, and 1181 engaged in facilitator-led ACP conversations. New end-of-life preferences were documented for 2190 of 18 314 patients in the intervention arm (12.0%) and 2130 of 32 321 in the control arm (6.6%). This treatment effect was significant for the overall cohort (adjusted odds ratio, 2.15; 95% CI, 2.02-2.30) and present but attenuated for Black patients, those 75 years and older, and those diagnosed dementia. Among 1498 Maryland resident decedents, potentially burdensome care was higher in the intervention group (150 of 521 [28.8%] vs 204 of 977 [20.9%]; adjusted odds ratio, 1.40; 95% CI, 1.08-1.81).Conclusions and relevanceIn this pragmatic cluster randomized clinical trial, the SHARING Choices intervention increased new documentation of end-of-life preferences but also increased potentially burdensome care at end of life. Mixed findings underscore the importance of comprehensive support for those with serious illness and prioritizing patient-relevant outcomes in ACP interventional research.Trial registrationClinicalTrials.gov Identifier: NCT04819191.

Project description:BackgroundHeart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice.ObjectiveAssess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life.DesignThis retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020.ParticipantsA total of 48,466 deceased patients diagnosed with heart failure on Medicare.Main measuresBilled advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services.Key resultsIn the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter.ConclusionsBilled advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.

Project description:BackgroundResources for healthcare professionals, patients and those important to them relating to planning and coordinating treatment and care at the end of life are abundant, and can be difficult to navigate. However, they have not been systematically collated or catalogued in terms of their purpose, scope or intended audience.AimTo collate, categorise and characterise advance care planning and end-of-life treatment and care (EoLT + C) resources directed towards healthcare professionals, patients and their families.MethodsRapid review and thematic synthesis of resources available in the United Kingdom. Google searches and reviews of websites belonging to selected organisations that develop and publish materials relating to EoLT + C, and advance care planning were used. Materials were included if they were intended for those over 18 living in the UK and pertained to five domains of EoLT + C: identifying those approaching end of life; accessing EoLT + C services; conducting important conversations about EoLT + C and preferences; advance care planning, including recording of preferences and plans; and ensuring that plans and preferences are accessed and used by health and social care services.Results246 resources directed at healthcare professionals, patients and their families were identified, collated, catalogued and made internationally available for clinicians, researchers, patients and the public. 61 were classified as interactive, providing decision support in EoLT + C that went beyond simply providing information. Of these, there was notable content overlap among tools for identifying patients in their last year of life. There was variation in the development of tools across all domains of end-of-life care by geography and patient group. Few interactive resources integrated seamlessly with a digital interface or healthcare provider workflows. Incentives for the adoption of best-practice appeared rare.ConclusionsWe present a repeatable and scalable approach to the cataloguing and characterisation of palliative care resources. The identified resources will be of benefit not only to those in the UK but to those in other countries, developing or evaluating their own resources for aiding professionals and patients to plan and deliver excellent treatment and care at the end of life.

Project description:Importance:Although advance care planning is known to increase patient and caregiver satisfaction, its association with health care utilization is not well understood. Objective:To examine the association between billed advance care planning encounters and subsequent health care utilization among seriously ill patients. Design, Setting, and Participants:This retrospective cohort study conducted from October 1, 2015, to May 31, 2018, used a national commercial insurance claims database to retrieve data from 18 484 Medicare Advantage members 65 years or older who had a claim that contained a serious illness diagnosis. Exposure:A claim that contained an advance care planning billing code between October 1, 2016, and November 30, 2017. Main Outcomes and Measures:Receipt of intensive therapies, hospitalization, emergency department use, hospice use, costs, and death during the 6-month follow-up period. Results:The final study sample included 18 484 seriously ill patients (mean [SD] age, 79.7 [7.9] years; 10 033 [54.3%] female), 864 (4.7%) of whom had a billed advanced care planning encounter between October 1, 2016, and November 30, 2017. In analyses adjusted for patient characteristics and a propensity score for advance care planning, the presence of a billed advance care planning encounter was associated with a higher likelihood of hospice enrollment (incidence rate ratio [IRR], 2.52; 95% CI, 2.22-2.86) and mortality (hazard ratio, 2.27; 95% CI, 1.79-2.88) compared with no billed advance care planning encounter. Although patients with billed advance care planning encounters were also more likely to be hospitalized (IRR, 1.37; 95% CI, 1.26-1.49), including in the intensive care unit (IRR, 1.25; 95% CI, 1.08-1.45), they were less likely to receive any intensive therapies (IRR, 0.85; 95% CI, 0.78-0.92), such as chemotherapy (IRR, 0.65; 95% CI, 0.55-0.78). Similar results were observed in a propensity score-matched analysis (99% matched) and in a decedent analysis of patients who died during the 6-month follow-up period. Conclusions and Relevance:Patients with billed advance care planning encounters were more likely than those without these encounters to receive hospice services and less likely to receive any intensive therapies, such as chemotherapy. However, they were also hospitalized more frequently than patients without billed advance care planning encounters. Although these findings were robust to multiple analytic methods, the results may be attributable to residual confounding because of a higher unmeasured severity of illness in the advance care planning group. Additional evidence appears to be needed to understand the effect of advance care planning on these outcomes.

Dataset Information

Preferences on advance care planning and end-of-life care in patients hospitalized for heart failure.

Aims

Methods and results

Conclusions

Publications

Preferences on advance care planning and end-of-life care in patients hospitalized for heart failure.

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