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In 2014 the California legislature passed Senate Bill 1004 (SB 1004) that was designed to expand access to specialty palliative care for individuals served by California's Medicaid (known as Medi-Cal) Managed Care Plans (MCPs). The California Department of Health Care Services (DHCS) operationalized the legislation by developing minimum requirements for palliative care programs that all MCPs must meet or exceed. 7 Quality and utilization data specific to California's Medicaid population are needed for stakeholders to identify care deficiencies and disparities, describe the end of life experience and utilization patterns of MCP members, compare these patterns to Medicare beneficiaries or other populations, and set appropriate targets to help monitor progress. We evaluated the feasibility of using Medicaid claims data and encounter data either by partnering with MCPs or by obtaining statewide data from DHCS to measure the quality of palliative care and end of life care. In a concurrent but separate effort, we analyzed administrative data supplied by three MCPs as part of a prospective pilot of standards for home-based palliative care in California, including care delivered to Medicaid beneficiaries under SB 1004. Beyond the practical challenges of allowing time for data access and approvals, both projects revealed several limitations to using administrative data to assess quality of palliative and end of life care for a Medicaid population. We describe these challenges that undermined our confidence in analysis results and propose solutions to measuring the quality of palliative and end of life care for Medicaid patients and suggested next steps., Competing Interests: Disclosures and Acknowledgments The authors would like to acknowledge Katherine Santos for her administrative work on this paper. Dr. Zingmond, Dr. Walling, Dr. Wenger (awards G-30966 and G-31311), Dr. Cassel, and Ms. Kerr (awards G-20493, and G-20495) were supported by the California Health Care Foundation. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. Funding: Dr. Garcia-Jimenez has nothing to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Background: End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age., Methods: We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL., Results: Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001)., Conclusions: We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education., (© 2024 The American Geriatrics Society.)

Objective: Pragmatic trials often implement an intervention across a population of patients but require information unavailable at the population level that must be reported by a subset of patients. In this pragmatic clinical trial, we compared characteristics of seriously ill patients with those who completed a survey evaluating advance care planning across 3 academic health systems., Methods: A deliberate process including health system and external stakeholders and patients was used to design materials for and the approach to seriously ill patients. We developed a survey and conducted a multistep process to identify seriously ill primary care patients. We evaluated the relationships of age, gender, race and ethnicity, and vulnerability using the social vulnerability index in this population, and explored the representativeness of survey respondents compared with the underlying seriously ill population in terms of age, race and ethnicity, and vulnerability measured., Results: About 5% (8707 patients) of the primary care population was classified as seriously ill, 5351 were mailed a survey and 1100 provided survey responses. Hispanic and Black patients were younger than White patients, and Black and Hispanic patients were more vulnerable than White and Asian patients and patients of other races. Representativeness was high across age and race and ethnicity, although White and Hispanic patients were more likely to respond than Black and Asian patients and patients of other races. Vulnerability in the surveyed sample was nearly identical to the population., Conclusions: A tailored survey and recruitment strategy yielded a representative sample of seriously ill, largely older, primary care respondents in the context of a pragmatic clinical trial., Competing Interests: Conflict of Interest: None.

Objectives: POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research., Design: Integrative review., Setting and Participants: Not applicable., Methods: We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization., Results: Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified., Conclusions and Implications: Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Physician Orders for Life Sustaining Treatment (POLST) document instructions for intensity of care based upon patient care preferences. POLST forms generally reflect patients' wishes and dictate subsequent medical care, but it is not known how POLST use and content among nursing home residents is associated with inpatient utilization across a large population., Objective: Evaluate the relationship between POLST use and content with hospital utilization among nursing home residents in California., Design: Retrospective cohort study using the Minimum Data Set linked to California Section S (POLST documentation), the Medicare Beneficiary Summary File, and Medicare line item claims., Patients: California nursing home residents with Medicare fee-for-service insurance, 2011-2016., Main Measures: Hospitalization, days in the hospital, and days in the intensive care unit (ICU) after adjustment for resident and nursing home characteristics., Key Results: The 1,112,834 residents had a completed and signed (valid) POLST containing orders for CPR with Full treatment 29.6% of resident-time (in person-years) and a DNR order with Selective treatment or Comfort care 27.1% of resident-time. Unsigned POLSTs accounted for 11.3% of resident-time. Residents experienced 14 hospitalizations and a mean of 120 hospital days and 37 ICU days per 100 person-years. Residents with a POLST indicating CPR Full treatment had utilization nearly identical to residents without a POLST. A gradient of decreased utilization was related to lower intensity of care orders. Compared to residents without a POLST, residents with a POLST indicating DNR Comfort care spent 56 fewer days in the hospital and 22 fewer days in the ICU per 100 person-years. Unsigned POLST had a weaker and less consistent relationship with hospital utilization., Conclusions: Among California NH residents, there is a direct relationship between intensity of care preferences in POLST and hospital utilization. These findings emphasize the importance of a valid POLST capturing informed preferences for nursing home residents., (© 2023. The Author(s).)

Background: Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity., Methods: California requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content-orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned., Results: POLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two-thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p < 0.001). Increases over time in POLST with CPR and full treatment were greater for Black and Hispanic residents compared to White residents. The increase in POLST with DNR and DNR with Selective treatment and Comfort orders was greater for White compared to Black patients (p < 0.001). Unsigned POLST with CPR and DNR orders decreased across all racial and ethnic groups., Conclusions: Racial and ethnic differences in POLST intensity of care orders increased between 2011 and 2016 suggesting that efforts to mitigate factors underlying differences were ineffective. Studies of newer POLST data are imperative., (© 2023 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: High-quality doctor-patient communication is essential for patients with serious illnesses. The reliability and validity of Consumer Assessment of Healthcare Providers and Systems (CAHPS ® ) communication items among these patients are unknown. Methods: Five CAHPS communication items, a 4-item Advance Care Planning (ACP) engagement scale, 5-item confidence in others' knowledge of ACP medical wishes scale, and a question about confidence in filling out ACP-related medical forms were administered to 1100 patients (20% response rate) with serious illness receiving primary care at three University of California Health Systems. Results: Average age was 69 (range 22-102); 52% male, 18% Hispanic, 9% Asian, and 7% Black; 24% had high school or less education. Eigenvalues and internal consistency reliability (0.88) supported a 5-item communication scale. Item characteristic curves showed a monotonic relationship of response options with the communication score. Item thresholds indicated that most patients reported positive patient experiences (i.e., items were negatively skewed). Item slopes ranging from 2.52 to 5.10 confirmed that all items were strongly related to the communication score. Information (reliability) of the communication scale was higher for assessing patients with negative experiences of care than for the positive end of the spectrum. Communication was positively correlated with confidence in other's knowledge of ACP medical wishes ( r  = 0.32, p  < 0.0001), ACP engagement ( r  = 0.14, p  < 0.0001), and confidence in filling out ACP-related medical forms ( r  = 0.09, p  = 0.0022). Conclusions: These findings support the use of CAHPS survey items to assess communication among patients with serious illnesses in primary care. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04012749.

Background/problem: Advance care planning (ACP) pragmatic trials are needed., Proposed Solution: We determined key system-level activities to implement ACP interventions for a cluster-randomized pragmatic trial. We identified patients with serious illness from 50 primary care clinics across three University of California health systems using a validated algorithm. If patients lacked documented ACP within the last 3 years, they were eligible for an intervention: (Arm 1) an advance directive (AD); (Arm 2) AD + PREPAREforYourCare.org; (Arm 3) AD + PREPARE + lay health navigator outreach. Triggered by an appointment, we mailed and sent interventions through automated electronic health record (EHR) messaging. We collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. We are currently finalizing 24 months follow-up data., Outcomes/methods: We used the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to track secular trends and implementation efforts., Key Message/results: Required multisite, system-level activities: 1) obtaining leadership, legal/privacy, and EHR approvals; 2) standardizing ACP documentation; 3) providing clinician education; 3) validating an automated serious illness identification algorithm; 4) standardizing ACP messaging with input from over 100 key advisors; 5) monitoring secular trends (e.g., COVID); and 6) standardizing ACP workflows (e.g., scanned ADs). Of 8707 patients with serious illness, 6883 were eligible for an intervention. Across all arms, 99% received the mailed intervention, 78.3% had an active patient portal (64.2% opened intervention), and 90.5% of arm three patients (n = 2243) received navigator outreach., Lessons Learned: Implementing a multisite health system-wide ACP program and pragmatic trial, with automated EHR-based cohort identification and intervention delivery, requires a high level of multidisciplinary key advisor engagement, standardization, and monitoring. These activities provide guidance for the implementation of other large-scale, population-based ACP efforts., (Copyright © 2023. Published by Elsevier Inc.)

Background: Patients experiencing systemic patterns of disadvantage, such as racial/ethnic minorities and those with limited English proficiency, are underrepresented in research. This is particularly true for large pragmatic trials of potentially sensitive research topics, such as advance care planning (ACP). It is unclear how phone outreach may affect research participation by underrepresented individuals., Objective: To assess the effect of phone outreach, in addition to standard mail survey recruitment, in a population-based ACP pragmatic trial at three academic health systems in California., Design: Retrospective cohort study PATIENTS: Primary care patients with serious illness were mailed a survey in their preferred language. Patients who did not initially respond by mail received up to three reminder phone calls with the option of survey completion by phone., Main Measures: Effect of phone outreach on survey response rate associated with respondent demographic characteristics (e.g., Social Vulnerability Index [SVI], range 0 (low) to 1 (high))., Results: Across the health systems, 5998 seriously ill patients were mailed surveys. We obtained completed surveys from 1215 patients (20% response rate); 787 (65%) responded after mail alone and 428 (35%) participated only after phone outreach. Patients recruited after phone outreach compared to mail alone were more socially vulnerable (SVI 0.41 v 0.35, P < 0.001), were more likely to report being a racial/ethnic minority (35% v 28%, P = 0.006), and non-English speaking (16% v 10%, P = 0.005). Age and gender did not differ significantly. The inclusion of phone outreach resulted in a sample that better represented the baseline population than mail alone in racial/ethnic minority (28% mail alone, 30% including phone outreach, 36% baseline population), non-English language preference (10%, 12%, 15%, respectively), and SVI (0.35, 0.37, 0.38, respectively)., Conclusions: Phone outreach for a population-based survey in a pragmatic trial concerning a potentially sensitive topic significantly enhanced recruitment of underrepresented seriously ill patients., (© 2023. The Author(s).)

Introduction: Interventions are needed to promote utilization of the Medicare Annual Wellness Visit (AWV), an underused opportunity to perform screenings and plan individualized preventive health services., Method: Using remote practice redesign and electronic health record (EHR) support, we implemented the Practice-Tailored AWV intervention in 2021 (during the COVID-19 pandemic) in 3 small community-based practices. The intervention combines EHR-based tools with practice redesign approaches and resources. Outcomes included completion of AWV and fulfillment of recommended preventive services., Results: At baseline the 3 practices had 1,513 Medicare patients with at least 1 visit in the past 12 months. AWV utilization went from 7% at baseline to 54% 8 months postintervention implementation; advance care planning increased 10.7% (from 7.9% to 18.6%); depression screening increased 16.3% (from 51.7% to 68.0%); and alcohol misuse screening increased 17.3% (from 42.6% to 59.9%). Every individual preventive health service was received more often by patients with an AWV than those without. At the patient level, fulfillment of all eligible preventive services (of a maximum of 12 evaluated) went from 47.5% to 53.8% ( P <  .001). Subgroup analyses showed that patients with AWVs completed a greater percentage of their total recommended preventive health services than those without an AWV., Conclusion: Virtual implementation of an intervention that combined EHR-based tools with practice redesign approaches increased AWV and preventive services utilization in Medicare patients. Given the success of this intervention during the COVID-19 pandemic (when practices had many competing demands), greater consideration should be given to delivering future interventions virtually., Competing Interests: Conflict of interest: Dr. Tarn has been funded by the BMS/Pfizer Alliance ARISTA-USA to conduct unrelated research studies., (© Copyright by the American Board of Family Medicine.)

Importance: Neuropsychiatric symptoms are common in acute SARS-CoV-2 infection and in post-COVID-19 condition (PCC; colloquially known as long COVID), but the association between early presenting neuropsychiatric symptoms and PCC is unknown., Objective: To describe the characteristics of patients with perceived cognitive deficits within the first 4 weeks of SARS-CoV-2 infection and the association of those deficits with PCC symptoms., Design, Setting, and Participants: This prospective cohort study was conducted from April 2020 to February 2021, with follow-up of 60 to 90 days. The cohort consisted of adults enrolled in the University of California, Los Angeles, SARS-CoV-2 Ambulatory Program who had a laboratory-confirmed symptomatic SARS-CoV-2 infection and were either hospitalized in a University of California, Los Angeles, hospital or one of 20 local health care facilities, or were outpatients referred by a primary care clinician. Data analysis was performed from March 2022 to February 2023., Exposure: Laboratory-confirmed SARS-CoV-2 infection., Main Outcomes and Measures: Patients responded to surveys that included questions about perceived cognitive deficits modified from the Perceived Deficits Questionnaire, Fifth Edition, (ie, trouble being organized, trouble concentrating, and forgetfulness) and symptoms of PCC at 30, 60, and 90 days after hospital discharge or initial laboratory-confirmed infection of SARS-CoV-2. Perceived cognitive deficits were scored on a scale from 0 to 4. Development of PCC was determined by patient self-report of persistent symptoms 60 or 90 days after initial SARS-CoV-2 infection or hospital discharge., Results: Of 1296 patients enrolled in the program, 766 (59.1%) (mean [SD] age, 60.0 [16.7] years; 399 men [52.1%]; 317 Hispanic/Latinx patients [41.4%]) completed the perceived cognitive deficit items at 30 days after hospital discharge or outpatient diagnosis. Of the 766 patients, 276 (36.1%) perceived a cognitive deficit, with 164 (21.4%) having a mean score of greater than 0 to 1.5 and 112 patients (14.6 %) having a mean score greater than 1.5. Prior cognitive difficulties (odds ratio [OR], 1.46; 95% CI, 1.16-1.83) and diagnosis of depressive disorder (OR, 1.51; 95% CI, 1.23-1.86) were associated with report of a perceived cognitive deficit. Patients reporting perceived cognitive deficits in the first 4 weeks of SARS-CoV-2 infection were more likely to report symptoms of PCC than those without perceived cognitive deficits (118 of 276 patients [42.8%] vs 105 of 490 patients [21.4%]; χ21, 38.9; P < .001). Adjusting for demographic and clinical factors, perceived cognitive deficits in the first 4 weeks of SARS-CoV-2 were associated with PCC symptoms (patients with a cognitive deficit score of >0 to 1.5: OR, 2.42; 95% CI, 1.62-3.60; patients with cognitive deficit score >1.5: OR, 2.97; 95% CI, 1.86-4.75) compared to patients who reported no perceived cognitive deficits., Conclusions and Relevance: These findings suggest that patient-reported perceived cognitive deficits in the first 4 weeks of SARS-CoV-2 infection are associated with PCC symptoms and that there may be an affective component to PCC in some patients. The underlying reasons for PCC merit additional exploration.

Background: The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL., Aim: To assess whether the 3WP is associated with improved ratings of EOL care., Program Description: In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families., Setting: 2-hospital academic healthcare system., Participants: Dying patients in the ICU and their families., Program Evaluation: A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care)., Results: Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups., Discussion: The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience., (© 2022. The Author(s).)

Background: Understanding the long-term sequelae of severe COVID-19 remains limited, particularly in the United States., Objective: To examine long-term outcomes of patients who required intensive care unit (ICU) admission for severe COVID-19., Design, Patients, and Main Measures: This is a prospective cohort study of patients who had severe COVID-19 requiring an ICU admission in a two-hospital academic health system in Southern California. Patients discharged alive between 3/21/2020 and 12/31/2020 were surveyed approximately 6 months after discharge to assess health-related quality of life using Patient-Reported Outcomes Measurement Information System (PROMIS®)-29 v2.1, post-traumatic stress disorder (PTSD) and loneliness scales. A preference-based health utility score (PROPr) was estimated using 7 PROMIS domain scores. Patients were also asked their attitude about receiving aggressive ICU care., Key Results: Of 275 patients admitted to the ICU for severe COVID-19, 205 (74.5%) were discharged alive and 132 (64%, median age 59, 46% female) completed surveys a median of 182 days post-discharge. Anxiety, depression, fatigue, sleep disturbance, ability to participate in social activities, pain interference, and cognitive function were not significantly different from the U.S. general population, but physical function (44.2, SD 11.0) was worse. PROPr mean score of 0.46 (SD 0.30, range -0.02 to 0.96 [<0 is worse than dead and 1 represents perfect health]) was slightly lower than the U.S. general population, with an even distribution across the continuum. Poor PROPr was associated with chronic medical conditions and receipt of life-sustaining treatments, but not demographics or social vulnerability. PTSD was suspected in 20% and loneliness in 29% of patients. Ninety-eight percent of patients were glad they received life-saving treatment., Conclusion: Most patients who survive severe COVID-19 achieve positive outcomes, with health scores similar to the general population at 6 months post-discharge. However, there is marked heterogeneity in outcomes with a substantial minority reporting severely compromised health.

Background: Physician Orders for Life-Sustaining Treatment (POLST) facilitates documentation and transition of patients' life-sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016., Methods: California requires NHs to document in the Minimum Data Set whether residents complete a POLST and orders within POLST. Using a serial cross-sectional design for each year, we describe POLST completion and orders for all California NH residents from 2011 to 2016 (N = 1,112,668). We used logistic mixed-effects regression models to estimate POLST completion and resuscitation orders to understand the relationship with resident and facility characteristics, including Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare overall five-star quality rating., Results: POLST completion significantly increased from 2011 to 2016 with most residents having a POLST in 2016 (short-stay:68%; long-stay:81%). Among those with a POLST in 2016, 54% of long-stay and 41% of short-stay residents had a DNR order. Among residents with DNR, >90% had orders for limited medical interventions or comfort measures. Few residents (<6%) had a POLST with contradictory orders. In regression analyses, POLST completion was greater among residents with more functional dependence, but was lower among those with more cognitive impairment. Greater functional and cognitive impairment were associated with DNR orders. Racial and ethnic minorities indicated more aggressive care preferences. Higher CMS five-star facility quality rating was associated with greater POLST completion., Conclusions: Six years after a state mandate to document POLST completion in NHs, most California NH residents have a POLST, and about half of long-stay residents have orders to limit life-sustaining treatment. Future work should focus on determining the quality of care preference decisions documented in POLST., (© 2022 The American Geriatrics Society.)

Background: The incidence of persistent clinical symptoms and risk factors in Post-Acute Sequelae of SARS-CoV-2 (PASC) in diverse US cohorts is unclear. While there are a disproportionate share of COVID-19 deaths in older patients, ethnic minorities, and socially disadvantaged populations in the USA, little information is available on the association of these factors and PASC., Objective: To evaluate the association of demographic and clinical characteristics with development of PASC., Design: Prospective observational cohort of hospitalized and high-risk outpatients, April 2020 to February 2021., Participants: One thousand thirty-eight adults with laboratory-confirmed symptomatic COVID-19 infection., Main Measures: Development of PASC determined by patient report of persistent symptoms on questionnaires conducted 60 or 90 days after COVID-19 infection or hospital discharge. Demographic and clinical factors associated with PASC., Key Results: Of 1,038 patients with longitudinal follow-up, 309 patients (29.8%) developed PASC. The most common persistent symptom was fatigue (31.4%) followed by shortness of breath (15.4%) in hospitalized patients and anosmia (15.9%) in outpatients. Hospitalization for COVID-19 (odds ratio [OR] 1.49, 95% [CI] 1.04-2.14), having diabetes (OR, 1.39; 95% CI 1.02-1.88), and higher BMI (OR, 1.02; 95% CI 1-1.04) were independently associated with PASC. Medicaid compared to commercial insurance (OR, 0.49; 95% CI 0.31-0.77) and having had an organ transplant (OR 0.44, 95% CI, 0.26-0.76) were inversely associated with PASC. Age, race/ethnicity, Social Vulnerability Index, and baseline functional status were not associated with developing PASC., Conclusions: Three in ten survivors with COVID-19 developed a subset of symptoms associated with PASC in our cohort. While ethnic minorities, older age, and social disadvantage are associated with worse acute COVID-19 infection and greater risk of death, our study found no association between these factors and PASC., (© 2022. The Author(s).)

Background: On-body wearable sensors have been used to predict adverse outcomes such as hospitalizations or fall, thereby enabling clinicians to develop better intervention guidelines and personalized models of care to prevent harmful outcomes. In our previous work, we introduced a generic remote patient monitoring framework (Sensing At-Risk Population) that draws on the classification of human movements using a 3-axial accelerometer and the extraction of indoor localization using Bluetooth low energy beacons, in concert. Using the same framework, this paper addresses the longitudinal analyses of a group of patients in a skilled nursing facility. We try to investigate if the metrics derived from a remote patient monitoring system comprised of physical activity and indoor localization sensors, as well as their association with therapist assessments, provide additional insight into the recovery process of patients receiving rehabilitation., Objective: The aim of this paper is twofold: (1) to observe longitudinal changes of sensor-based physical activity and indoor localization features of patients receiving rehabilitation at a skilled nursing facility and (2) to investigate if the sensor-based longitudinal changes can complement patients' changes captured by therapist assessments over the course of rehabilitation in the skilled nursing facility., Methods: From June 2016 to November 2017, patients were recruited after admission to a subacute rehabilitation center in Los Angeles, CA. Longitudinal cohort study of patients at a skilled nursing facility was followed over the course of 21 days. At the time of discharge from the skilled nursing facility, the patients were either readmitted to the hospital for continued care or discharged to a community setting. A longitudinal study of the physical therapy, occupational therapy, and sensor-based data assessments was performed. A generalized linear mixed model was used to find associations between functional measures with sensor-based features. Occupational therapy and physical therapy assessments were performed at the time of admission and once a week during the skilled nursing facility admission., Results: Of the 110 individuals in the analytic sample with mean age of 79.4 (SD 5.9) years, 79 (72%) were female and 31 (28%) were male participants. The energy intensity of an individual while in the therapy area was positively associated with transfer activities (β=.22; SE 0.08; P=.02). Sitting energy intensity showed positive association with transfer activities (β=.16; SE 0.07; P=.02). Lying down energy intensity was negatively associated with hygiene activities (β=-.27; SE 0.14; P=.04). The interaction of sitting energy intensity with time (β=-.13; SE 0.06; P=.04) was associated with toileting activities., Conclusions: This study demonstrates that a combination of indoor localization and physical activity tracking produces a series of features, a subset of which can provide crucial information to the story line of daily and longitudinal activity patterns of patients receiving rehabilitation at a skilled nursing facility. The findings suggest that detecting physical activity changes within locations may offer some insight into better characterizing patients' progress or decline., (©Ramin Ramezani, Wenhao Zhang, Pamela Roberts, John Shen, David Elashoff, Zhuoer Xie, Annette Stanton, Michelle Eslami, Neil S Wenger, Jacqueline Trent, Antonia Petruse, Amelia Weldon, Andy Ascencio, Majid Sarrafzadeh, Arash Naeim. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 23.05.2022.)

Background: COVID-19 restrictions and fear dramatically changed the use of medical care. Understanding the magnitude of cancelled and postponed appointments and associated factors can help identify approaches to mitigate unmet need., Objective: To determine the proportion of medical visits cancelled or postponed and for whom. We hypothesized that adults with serious medical conditions and those with higher anxiety, depressive symptoms, and avoidance-oriented coping would have more cancellations/postponements., Design: Four nationally representative cross-sectional surveys conducted online in May, July, October, and December 2020., Participants: 59,747 US adults who completed 15-min online surveys. 69% cooperation rate., Measures: Physical and mental health visits and cancer screening cancelled or postponed over prior 2 months. Plan to cancel or postpone visits over the next 2 months. Relationship with demographics, medical conditions, local COVID-19 death rate, anxiety, depressive symptoms, coping, intolerance of uncertainty, and perceived COVID-19 risk., Key Results: Of the 58% (N = 34,868) with a medical appointment during the 2 months before the survey, 64% had an appointment cancelled or postponed in May, decreasing to 37% in December. Of the 41% of respondents with scheduled cancer screening, 20% cancelled/postponed, which was stable May to December. People with more medical conditions were more likely to cancel or postpone medical visits (OR 1.19 per condition, 95% CI 1.16, 1.22) and cancer screening (OR 1.20, 95% CI 1.15, 1.24). Race, ethnicity, and income had weak associations with cancelled/postponed visits, local death rate was unrelated, but anxiety and depressive symptoms were strongly related to cancellations, and this grew between May and December., Conclusions: Cancelled medical care and cancer screening were more common among persons with medical conditions, anxiety and depression, even after accounting for COVID-19 deaths. Outreach and support to ensure that patients are not avoiding needed care due to anxiety, depression and inaccurate perceptions of risk will be important., (© 2021. The Author(s).)

Purpose: Guidelines support early integration of palliative care (PC) into standard oncology practice; however, little is known as to whether outcomes can be improved by modifying health care delivery in a real-world setting., Methods: We report our 6-year experience of embedding a nurse practitioner in an oncology clinic (March 2014-March 2020) to integrate early, concurrent advance care planning and PC., Results: Compared with patients with advanced cancer not enrolled in the palliative care nurse practitioner program, in March 2020, patients who are enrolled are more likely to have higher quality of PC (eg, goals of care note documentation [82% v 15%; P < .01], referral to the psychosocial oncology program [67% v 37%; P < .01], and referral to hospice [61% v 34%; P < .01]) and less inpatient utilization in the last 6 months of life (eg, hospital days [12 v 18; P < .01] and intensive care unit days [1.2 v 2.3; P < .01]). The program expanded over time with the support of faculty skills training for advance care planning and PC, supporting a shared mental model of PC delivery within the oncology clinic., Conclusion: Embedding a trained palliative care nurse practitioner in oncology clinics to deliver early integrated PC can lead to improved quality of care for patients with advanced cancer., Competing Interests: Sarah F. D'AmbruosoStock and Other Ownership Interests: Bristol Myers Squibb, Merck, Pfizer, Gilead Sciences, Moderna Therapeutics Sara A. HurvitzStock and Other Ownership Interests: Ideal Implant, ROM TechResearch Funding: Genentech/Roche (Inst), Novartis (Inst), GlaxoSmithKline (Inst), Sanofi (Inst), Pfizer (Inst), Amgen (Inst), OBI Pharma (Inst), Puma Biotechnology (Inst), Dignitana (Inst), Bayer (Inst), Biomarin (Inst), Lilly (Inst), Merrimack (Inst), Cascadian Therapeutics (Inst), Seattle Genetics (Inst), Daiichi Sankyo (Inst), Macrogenics (Inst), Ambryx (Inst), Immunomedics (Inst), Pieris Pharmaceuticals (Inst), Radius Health (Inst), Arvinas (Inst), Zymeworks (Inst), Gilead Sciences (Inst), Phoenix Molecular Designs (Inst), CytomX Therapeutics (Inst), Samumed (Inst)Travel, Accommodations, Expenses: LillyOther Relationship: Roche, Pfizer Alexandra DrakakiEmployment: Athos Therapeutics (I), Attica Sciences (I), Dyania Health (I)Leadership: Athos Therapeutics (I), Attica Sciences (I)Stock and Other Ownership Interests: Urogen Pharma (I), Alimera Sciences (I), Kyn therapeutics (I), Athos Therapeutics (I), Attica Sciences (I), Dyania Health (I), Moderna Therapeutics (I), Proteas Bioanalytics (I)Consulting or Advisory Role: Bristol Myers Squibb, AstraZeneca, Radmetrix, Seattle Genetics, Janssen, PACT Pharma, Merck, Roche/Genentech, Exelixis, Dyania HealthResearch Funding: Kite/Gilead, AstraZeneca (Inst), Genentech/Roche (Inst), BMS (Inst), Merck Sharp & Dohme (Inst), Jounce Therapeutics (Inst), Infinity Pharmaceuticals (Inst), Seattle Genetics/Astellas (Inst)Patents, Royalties, Other Intellectual Property: My significant other has several patents with UCLA, Harvard Medical School, Athos Therapeutics, Proteas Bioanalytics, and ATTICA SciencesTravel, Accommodations, Expenses: Lilly, AstraZeneca, Seattle Genetics Jonathan Wade GoldmanConsulting or Advisory Role: AstraZeneca, Bristol Myers Squibb, Lilly, Amgen, PfizerResearch Funding: Lilly (Inst), Genentech/Roche (Inst), Bristol Myers Squibb (Inst), AstraZeneca/MedImmune (Inst), Array BioPharma (Inst), AbbVie (Inst), Corvus Pharmaceuticals (Inst), Spectrum Pharmaceuticals (Inst), Advaxis (Inst), Pfizer (Inst)Travel, Accommodations, Expenses: AstraZenecaOpen Payments Link: https://openpaymentsdata.cms.gov/physician/124819 Sidharth AnandConsulting or Advisory Role: SignateraTravel, Accommodations, Expenses: Curio Science Lee S. RosenResearch Funding: Pfizer (Inst), Bayer (Inst), PsiOxus Therapeutics (Inst), CytomX Therapeutics (Inst), Rgenix (Inst) Parvin F. PeddiConsulting or Advisory Role: BioTheranosticsResearch Funding: Sanofi, Lilly Deborah J. L. WongConsulting or Advisory Role: Bristol Myers Squibb, Genentech/Roche, Sanofi/Aventis, Blueprint Medicines, RegeneronResearch Funding: BioMed Valley Discoveries (Inst), Merck Serono (Inst), Merck Sharp & Dohme (Inst), ARMO BioSciences (Inst), AstraZeneca/MedImmune (Inst), Kura Oncology (Inst), Regeneron (Inst), Genentech/Roche (Inst), Bristol Myers Squibb (Inst), FSTAR (Inst), Pfizer (Inst), Astellas Pharma (Inst), Enzychem Lifesciences (Inst), Lilly (Inst), Elevar Therapeutics (Inst) Anne M. WallingPatents, Royalties, Other Intellectual Property: UpToDateNo other potential conflicts of interest were reported.

Background: Although specialists are skilled in the management of urinary incontinence, primary care clinicians are integral in early diagnosis and initiation of management in order to decrease overuse of specialty care and improve the quality of specialist visits. We measured the quality of incontinence care provided by primary care clinicians prior to referral to a specialist and evaluated the impact of provider variables on quality of care., Methods: We performed a retrospective review of 200 women referred for urinary incontinence to a Female Pelvic Medicine and Reconstructive Surgery specialist between March 2017 and July 2018. We measured primary care adherence to 12 quality indicators in the 12 months prior to specialist consultation. We stratified adherence to quality indicators by clinician sex and years of experience., Results: Half of women with incontinence underwent a pelvic examination or had a urinalysis ordered. Few patients with urge urinary incontinence were recommended behavioral therapy (14%) or prescribed medication (8%). When total aggregate scores were compared, female clinicians performed the recommended care 47% ± 25% of the time, compared with 35% ± 23% for male clinicians (P = .003). Increasing years of experience was associated with worse overall urinary incontinence care (r -0.157, P = .02)., Conclusions: We found low rates of adherence to a set of quality indicators for women with urinary incontinence, with male clinicians performing significantly worse than female clinicians. Improvement of incontinence care in primary care could significantly reduce costs of care and preserve outcomes., (Copyright © 2022. Published by Elsevier Inc.)

Objective: Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients., Summary of Background Data: PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery., Methods: We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion., Results: After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care., Conclusions: This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis., Objective: To describe the experience of ACP in patients with decompensated cirrhosis at liver transplant centers., Design, Setting, and Participants: For this multicenter qualitative study, face-to-face semistructured interviews were conducted between July 1, 2017, and May 30, 2018, with clinicians and patients with decompensated cirrhosis at 3 high-volume transplant centers in California. Patient participants were adults and had a diagnosis of cirrhosis, at least 1 portal hypertension-related complication, and current or previous Model for End-Stage Liver Disease with sodium score of 15 or higher. Clinician participants were health care professionals who provided care during the illness trajectory., Main Outcomes and Measures: Experiences with ACP reported by patients and clinicians. Participants were asked about the context, behaviors, thoughts, and decisions concerning elements of ACP, such as prognosis, health care preferences, values and goals, surrogate decision-making, and documentation., Results: The study included 42 patients (mean [SD] age, 58.2 [11.2] years; 28 men [67%]) and 46 clinicians (13 hepatologists [28%], 11 transplant coordinators [24%], 9 hepatobiliary surgeons [20%], 6 social workers [13%], 5 hepatology nurse practitioners [11%], and 2 critical care physicians [4%]). Five themes that represent the experiences of ACP were identified: (1) most patient consideration of values, goals, and preferences occurred outside outpatient visits; (2) optimistic attitudes from transplant teams hindered the discussions about dying; (3) clinicians primarily discussed death as a strategy for encouraging behavioral change; (4) transplant teams avoided discussing nonaggressive treatment options with patients; and (5) surrogate decision makers were unprepared for end-of-life decision-making., Conclusions and Relevance: This study found that, despite a guarded prognosis, patients with decompensated cirrhosis had inadequate ACP throughout the trajectory of illness until the end of life. This finding may explain excessively aggressive life-sustaining treatment that patients receive at the end of life.

Background/objectives: Briefer measures of symptoms and functional limitations may reduce assessment burden and facilitate monitoring populations of persons with dementia (PWD)., Design: Prospective follow-up study., Setting: University-based dementia care management program., Participants: 1,091 PWD., Measurements: We assessed cognition (Mini Mental State Examination (MMSE)-11 tasks), neuropsychiatric symptom severity (Neuropsychiatric Inventory Questionnaire Severity Scale (NPIQ-S)-12 items), and functional ability (Activities of Daily Living (ADL)-6 items; Functional Activities Questionnaire (FAQ)-10 items). Item response theory was used to select subsets of items by identifying low item discrimination (<1.50), poor item fit (χ 2 ), local dependence (LD), and with difficulty similar to other items. We estimated correlations between original and shorter scales and compared their associations with mortality. We added two symptoms (trouble swallowing, coughing when eating) reflecting late-stage dementia complications, created a multi-dimensional dementia assessment composite, and examined its association with mortality., Results: Five MMSE tasks were eliminated: two with low discrimination, two with difficulty similar to other items, and one with poor fit. The remaining tasks were correlated with the full MMSE at r = 0.82. We retained three ADLs that were correlated with the total ADL set at r = 0.95 and kept five FAQ items that were not LD (correlation with full FAQ, r = 0.97). Associations with mortality were similar between the longer and shorter scales. A higher score on the composite (range 0-100) indicates worse dementia impact and was associated with mortality (hazard ratio (HR) per scale point: 1.03 (1.02-1.04))., Conclusion: These brief assessments and dementia composite may reduce administration time while preserving validity., (© 2020 The American Geriatrics Society.)

Purpose of Review: People with isolated REM (rapid eye movement) sleep behavior disorder (iRBD) have a high lifetime risk of developing a neurodegenerative disease, including dementia, but disclosure of this risk remains controversial. Herein, we summarize this controversy and provide guidance on disclosure., Recent Findings: Neurodegeneration risk disclosure in iRBD is controversial because of a long latency to disease onset and a lack of preventative strategies. Balancing the relevant ethical principles of beneficence, nonmaleficence, and autonomy is challenging. Although there are few data on disclosure in iRBD, evidence from discussing risk in other diseases with dementia provides some guidance., Summary: We provide an approach to risk disclosure for patients with iRBD. Patients should be asked if they want to know about future risks. If so, disclosure should be patient centered, focusing on what might happen. Discussion should occur early to give patients time to prepare for the future and consider participating in research., Competing Interests: Conflict of InterestThe authors have nothing to disclose., (© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2021, corrected publication 2022.)

Purpose: Intensive care interventions that prolong life without achieving meaningful benefit are considered clinically "inappropriate". In 2012, the frequency of perceived-inappropriate critical care was 10.8% at one academic health system; and we aimed to re-evaluate this frequency., Methods: For 4 months in 2017, we surveyed critical care physicians daily and asked whether each patient was receiving appropriate, probably inappropriate, or inappropriate critical care. Patients were categorized into three groups: 1) patients for whom treatment was never inappropriate, 2) patients with at least one assessment that treatment was probably inappropriate, but no inappropriate treatment assessments, and 3) patients who had at least one assessment of inappropriate treatment., Results: Fifty-five physicians made 10,105 assessments on 1424 patients. Of these, 94 (6.6%) patients received at least one assessment of inappropriate critical care, which is lower than 2012 (10.8% (p < 0.01)). Comparing 2017 and 2012, patient age, MS-DRG, length of stay, and hospital mortality were not significantly different (p > 0.05). Inpatient mortality in 2017 was 73% for patients receiving inappropriate critical care., Conclusions: Over five years the proportion of patients perceived to be receiving inappropriate critical care dropped by 40%. Understanding the reasons for such change might elucidate how to continue to reduce inappropriate critical care., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background/objectives: Although nurse practitioner dementia care co-management has been shown to reduce total cost of care for fee-for-service (FFS) Medicare beneficiaries, the reasons for cost savings are unknown. To further understand the impact of dementia co-management on costs, we examined acute care utilization, long-term care admissions, and hospice use of program enrollees as compared with persons with dementia not in the program using FFS and managed Medicare claims data., Design: Quasi-experimental controlled before-and-after comparison., Setting: Urban academic medical center., Participants: A total of 856 University of California, Los Angeles (UCLA) Alzheimer's and Dementia Care program patients were enrolled between July 1, 2012, and December 31, 2015, and 3,139 similar UCLA patients with dementia not in the program. Comparison patients were identified as having dementia using International Classification of Diseases-9 codes and natural language processing of clinical notes. Coarsened exact matching was used to reduce covariate imbalance between intervention and comparison patients., Intervention: Dementia co-management model using nurse practitioners partnered with primary care providers and community organizations., Measurements: Average difference-in-differences per quarter over the 2.5-year intervention period for all-cause hospitalization, emergency department (ED) visits, intensive care unit (ICU) stays, and number of inpatient hospitalization days; admissions to long-term care facilities; and hospice use in the last 6 months of life., Results: Intervention patients had fewer ED visits (odds ratio [OR] = .80; 95% confidence interval [CI] = .66-.97) and shorter hospital length of stay (incident rate ratio = .74; 95% CI = .55-.99). There were no significant differences between groups for hospitalizations or ICU stays. Program participants were less likely to be admitted to a long-term care facility (hazard ratio = .65; 95% CI = .47-.89) and more likely to receive hospice services in the last 6 months of life (adjusted OR = 1.64; 95% CI = 1.13-2.37)., Conclusion: Comprehensive nurse practitioner dementia care co-management reduced ED visits, shortened hospital length of stay, increased hospice use, and delayed admission to long-term care., (© 2020 The American Geriatrics Society.)

Rationale: Medical interventions that prolong life without achieving an effect that the patient can appreciate as a benefit are often considered futile or inappropriate by healthcare providers. In recent years, a multicenter guideline has been released with recommendations on how to resolve conflicts between families and clinicians in these situations and to increase public engagement. Although laypeople are acknowledged as important stakeholders, their perceptions and understanding of the terms "potentially inappropriate" or "futile" treatment have received little formal evaluation. Objectives: To evaluate the community perspective about the meaning of futile treatment. Methods: Six focus groups (two groups each of ages <65, 65-75, and >75 yr) were convened to explore what constitutes futile treatment and who should decide in situations of conflict between doctors and families. Focus group discussions were analyzed using grounded theory. Results: There were 39 participants aged 18 or older with at least one previous hospitalization (personal or by immediate relative). When asked to describe futile or inappropriate treatment, community members found the concept difficult to understand and the terminology inadequate, though when presented with a case describing inappropriate treatment, most participants recognized it as the provision of inappropriate treatment. Several themes emerged regarding participant difficulty with the concept, including inadequate physician-patient communication, lack of public emphasis on end-of-life issues, skepticism that medical treatment can be completely inappropriate, and doubts and fears that medical futility could undermine patient and/or family autonomy. Participants also firmly believed that in situations of conflict families should be the ultimate decision-makers. Conclusions: Public engagement in policy development and discourse around medical futility will first require intense education to familiarize the lay public about use of inappropriate treatment at the end of life.

Objective: To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations., Methods: Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional., Results: Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended., Conclusion: Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout., (© 2020, American College of Rheumatology.)

Objective: To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations., Methods: Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional., Results: Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended., Conclusion: Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout., (© 2020, American College of Rheumatology.)

Background: The End of Life Option Act (EOLOA) legalized physician aid in dying for competent, terminally ill Californians in 2016. The law allows clinicians, hospitals, and health systems to decide whether to participate. About 4 in 10 California hospitals permit the EOLOA, but little is known about their approaches and concerns. Objective: Describe hospital EOLOA policies and challenges. Design and Measurements: Survey study of hospitals in California, administered September 2017 to March 2018. We describe hospital policies concerning the EOLOA and perform thematic analysis of open-ended questions about challenges, including availability of providers, process of implementing EOLOA, experiences of distress by providers and patients, and questions about medications. Results: Of 315 hospitals surveyed, 270 (86%) responded. Every surveyed hospital had established a position on the EOLOA. Among hospitals permitting EOLOA, 38% required safeguards not required in the law, 87% provided for referral to another provider if the patient's physician did not participate, and 65% counseled staff, if needed. Among hospitals not permitting the EOLOA, nearly all allowed providers to follow patients choosing to pursue the EOLOA elsewhere and most permitted a provider to refer to another provider or system. Most hospitals expressed concerns about implementation of the EOLOA and interest in sharing promising practices. Conclusions: This survey of California hospitals demonstrates considerable heterogeneity in implementing the EOLOA. For many Californians, access to the EOLOA depends on where one receives medical care. Implementation would be improved by hospitals and health systems sharing promising practices.

Background/objectives: Persons with Alzheimer disease and related dementias (ADRDs) require comprehensive care that spans health systems and community-based organizations. This study examined the clinical outcomes of a comprehensive dementia care program and identified subgroups who were more likely to benefit., Design: Observational, baseline and 1 year after intervention., Setting: Urban, academic medical center., Participants: A total of 554 persons with dementia and their caregivers who had 1-year follow-up evaluations and data on clinical outcomes., Intervention: Health system-based comprehensive dementia care management program using nurse practitioner dementia care managers., Measurements: Patient measures included the Mini-Mental State Examination (MMSE), the Functional Activities Questionnaire, Basic and Instrumental Activities of Daily Living scales, the Cornell Scale for Depression in Dementia, and the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity. Caregiver measures included the Modified Caregiver Strain Index, the Patient Health Questionnaire-9, NPI-Q Distress, and the Dementia Burden Scale-Caregiver). We used established minimal clinically important differences and lowest tertiles of baseline symptoms to define improving symptoms and maintaining low symptoms as clinical benefit for patients and caregivers., Results: At year 1, persons with ADRD improved on all scales, except MMSE and functional status measures; caregivers improved on all scales. Using validated instruments, 314/543 (58%) of patients, 282/447 (63%) of caregivers, and 376/501 (75%) of patients or caregivers demonstrated clinical benefit. In adjusted multivariate models, at year 1, more behavioral symptoms and fewer depression symptoms at baseline were associated with patient improvement; and fewer baseline depression symptoms were associated with maintaining low behavioral symptoms. Male caregiver sex, higher baseline caregiver burden, and caring for patients with fewer baseline depression symptoms were associated with caregiver improvement. Male caregiver sex and patients with fewer depression symptoms, fewer behavioral symptoms, and more functional impairment at baseline were associated with caregivers maintaining low burden at 1 year., Conclusions: Health system-based comprehensive dementia care management is a promising approach to improving clinical outcomes, with benefits for both patients and caregivers. J Am Geriatr Soc 67:2267-2273, 2019., (© 2019 The American Geriatrics Society.)

Objective: Medical interventions that do not offer the patient meaningful benefit due to inconsistency with prognoses are often considered "inappropriate" by clinicians. We described the clinical details and resource utilisation of patients who were assessed as receiving inappropriate treatment., Design: Chart abstraction was performed on 123 patients who were assessed by their critical care physician as having received inappropriate treatment to document clinical characteristics, diagnostic testing, life-sustaining treatments and nursing assessments of daily pain and level of consciousness., Results: The mean age was 67 and on admission, 41% had cancer and 25% had advanced pulmonary disease. At least one of the following three conditions was noted in 57% of the patients: severe neurological injury, overwhelming sepsis or irreversible respiratory failure. Patients were less likely to be alert (OR 0.39, CI 0.16-0.91, p = 0.03) on days they were assessed as receiving inappropriate critical care. After they were assessed as receiving inappropriate critical care, they received 172 imaging studies, 151 procedures, 522 days of mechanical ventilation (excludes one patient who received 1020 days of mechanical ventilation), 254 days of vasopressors, 226 days of hemodialysis and 10 attempts at cardiopulmonary resuscitation., Conclusions: Patients assessed as receiving inappropriate critical care receive resource-intensive medical care, largely while non-alert., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Varying intensity of advance care planning (ACP) interventions at the population level has not been compared among seriously ill patients in primary care. This project will implement, test, and disseminate real-world scalable ACP interventions among primary care clinics across three University of California Health systems. The three ACP interventions are (1) distribution of an advance directive (AD) with targeted ACP messaging, (2) the AD, messaging, plus prompting patients to engage with the Prepare For Your Care website (PREPARE), and (3) the AD, messaging, PREPARE, plus Care Coordinator engagement with patients and clinicians. Methods: We will identify a population cohort of seriously ill primary care patients and implement the ACP interventions using electronic health record (EHR) patient portals and postal mailings. Forty-five clinics across the three health systems will be cluster randomized to one of the three ACP interventions. The primary outcome for the population cohort is AD or Physician Orders for Life-Sustaining Treatment documentation in the EHR. A subset of the population cohort will be surveyed to assess patient-centered outcomes, including care consistent with goals at baseline, 12 months, and 24 months. Caregivers will be interviewed if patients are unable to be surveyed or die. ACP documentation, goal concordant care, and among decedents, health care utilization will be compared among intervention arms. Study Implementation: Challenges and Contributions: The project is guided by a Study Advisory Group and Community Advisory Groups at each site to ensure rigorous patient-centered methods and consistency of implementation. Intervention fidelity will be evaluated using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Challenges to implementation of this three-site health system trial and to intervention fidelity stem from site/clinic/system cultures, increasing attention to end-of-life care from payers and regulators, and growing pressures by health systems to implement ACP interventions. Stakeholder engagement is required to ensure consistent interventions across sites.

Background: Physician Orders for Life-Sustaining Treatment (POLST) can help ensure continuity of do-not-resuscitate (DNR) decisions and other care preferences after discharge from the hospital. Objective: We aimed to improve POLST completion rates for patients with DNR orders who were being discharged to a nursing home (NH) after an acute hospitalization at our institution. Design: We implemented an interprofessional quality improvement intervention involving education, communication skills, and nursing and case manager cues regarding POLST use. The intervention was later augmented with performance feedback and financial incentives for resident physicians who completed a POLST at NH transfer. Measure: Whether patients with DNR orders at hospital discharge have a POLST at NH transfer. Results: The intervention resulted in increased POLST use for patients with DNR orders discharged to NH: baseline 25/65 (38%), intervention 36/71 (51%), and augmented intervention 44/63 (70%) ( p  < 0.01). Conclusions: An interdisciplinary intervention can increase POLST use for patients with DNR orders transitioning to NH. Multiple components, including financial incentives and performance feedback, may be needed to effect statistically significant change.

Background/objectives: Although Alzheimer disease and other dementias are life limiting, only a minority of these patients or their proxy decision makers participate in advance care planning. We describe end-of-life care preferences and acute care and hospice use in the last 6 months of life for persons enrolled in a comprehensive dementia care management program., Design: Observational, retrospective cohort., Setting: Urban, academic medical center., Participants: A total of 322 persons enrolled in dementia care management after July 1, 2012, who died before July 1, 2016., Intervention: Dementia care comanagement model using nurse practitioners partnered with primary care providers and community organizations to provide comprehensive dementia care, including advance care planning., Measurements: Advance care preferences, use of Physician Orders for Life Sustaining Treatment (POLST), hospice enrollment, and hospitalizations and emergency department (ED) visits in the last 6 months of life obtained from electronic health record data., Results: Nearly all decedents (99.7%, N = 321) had a goals-of-care conversation documented (median = 3 conversations; interquartile range = 2-4 conversations), and 64% had advance care preferences recorded. Among those with recorded preferences, 88% indicated do not resuscitate, 48% limited medical interventions, and 35% chose comfort-focused care. Most patients (89%) specified limited artificial nutrition, including withholding feeding tubes. Over half (54%) had no hospitalizations or ED visits in the last 6 months of life, and intensive care unit stays were rare (5% of decedents). Overall, 69% died on hospice. Decedents who had completed a POLST were more likely to die in hospice care (74% vs 62%; P = .03) and die at home (70% vs 59%; P = .04)., Conclusions: Enrollees in a comprehensive dementia care comanagement program had high engagement in advance care planning, high rates of hospice use, and low acute care utilization near the end of life. Wider implementation of such programs may improve end-of-life care for persons with dementia. J Am Geriatr Soc 67:443-448, 2019., (© 2019 The American Geriatrics Society.)

Importance: An estimated 4 to 5 million Americans have Alzheimer disease or another dementia., Objective: To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries., Design, Setting, and Participants: In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups., Interventions: Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week., Main Outcomes and Measures: Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates., Results: Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, -$1198 to -$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of -$284 (95% CI, -$881 to $312) per program participant per quarter., Conclusions and Relevance: Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.

Objectives: To develop a process of goal-setting and measurement of goal attainment in a dementia care management program., Design: Observational., Setting: Dementia care management program in an urban academic medical center., Participants: Persons with dementia (N=101) and their caregivers; nurse practitioner dementia care managers (N=5)., Intervention: Specification of a personalized health goal and action plan and measurement of goal attainment using goal attainment scaling in a clinical care visit., Measurements: Goal attainment at 6 and 12 months; focus groups of 5 dementia care managers., Results: Eighty-four percent of participant goals were nonmedical, 47% were related to quality of life, and 29% were caregiver support goals. Eighty-eight percent of participants felt that the goal they set was meaningful and 74% that the goal-setting process captured something different from usual care, and 85% found the process helpful in planning for future care. At 6 months, 74% of dyads had achieved or exceeded their expected level of goal attainment. Dementia care managers felt that the goal-setting process improved their understanding of what was most important to the patient, helped set expectations about disease progression and care needs, and provided positive reinforcement when goals were accomplished and an opportunity for revision when goals were not met., Conclusion: Goal setting using goal attainment scaling can be incorporated into the care of persons with dementia to establish and attain person-centered goals. Research is needed to further develop personalized goal attainment as an outcome measure for dementia care. J Am Geriatr Soc 66:2120-2127, 2018., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Objective: Information sharing between mental health providers (MHPs) and primary care providers (PCPs) is important for persons with mental illnesses. The authors determined the level of information continuity between MHPs who saw a patient for a new consult and PCPs and whether continuity varied between providers with and without access to a shared electronic health record (EHR)., Methods: Data were analyzed for 141 randomly selected enrollees in six Medicare Advantage plans receiving a new outpatient mental health consultation in 2012. Medical records of MHPs and PCPs were abstracted to evaluate whether PCP records recognized the consultation, documented mental health hospitalizations and emergency department visits, and acknowledged psychotropic medications. Measures were compared between patients whose providers used and did not use mutual-access EHRs., Results: For 21% of patients, the PCP record documented communication from the MHP within three months of the consultation. The PCP record showed evidence of timely communication (within seven days) for 42% of mental health hospitalizations and emergency department visits. Of 152 medications recorded by MHPs, 103 (68%) were acknowledged in the PCP record by the next visit. For patients with mutual-access EHRs, provider communication about the consultation was documented for a greater percentage of patients, compared with those without mutual-access EHRs (46% versus 11%, p<.001), as was communication about psychotropic medication (100% versus 57%, p<.001)., Conclusions: This small but detailed study of patients receiving new outpatient mental health consults found poor continuity of information between MHPs and PCPs. A mutual-access EHR facilitated but did not guarantee such information sharing.

Background: Advance care planning (ACP) is fundamental to guiding medical care at the end of life. Understanding the economic impact of ACP is critical to implementation, but most economic evaluations of ACP focus on only a few actors, such as hospitals., Objective: To develop a framework for understanding and quantifying the economic effects of ACP, particularly its distributional consequences, for use in economic evaluations., Design: Literature review of economic analyses of ACP and related costs to estimate magnitude and direction of costs and benefits for each actor and how data on these costs and benefits could be obtained or estimated., Results: ACP can lead to more efficient allocation of resources by reducing low-value care and reallocating resources to high-value care, and can increase welfare by aligning care to patient preferences. This economic framework considers the costs and benefits of ACP that accrue to or are borne by six actors: the patient, the patient's family and caregivers, healthcare providers, acute care settings, subacute and home care settings, and payers. Program implementation costs and nonhealthcare costs, such as time costs borne by patients and caregivers, are included. Findings suggest that out-of-pocket costs for patients and families will likely change if subacute or home care is substituted for acute care, and subacute care utilization is likely to increase while primary healthcare providers and acute care settings may experience heterogeneous effects., Conclusions: A comprehensive economic evaluation of ACP should consider how costs and benefits accrue to different actors.

Objectives: To better capture the scope of caregiver burden by creating a composite of 3 existing measures that assess different health domains., Design: Prospective follow-up study., Setting: University-based dementia care management program., Participants: Caregivers of persons with dementia (PWD) (N=1,091)., Measurements: The composite measure (the Dementia Burden Scale-Caregiver (DBS-CG)) was based on the Modified Caregiver Strain Index, Neuropsychiatric Inventory Questionnaire Distress Scale, and Patient Health Questionnaire (PHQ-9). Alternative factor structures were evaluated using 2 confirmatory factor analysis (CFA) models: a bifactor model and a 3 correlated factors model. Good model fit was defined as a root mean square error of approximation (RMSEA) of less than 0.06 and comparative fit index (CFI) value greater than 0.95. Coefficient omega was used to estimate scale reliability. Minimally important differences (MIDs) were estimated by anchoring the magnitude of DBS-CG change to change in caregiver self-efficacy and functional ability of PWD., Results: The bifactor CFA model fit best (RMSEA = 0.04, CFI = 0.95). Based on this model, a DBS-CG scale was created wherein all items were transformed to a possible range of 0 to 100 and then averaged. Higher scores indicate higher burden. Mean DBS-CG score was 27.3. The reliability was excellent (coefficient omega=0.93). MID estimates ranged from 4 to 5 points (effect sizes: 0.20-0.49)., Conclusion: This study provides support for the reliability and validity of the DBS-CG. It can be used as an outcome measure to assess the effect of interventions to reduce dementia caregiver burden., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Quality measures based on processes of care (e.g., breast cancer screening) are frequently used to compare performance of providers and healthcare organizations in a value-based reimbursement system, but using these measures to make performance comparisons could penalize clinicians caring for older adults with multiple comorbidities. These clinicians may more frequently withhold recommended care based on limited prognosis, patient preference, or potential adverse effects and, as a result, may incur financial penalties because of poor measured performance. Alternatively, they may need to perform additional administrative work to exclude patients from quality measurement. To examine the potential performance handicap associated with caring for complex populations, we cross-sectionally examined the association between broad outpatient processes of care and 5-year mortality risk in a nationally representative older adult sample (≥ 65) from the 2002 to 2015 Medical Expenditure Panel Survey (n=26,006). In adjusted analyses, performance score based on process-of-care measures was significantly worse in the high-risk group (5-year mortality risk ≥50; adjusted performance score 67.4%; adjusted absolute difference 6.7%, 95% confidence interval (CI)=5.3-8.1%, p<.001) and in the intermediate-risk group (5-year mortality risk 25-49%; adjusted performance score 71.7%; adjusted absolute difference 2.4%, 95% CI=1.7-3.1%, p<.001) than in the low-risk group (5-year mortality risk <25%); adjusted performance score 74.1% following <25%. The trend was overall constant across types of care processes and was more prominent in the younger age brackets of our sample. These results suggest that use of process-of-care measures can lead to disproportionate burden for clinicians and organizations primarily taking care of complex populations., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Purpose: We sought to develop a core set of clinical indicators to enable international benchmarking of localized prostate cancer management using data available in the TrueNTH Global Registry., Materials and Methods: An international expert panel completed an online survey and participated in a face-to-face meeting. Participants included 3 urologists, 3 radiation oncologists, 2 psychologists, 1 medical oncologist, 1 nurse and 1 epidemiologist with prostate cancer expertise from a total of 7 countries. Current guidelines on prostate cancer treatment and potential quality indicators were identified from a literature review. These potential indicators were refined and developed through a modified Delphi process during which each panelist independently and repeatedly rated each indicator based on importance (satisfying the indicator demonstrated a provision of high quality care) and feasibility (the likelihood that data used to construct the indicator could be collected at a population level). The main outcome measure was items with panel agreement indicated by a disagreement index less 1, median importance 8.5 or greater and median feasibility 9 or greater., Results: The expert panel endorsed 33 indicators. Seven of these 33 prostate cancer quality indicators assessed care relating to diagnosis, 7 assessed primary treatment, 1 assessed salvage treatment and 18 assessed health outcomes., Conclusions: We developed a set of quality indicators to measure prostate cancer care using numerous international evidence-based clinical guidelines. These indicators will be pilot tested in the TrueNTH Global Registry. Reports comparing indicator performance will subsequently be distributed to groups at participating sites with the purpose of improving the consistency and quality of prostate cancer management on a global basis., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Factors leading to inappropriate critical care, that is treatment that should not be provided because it does not offer the patient meaningful benefit, have not been rigorously characterized., Objective: We explored medical record documentation about patients who received inappropriate critical care and those who received appropriate critical care to examine factors associated with the provision of inappropriate treatment., Design: Medical records were abstracted from 123 patients who were assessed as receiving inappropriate treatment and 66 patients who were assessed as receiving appropriate treatment but died within six months of intensive care unit (ICU) admission. We used mixed methods combining qualitative analysis of medical record documentation with multivariable analysis to examine the relationship between patient and communication factors and the receipt of inappropriate treatment, and present these within a conceptual model., Setting: One academic health system., Results: Medical records revealed 21 themes pertaining to prognosis and factors influencing treatment aggressiveness. Four themes were independently associated with patients receiving inappropriate treatment according to physicians. When decision making was not guided by physicians (odds ratio [OR] 3.76, confidence interval [95% CI] 1.21-11.70) or was delayed by patient/family (OR 4.52, 95% CI 1.69-12.04), patients were more likely to receive inappropriate treatment. Documented communication about goals of care (OR 0.29, 95% CI 0.10-0.84) and patient's preferences driving decision making (OR 0.02, 95% CI 0.00-0.27) were associated with lower odds of receiving inappropriate treatment., Conclusions: Medical record documentation suggests that inappropriate treatment occurs in the setting of communication and decision-making patterns that may be amenable to intervention.

Purpose: To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic., Methods: We evaluated the effect of the intervention in two oncologists' clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies., Results: Of approximately 10,000 patients with active cancer treated in the health system, 2,829 patients had advanced cancer and were treated by 42 oncologists. Documentation of advance care planning increased for patients of the two intervention oncologists compared with patients of the other oncologists. Hospice referral before death was not different at baseline, but was significantly higher for patients of intervention oncologists compared with patients of control oncologists (53% v 23%; P = .02) over the intervention period. Efficiency evaluation revealed that approximately half the time spent by the embedded NP potentially could have been completed by other staff (eg, a nurse, a social worker, or administrative staff)., Conclusion: An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.