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The frequency of training, more than total hours spent, seems to correlate with higher ETI success rates. [ABSTRACT FROM AUTHOR]

Objective: To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative cardiopulmonary resuscitation (CPR) in surgical patients with frailty., Background: The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding the appropriateness of CPR in patients with frailty, providers' views regarding frailty and perioperative CPR are unknown., Methods: We performed qualitative thematic analysis of transcripts from semistructured interviews of anesthesiologists (8), surgeons (10), and geriatricians (9) who care for high-risk surgical patients at 2 academic medical centers in Boston, MA. The interview guide elicited clinicians' understanding of frailty, approach to decision-making regarding perioperative CPR, and perceptions of perioperative CPR in frail surgical patients., Results: We identified 5 themes: (1) perceptions of perioperative CPR in patients with frailty vary by provider specialty, (2) judgments regarding the appropriateness of CPR in surgical patients with frailty are typically multifactorial and include patient goals, age, comorbidities, and arrest etiology, (3) resuscitation in patients with frailty is sometimes associated with moral distress, (4) biases, such as ableism and ageism, may skew clinicians' perceptions of the appropriateness of perioperative CPR in patients with frailty, and (5) evidence to guide risk stratification for patients with frailty undergoing perioperative CPR is inadequate., Conclusions: Anesthesiologists, surgeons, and geriatricians offer different accounts of frailty's relevance to judgments regarding CPR in surgical patients. Divergent views regarding frailty and perioperative CPR may impede efforts to deliver goal-concordant care and suggest a need for research to inform risk stratification, predict patient-centered outcomes, and understand the role of potential biases, such as ageism and ableism., Competing Interests: M.B.A.’s work was supported by a Department of Anesthesiology, Brigham and Women’s Hospital, Perioperative and Pain Medicine Clinical Translational Starter Grant. The remaining authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Qualitative methods have been increasingly applied in our literature, providing richness to data and incorporating the nuances of patient and family perspectives. These qualitative research techniques provide breadth and depth beyond what can be gleaned through quantitative methods alone. When both quantitative and qualitative approaches are coupled, their findings provide complementary information which can further substantiate study conclusions. We thus aim to provide insight into qualitative and quantitative methods in comparison and contrast to each other, as well as guidance on when each approach is most apt. In relation, we also describe mixed methods and the theory supporting their framework. In doing so, we provide the foundation for an ensuing, more detailed exposition of qualitative methods., (© 2023 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Background/Objectives : Comprehending the patient composition of bladder cancer (BC) clinical trials is crucial for effectively designing clinical trials and contextualizing the generated science. In this study, we reviewed publicly available data and explored the demographic information of BC studies administering immune checkpoint inhibitors (ICIs). Methods : Trial eligibility was irrespective of government or private sponsorship, and trial activation dates were limited to between 2013 and 2023. The main inclusion criteria were use of ICIs and trials reporting endpoints that include progression-free survival (PFS), overall survival (OS), disease-free survival (DFS), and event-free survival (EFS). The key exclusion terms were review articles and meta-analysis. Results : We identified a total of 109 clinical trials with an aggregate total of 8936 enrolled patients. Ninety-six percent identified as Caucasian or White European, and 23% identified as female. Further analyses revealed that 65% of the patients were aged 65 years or older. One-third of the trials listed similar comorbidities, such as cardiovascular disease and diabetes, that were exhibited by approximately 30 percent of the patients. Conclusions : Our data suggest that recruitment strategies should be mindful of comorbidities that may interfere with ICI treatments. Additionally, our results are consistent with findings from other reviews that indicate that certain patient groups may be under-represented in BC trials.

Background: Patients with advanced heart failure (AHF) desire communication around values and goals prior to treatment decisions., Objectives: To evaluate the timing and content of the first serious illness communication (SI conversation) for patients with AHF after referral to a specialist palliative care (PC) team (HeartPal)., Methods: In this retrospective cohort study, we used electronic health records to identify patients referred to HeartPal and their first SI conversations at a tertiary care hospital between October 2018 and September 2021. We used natural language processing and predetermined codes to quantify prevalence of prior goals of care conversations by the cardiology team within six months preceding the HeartPal consultation and the prevalence of hopes, fears, and seven conversation content codes. Consecutive SI conversations and patient outcomes were followed until March 2022., Results: Of 468 patients (mean age: 64 years, 72 % male, 66 % referred for goals of care conversation), 25.2 % had prior documented goals of care conversations preceding the HeartPal consultation. During the study period, 206 (44.0 %) patients died (median time from initial SI conversation to death: 65 days, IQR 206) and 43.2 % engaged in multiple SI conversations before death. SI conversation analysis (n = 324) revealed that patients hoped to "be at home" (74.1 %, n = 240), "be independent" (65.7 %, n = 213) and "live as long as possible" (53.4 %, n = 173). Conversation content included goals of care (83.0 %), strengths (83.0 %), decision-making (79.3 %), spirituality (71.0 %), coping (52.2 %), and prognostic communication (43.5 %)., Conclusion: Specialist PC service provides documentation of goals and values and offers longitudinal follow-up for patients with AHF., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To compare differences in pain, depression, function, and informal caregiving pre-and-post major elective surgery among older adults with and without serious illness; and determine if serious illness was independently associated with increasing pain, depression, assistance in activities of daily living (ADLs) and informal caregiving post-surgery., Background: The American College of Surgeons has endorsed the integration of palliative care (PC) into surgical care in adults with serious illness but targets for PC during surgical episodes such as pain, depression, function, and informal caregiving are understudied., Methods: We used Health and Retirement Study-linked Medicare data (2008-2018) to identify older (≥66 y) adults with and without serious illness who had major elective surgery. We performed difference-in-difference analysis to measure changes in pain, depression, function and informal caregiving pre-and-post-surgery between groups. We tested associations between serious illness and changes in pain, depression, function and informal caregiving using multivariable regression., Results: Among 1896 adults who had major surgery, 1139 (60%) were seriously ill. Compared to adults without serious illness, those with serious illness had greater baseline pain (43 vs. 38%), depression (22 vs.13%), assistance with ADLs(12 vs.0%) and informal caregiving (18 vs.4%); and, greater increases in assistance with ADLs pre-and-post-surgery(DID 6%, 95%CI 3.7-8.3). Serious illness was independently associated with increasing pain (OR 1.6, 95%CI 1.1-2.2), depression (OR 1.5, 95%CI 1.1-2.2), assistance with ADLs (OR 2.1, 95%CI 1.3-3.4) and informal caregiving (OR 2.1, 95%CI 1.4-3.1) post-surgery., Conclusions: Most older adults having elective surgery are seriously ill. Pain, depression, function, and caregiving are targets for PC to improve post-surgical outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Spanish-speaking trauma and burn patients have unique needs in their postdischarge care navigation. The confluence of limited English proficiency, injury recovery, mental health, socioeconomic disadvantages, and acute stressors after hospital admission converge to enhance patients' vulnerability, but their specific needs and means of meeting these needs have not been well described., Study Design: This prospective, cross-sectional survey study describes the results of a multi-institutional initiative devised to help Spanish-speaking trauma and burn patients in their care navigation after hospitalization. The pathway consisted of informational resources, intake and follow-up surveys, and multiple points of contact with a community health worker who aids in accessing community resources and navigating the healthcare system., Results: From January 2022 to November 2023, there were 114 patients identified as eligible for the Non-English-Speaking Trauma Survivors pathway. Of these, 80 (70.2%) were reachable and consented to participate, and 68 were approached in person during their initial hospitalization. After initial screening, 60 (75.0%) eligible patients had a mental health, social services, or other need identified via our survey instrument. During the initial consultation with the community health worker, 48 of 60 patients with any identified need were connected to a resource (80%). Food support was the most prevalent need (46, 57.5%). More patients were connected to mental health resources (16) than reported need in this domain (7)., Conclusions: The Non-English-Speaking Trauma Survivors pathway identified the specific needs of Spanish-speaking trauma and burn patients in their recovery, notably food, transportation, and utilities. The pathway also addressed disparities in postdischarge care by connecting patients with community resources, with particular improvement in access to mental healthcare., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Rationale & Objective: Nearly half of kidney transplant recipients develop allograft failure within 10 years of transplantation and experience high mortality, significant symptom burden, and complex communication challenges. These patients may benefit from palliative care, but palliative care is infrequently provided in this population. This study explores palliative care perceptions and needs among patients with poorly functioning and declining kidney allografts., Study Design: A qualitative study using semistructured interviews., Setting & Participants: Adult kidney transplant recipients with a glomerular filtration rate of <20 mL/min/1.73m 2 followed at a single transplant center were interviewed from April 2022 to November 2022., Analytical Approach: An interdisciplinary team, including nephrology, palliative care, and surgery, conducted a thematic analysis., Results: Twelve participants (3 women, 9 men; 9 White, 2 Black, and 1 Hispanic patient) were interviewed. The median age of participants was 59 (IQR 48-73). At 6 months postinterview, 7 participants had resumed dialysis, 1 participant had been retransplanted, and 1 participant was deceased. Most participants had not heard of palliative care and those who had equated it with end-of-life care. Participants reported that emotional distress, particularly pervasive concern about the worsening of their kidney disease, was their most significant priority related to unmet palliative care needs. They also desired more discussion with their care team about future quality of life and lifespan. Participants described high trust in their transplant teams, suggesting that palliative care integration with these teams would be well-received., Limitations: Limitations include recruitment from a single institution, lack of subject familiarity with palliative care, and limited racial and ethnic diversity among participants., Conclusions: Patients with declining kidney allografts have heterogeneous, unmet palliative care needs, including emotional symptoms and a desire for better prognostic awareness. Our results suggest that patients are largely unaware of palliative care and may benefit from practice models in which transplant teams integrate palliative care education and timely palliative care engagement., (© 2024 The Authors.)

Background: Despite mandated insurance coverage since 2006 and robust health infrastructure in urban settings with high concentrations of minority patients, race-based disparities in prostate cancer (PCa) treatment persist in Massachusetts. In this qualitative study, the authors sought to identify factors driving inequities in PCa treatment in Massachusetts., Methods: Four hospitals offering PCa treatment in Massachusetts were selected using a case-mix approach. Purposive sampling was used to conduct semistructured interviews with hospital stakeholders. Additional interviews were conducted with representatives from grassroots organizations providing PCa education. Two study staff coded the interviews to identify major themes and recurrent patterns., Results: Of the 35 informants invited, 25 participated in the study. Although national disparities in PCa outcomes were readily discussed, one half of the informants were unaware that PCa disparities existed in Massachusetts. Informants and grassroots organization representatives acknowledged that patients with PCa are willing to face transportation barriers to receive treatment from trusted and accommodating institutions. Except for chief equity officers, most health care providers lacked knowledge on accessing or using metrics regarding racial disparities in cancer outcomes. Although community outreach was recognized as a potential strategy to reduce treatment disparities and engender trust, informants were often unable to provide a clear implementation plan., Conclusions: This statewide qualitative study builds on existing quantitative data on the nature and extent of disparities. It highlights knowledge gaps in recognizing and addressing racial disparities in PCa treatment in Massachusetts. Improved provider awareness, the use of disparity metrics, and strategic community engagement may ensure equitable access to PCa treatment., Plain Language Summary: Despite mandated insurance and urban health care access, racial disparities in prostate cancer treatment persist in Massachusetts. This qualitative study revealed that, although national disparities were acknowledged, awareness about local disparities are lacking. Stakeholders highlighted the importance of ancillary services, including translators, rideshares, and navigators, in the delivery of care. In addition, whereas hospital stakeholders were aware of collected equity outcomes, they were unsure whether and who is monitoring equity metrics. Furthermore, stakeholders agreed that community outreach showed promise in ensuring equitable access to prostate cancer treatment. Nevertheless, most interviewed stakeholders lacked clear implementation plans., (© 2024 American Cancer Society.)

Background: The full-scale invasion of Ukraine by Russia in 2022 has significantly impacted the country's healthcare system including surgical education. To assess the current state and identify the strengths and opportunities for the improvement of Ukraine's surgical education system during the peri-war period, this study is one of the first to explore the state of surgical education across Ukraine in peri-war, providing essential insights for current and postwar healthcare reconstruction., Methods: This qualitative study involved semi-structured interviews with 24 Ukrainian surgical residents, surgeons, and program leadership from various regions. The study focused on clinical training, didactics, mentorship, autonomy, resident evaluation, the impact of war, and gender disparities in surgical education. Data analysis was conducted using a rapid qualitative analysis technique., Results: Interviews revealed strengths in surgical education such as adaptability to war conditions and international collaborations. However, opportunities for improvement were identified including a lack of structured clinical and didactic experiences, limited autonomy and access to simulators, gender discrimination, and war-time challenges. These issues highlight a need for more comprehensive training and support systems for surgical trainees in Ukraine., Conclusions: The study underscores the resilience and adaptability of Ukrainian surgical education in the face of war while also emphasizing the need for significant improvements. It calls for implementing structured training programs, enhanced mentorship, and attention to gender equality. These findings are crucial for improving surgical education in Ukraine and can be used as an example for other lower-middle-income countries, especially in conflict settings., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Importance: Timely diagnosis and treatment are of paramount importance for patients with head and neck cancer (HNC) because delays are associated with reduced survival rates and increased recurrence risk. Prompt referral to HNC specialists is crucial for the timeliness of care, yet the factors that affect the referral and triage pathway remain relatively unexplored. Therefore, to identify barriers and facilitators of timely care, it is important to understand the complex journey that patients undertake from the onset of HNC symptoms to referral for diagnosis and treatment., Objective: To investigate the referral and triage process for patients with HNC and identify barriers to and facilitators of care from the perspectives of patients and health care workers., Design, Participants, and Setting: This was a qualitative study using semistructured interviews of patients with HNC and health care workers who care for them. Participants were recruited from June 2022 to July 2023 from HNC clinics at 2 tertiary care academic medical centers in Boston, Massachusetts. Data were analyzed from July 2022 to December 2023., Main Outcomes and Measures: Themes identified from the perspectives of both patients and health care workers on factors that hinder or facilitate the HNC referral and triage process., Results: In total, 72 participants were interviewed including 42 patients with HNC (median [range] age, 60.5 [19.0-81.0] years; 27 [64%] females) and 30 health care workers (median [range] age, 38.5 [20.0-68.0] years; 23 [77%] females). Using thematic analysis, 4 major themes were identified: the HNC referral and triage pathway is fragmented; primary and dental care are critical for timely referrals; efficient interclinician coordination expedites care; and consistent patient-practitioner engagement alleviates patient fear., Conclusions and Relevance: These findings describe the complex HNC referral and triage pathway, emphasizing the critical role of initial symptom recognition, primary and dental care, patient information flow, and interclinician and patient-practitioner communication, all of which facilitate prompt HNC referrals.

Objective: To understand medical interpreters' perspectives on surgical informed consent discussions and provide feedback for surgeons on improving these conversations., Background: Informed consent is a critical component of patient-centered surgical decision-making. For patients with limited English proficiency, this conversation may be less thorough, even with a medical interpreter, leaving patients with an inadequate understanding of their diagnosis or treatment options., Methods: A semistructured interview guide was developed with input from interpreters and a qualitative research expert. We purposively sampled medical interpreters representing multiple languages until thematic saturation was achieved. Participants discussed their experience with the surgical consent discussion and process. Interview transcripts were analyzed using emergent thematic analysis., Results: Among 22 interpreters, there were 10 languages represented and an average experience of 15 years (range: 4-40 yr). Four major themes were identified. First, interpreters consistently described their roles as patient advocates and cultural brokers. Second, interpreters reported unique patient attributes that influence the discussion, often based on patients' cultural values/expectations, anticipated decisional autonomy, and family support. Third, interpreters emphasized the importance of surgeons demonstrating compassion and patience, using simple terminology, conversing around the consent, providing context about the form/process, and initiating a pre-encounter discussion. Finally, interpreters suggested reducing legal terminology on consent forms and translation into other languages., Conclusions: Experienced interpreters highlighted multiple factors associated with effective and culturally tailored informed consent discussions. Surgeons should recognize interpreters' critical and complex roles, be cognizant of cultural variations among patients with limited English proficiency, and improve interpersonal and communication skills to facilitate effective understanding., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Nearly one-quarter of all Americans die in the ICU. Many of their deaths are anticipated and occur following the withdrawal of mechanical ventilation (WMV). However, there are few data on which to base best practices for interdisciplinary ICU teams to conduct WMV., Research Question: What are the perceptions of current WMV practices among ICU clinicians, and what are their opinions of processes that might improve the practice of WMV at end of life in the ICU?, Study Design and Methods: This prospective two-center observational study conducted in Boston, Massachusetts, the Observational Study of the Withdrawal of Mechanical Ventilation (OBSERVE-WMV) was designed to better understand the perspectives of clinicians and experience of patients undergoing WMV. This report focuses on analyses of qualitative data obtained from in-person surveys administered to the ICU clinicians (nurses, respiratory therapists, and physicians) caring for these patients. Surveys assessed a broad range of clinician perspectives on planning, as well as the key processes required for WMV. This analysis used independent open, inductive coding of responses to open-ended questions. Initial codes were reconciled iteratively and then organized and interpreted using a thematic analysis approach. Opinions were assessed on how WMV could be improved for individual patients and the ICU as a whole., Results: Among 456 eligible clinicians, 312 in-person surveys were completed by clinicians caring for 152 patients who underwent WMV. Qualitative analyses identified two main themes characterizing high-quality WMV processes: (1) good communication (eg, mutual understanding of family preferences) between the ICU team and family; and (2) medical management (eg, planning, availability of ICU team) that minimizes patient distress. Team member support was identified as an essential process component in both themes., Interpretation: Clinician perceptions of the appropriateness or success of WMV prioritize the quality of team and family communication and patient symptom management. Both are modifiable targets of interventions aimed at optimizing overall WMV.

Rationale & Objective: Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population., Study Design: National explanatory sequential mixed methods study including an online survey and semistructured interviews., Setting & Participants: Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022., Analytical Approach: Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data., Results: A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care., Limitations: Potential selection bias., Conclusions: Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them., Plain-Language Summary: Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population., (Copyright © 2023 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the role of patients' personal social networks (SNs) in accessing head and neck cancer (HNC) care through patients' and health care workers' (HCWs) perspectives., Study Design: Qualitative study., Setting: Tertiary HNC centers at 2 academic medical centers, including 1 safety net hospital., Methods: Patients with newly diagnosed HNC, and HCWs caring for HNC patients, aged ≥18 years were recruited between June 2022 and July 2023. Semistructured interviews were conducted with both patients and HCWs. Inductive and deductive thematic analysis was performed with 2 coders (κ = 0.82) to analyze the data., Results: The study included 72 participants: 42 patients (mean age 57 years, 64% female, 81% white), and 30 HCWs (mean age 42 years, 77% female, 83% white). Four themes emerged: (1) Patients' SNs facilitate care through various forms of support, (2) patients may hesitate to seek help from their networks, (3) obligations toward SNs may act as barriers to seeking care, and (4) the SN composition and dedication influence care-seeking., Conclusion: Personal SNs play a vital role in prompting early care-seeking among HNC patients. SN-based interventions could enhance care and improve outcomes for HNC patients., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Importance: Geographic access, including mode of transportation, to health care facilities remains understudied., Objective: To identify sociodemographic factors associated with public vs private transportation use to access health care and identify the respondent, trip, and community factors associated with longer distance and time traveled for health care visits., Design, Setting, and Participants: This cross-sectional study used data from the 2017 National Household Travel Survey, including 16 760 trips or a nationally weighted estimate of 5 550 527 364 trips to seek care in the United States. Households that completed the recruitment and retrieval survey for all members aged 5 years and older were included. Data were analyzed between June and August 2022., Exposures: Mode of transportation (private vs public transportation) used to seek care., Main Outcomes and Measures: Survey-weighted multivariable logistic regression models were used to identify factors associated with public vs private transportation and self-reported distance and travel time. Then, for each income category, an interaction term of race and ethnicity with type of transportation was used to estimate the specific increase in travel burden associated with using public transportation compared a private vehicle for each race category., Results: The sample included 12 092 households and 15 063 respondents (8500 respondents [56.4%] aged 51-75 years; 8930 [59.3%] females) who had trips for medical care, of whom 1028 respondents (6.9%) were Hispanic, 1164 respondents (7.8%) were non-Hispanic Black, and 11 957 respondents (79.7%) were non-Hispanic White. Factors associated with public transportation use included non-Hispanic Black race (compared with non-Hispanic White: adjusted odds ratio [aOR], 3.54 [95% CI, 1.90-6.61]; P < .001) and household income less than $25 000 (compared with ≥$100 000: aOR, 7.16 [95% CI, 3.50-14.68]; P < .001). The additional travel time associated with use of public transportation compared with private vehicle use varied by race and household income, with non-Hispanic Black respondents with income of $25 000 to $49 999 experiencing higher burden associated with public transportation (mean difference, 81.9 [95% CI, 48.5-115.3] minutes) than non-Hispanic White respondents with similar income (mean difference, 25.5 [95% CI, 17.5-33.5] minutes; P < .001)., Conclusions and Relevance: These findings suggest that certain racial, ethnic, and socioeconomically disadvantaged populations rely on public transportation to seek health care and that reducing delays associated with public transportation could improve care for these patients.

Introduction: Serious illness is a life-limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major surgery annually, and national guidelines recommend that palliative care be available to all seriously ill patients. However, the palliative care needs of elective surgical patients are incompletely described. Understanding baseline caregiving needs and symptom burden among seriously ill older surgical patients could inform interventions to improve outcomes., Methods: Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients ≥66 years who met an established serious illness definition from administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality (AHRQ) criteria. Descriptive analyses were performed for preoperative patient characteristics, including: unpaid caregiving (no or yes); pain (none/mild or moderate/severe); and depression (no, CES-D < 3, or yes, CES-D ≥ 3). Multivariable regression was performed to examine the association between unpaid caregiving, pain, depression, and in-hospital outcomes, including hospital days (days admitted between discharge date and one-year post-discharge), in-hospital complications (no or yes), and discharge destination (home or non-home)., Results: Of the 1343 patients, 55.0% were female and 81.6% were non-Hispanic White. Mean age was 78.0 (SD 6.8); 86.9% had ≥2 comorbidities. Before admission, 27.3% of patients received unpaid caregiving. Pre-admission pain and depression were 42.6% and 32.8%, respectively. Baseline depression was significantly associated with non-home discharge (OR 1.6, 95% CI 1.2-2.1, p = 0.003), while baseline pain and unpaid caregiving needs were not associated with in-hospital or post-acute outcomes in multivariable analysis., Conclusions: Prior to elective surgery, older adults with serious illnesses have high unpaid caregiving needs and a prevalence of pain and depression. Baseline depression alone was associated with discharge destinations. These findings highlight opportunities for targeted palliative care interventions throughout the surgical encounter., (© 2023 The American Geriatrics Society.)

Introduction: Increasing numbers of individuals admitted to hospitals for trauma are older adults, many of whom also have underlying serious illnesses. Older adults with serious illness benefit from palliative care, but the palliative care needs of seriously ill older adults with trauma have not been elucidated. We hypothesize that older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours before trauma admission., Methods: Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients 66 years or older who met an established definition of serious illness in surgery and were admitted with trauma. Descriptive analyses were performed for baseline patient characteristics, pre-admission pain (dichotomized as none/mild vs. moderate/severe), depression (dichotomized as no, Center for Epidemiologic Studies Depression scale [CES-D] < 3 vs. yes, CES-D ≥ 3), and unpaid caregiving hours (dichotomized as low (<30 h/month), high (≥30 h/month))., Results: We identified 1741 patients, 67.4% were female and 86.8% White. Mean age was 83 (SD 7.5), and 60.3% had ≥4 comorbidities. The majority (62.9%) were admitted due to falls, 33.5% had isolated hip fracture. The prevalence of baseline moderate/severe pain and depression were 38.1% and 42.6%, respectively. Among the cohort, 42.2% had unpaid caregiving, of those 27.7% had ≥30 h/week of unpaid caregiving hours., Conclusions: Prior to trauma admission, older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours. These findings may inform targeted palliative care interventions to reduce symptom burden and post-discharge healthcare utilization., (© 2023 The American Geriatrics Society.)

Background: Elements of charrette planning were employed to develop and examine the relationship between transnationalism, culture and health., Objective: This paper describes the partnership, the first two stages of the planning charrette and lessons learned., Methods: During charrette planning phase 1 we collected data through social network interviews (n = 58), cultural conversations (n = 88), and photovoice (n = 9). In the second phase we performed five charrette planning meetings. Data were synthesized by the planning team., Lessons Learned: The issue centered focus facilitated trust among partners. The holistic, iterative process to planning and interpreting preliminary data provided a deeper understanding of the issues under investigation. Community partners at the table held us accountable to the communities we were studying and infused an undercurrent of social justice in our work., Conclusions: There are advantages in employing a community engaged transdisciplinary team-based approach to the study of transnationalism, culture and health.

Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m 2 ) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Advance care planning, shared decision making, and serious illness conversations are communication processes designed to promote patient-centered care. In onconephrology, patients face a series of complex medical decisions regarding their care at the intersection of oncology and nephrology. Clinicians who aim to ensure that patient preferences and values are integrated into treatment planning must work within a similarly complex care team comprising multiple disciplines. In this review, we describe key decision points in a patient's care trajectory, as well as guidance on how and when to engage in advance care planning, shared decision making, and serious illness discussions. Further research on these processes in the complex context of onconephrology is needed., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: We examined the use of advance care planning (ACP) among Medicare beneficiaries who were identified as transgender. Methods: This study is a cross-sectional analysis of Medicare claims from 2016 to 2018, comparing ACP visits between transgender and other beneficiaries. Results: Beneficiaries identified as transgender were slightly more likely than those who were dual eligible for Medicaid and Medicare, and the remaining fee-for-service Medicare population, to have received a claim for ACP. However, racial and ethnic differences exist and transgender beneficiaries were more likely to receive an ACP claim from hospice/palliative care clinicians compared with primary care clinicians relative to other beneficiaries. Conclusions: Differences in ACP provision may exacerbate disparities in access to ACP benefits faced by transgender patients.

Importance: Advance care planning (ACP) can promote patient-centered end-of-life (EOL) care and is intended to ensure that medical treatments are aligned with patient's values. Sexual and gender minority (SGM) people face greater discrimination in health care settings compared with heterosexual, cisgender people, but it is unknown whether such discrimination occurs in ACP and how it might affect the ACP experiences of SGM people., Objectives: To increase understanding of barriers and facilitators of ACP facing SGM individuals., Design, Setting, and Participants: This mixed-methods national study of ACP included a telephone survey of self-identified SGM and non-SGM participants in a nationally representative sample drawn from a larger omnibus national panel by SSRS. Qualitative interviews were conducted with a subset of survey participants who identified as SGM. Data were collected from October 2020 to March 2021., Exposures: Self-identified SGM., Main Outcomes and Measures: The survey included 4 items from the validated ACP Engagement Survey, adapted to capture experiences of discrimination. Interviews asked about participants' experiences with ACP, including the appointment of medical decision-makers, sharing preferences, and experiences within the health care system more broadly., Results: A total of 603 adults participated in the survey, with 201 SGM individuals (mean [SD] age, 45.7 [18.7] years; 101 [50.2%] female; 22 [10.9%] Black, 37 [18.4%] Hispanic, and 140 [69.7%] White individuals) and 402 non-SGM individuals (mean [SD] age, 53.7 [19.2] years; 199 [49.5%] female; 35 [8.7%] Black, 41 [10.2%] Hispanic, and 324 [80.6%] White individuals). Regarding reasons for not completing ACP, SGM respondents, compared with non-SGM respondents, were more likely to say "I don't see the need" (72 [73.5%] vs 131 [57.2%], P = .006) and "I feel discriminated against by others" (12 [12.2%] vs 6 [2.6%], P < .001). Of 25 completed interviews among SGM participants, 3 main themes were identified: how fear and experiences of discrimination affect selection of clinicians and whether to disclose SGM identity; concerns about whether EOL preferences and medical decision-makers would be supported; and a preference to discuss EOL decisions and values outside of clinical settings., Conclusions and Relevance: This study found that fear of disclosing sexual orientation or gender identity information and discrimination are important barriers to ACP for SGM in clinical settings, but discussions of preferences and values still occur between many SGM people and medical decision-makers. More SGM-specific patient-centered care might better support these discussions within the health care system. Furthermore, health systems can facilitate improved engagement by supporting clinician sensitivity training, including guidance on documentation and requirements.

Background: Patient-reported outcome measures (PROMs) are increasingly being used throughout surgical disciplines, but their use is limited in multilingual patient populations. We aimed to investigate facilitators and barriers to PROMs collection for patients with limited English proficiency (LEP)., Methods: Semi-structured interviews were performed with providers from multiple surgical disciplines across six academic medical centers until thematic saturation was achieved., Results: Among 24 interviews, respondents noted either systematic exclusion of patients with LEP or significant barriers to implementation. Barriers included lack of valid and translated PROMs, lack of multi-lingual electronic medical record integration, and insufficient time and resources to accommodate patients with LEP. Facilitators to collection included institutional leadership and funding support for validating translations., Conclusion: These barriers may result in inadvertent but systematic exclusion of patients with LEP from outcomes datasets as well as clinical decision making. Future implementation projects should consider these themes when developing initiatives for more equitable PROMs collection and utilization., (Copyright © 2022. Published by Elsevier Inc.)

Background: To date, most research on patients' experiences with advance care planning (ACP) focuses on motivations to engage in discussions and how patients prepare. Gaps remain in understanding how non-critically ill Medicare patients perceive ACP encounters, including how they characterize positive and negative experiences with ACP., Objectives: Understanding these patients' perceptions is imperative as Medicare has sought to incentivize provision of ACP services via two billing codes in 2016., Design: Qualitative focus group study. Thematic analysis was performed to assess participants ACP experience., Participants: Medicare beneficiaries who had engaged in or were billed for ACP., Key Results: Seven focus groups were conducted with 34 Medicare beneficiaries who had engaged in ACP across 5 US health systems. Participants described a spectrum of perceptions regarding ACP, and a range of delivery approaches, including group ACP, discussions with specialists during serious illness, and ACP in primary care settings during wellness visits. Despite being billed for ACP or having ACP services noted in their medical record, many did not recognize that they had engaged in ACP, expressed lack of clarity over the term "ACP," and were unaware of the Medicare billing codes. Among participants who described quality patient-centered ACP experiences, three additional themes were identified: trusted and established patient/clinician relationships, transparent communication and documentation, and an understanding that ACP is revisable. Participants offered recommendations for clinicians and health systems to improve the patient ACP experience., Conclusions: Findings include actionable steps to promote patient-centered ACP experiences, including clinician training to support improved communication and facilitating shared decision-making, allocating sufficient clinical time for discussions, and ensuring that documentation of preferences is clear and accessible. Other approaches such as group ACP and ACP navigators may help to support patient interests within clinical constraints and need to be further explored., (© 2022. Society of General Internal Medicine.)

Background: Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions., Method: In this national study, we conducted semi-structured interviews with purposively selected clinicians from 6 diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians' perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them., Results: Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians' difficulty approaching ACP (preconceived views of patients' preferences, narrow definitions of successful ACP, and lack of institutional resources), while the final theme illustrated facilitators to ACP (acknowledging bias and rejecting stereotypes, mission-driven focus on ACP, and acceptance of all preferences)., Conclusions: Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In 2016 Medicare introduced advance care planning Current Procedural Terminology (CPT) codes to reimburse clinicians for time spent providing the service. Despite recent increases, use of these codes remains low for reasons incompletely captured by quantitative research. To further identify barriers and facilitators to code use for Medicare fee-for-service enrollees, we conducted case studies at eleven health systems, including 272 interviews with clinicians, administrators, and key leadership. Five themes related to use of the new codes emerged: code-based constraints to billing, burdening patients with unexpected charges, ethical concerns with billing for discussion of advance care plans, incentives to signal the importance of their use in billing, and increasing both workflow burden and the need for institutional supports and training. Respondents also observed that use was facilitated by health systems' investment in clinician training and in processes to audit the codes' use. Our findings suggest that increased reimbursement, strong institutional commitment and support, and streamlined workflow could improve the use of the new CPT codes to document receipt of and ensure access to Medicare advance care planning.

Background: In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Including the DI in insurance claims could be a potent method to monitor implanted devices, yet implementation has lagged because of questions of benefit and operational concerns., Methods: To illustrate the potential benefit of including DIs in claims, rates of 90-day adverse events after implantation using an electronic health record (EHR) were compared with the EHR plus claims, which capture utilization outside that EHR's health system. To explore operations, we planned a pilot project to transmit the DI of implanted devices from the point of care to the claim at two provider/payer pairs., Results: By querying claims plus EHR, estimated rates of patients with potential adverse events were as much as 3.75 times higher. For our pilot, our multistakeholder team identified and resolved the following five challenges: (1) capturing the DI at the point of care; (2) selecting a location for the DI on the claim form; (3) transmitting the DI to the claim form; (4) analyzing the claim forms received by the payer; and (5) verifying the quality of the transmitted information., Conclusions: Including DIs on claims could allow more complete data capture of adverse events for implanted devices than the EHR data. We overcame challenges in transmitting the DI to the claim with attention to planning and multistakeholder involvement., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Advance care planning (ACP), in which patients or their surrogates discuss goals and preferences for care with physicians, attorneys, friends, and family, is an important approach to help align goals with actual treatment. ACP may be particularly valuable in patients with advanced serious illnesses such as Alzheimer's disease and related dementias (ADRDs) for whom surgery carries significant risks., Objective: To determine the frequency, timing, and factors associated with ACP billing in Medicare beneficiaries with ADRD undergoing nontrauma inpatient surgery., Design: This national cohort study analyzes Medicare fee-for-service claims data from 2016 to 2017. All patients had a 6-month lookback and follow-up period., Setting: National Medicare fee-for-service data., Participants: All patients with ADRD, defined according to the Chronic Conditions Warehouse, undergoing inpatient surgery from July 1, 2016 to June 30, 2017., Exposures: Patient demographics, medical history, and procedural outcomes., Main Outcome: ACP billing codes from 6 months before to 6 months after admission for inpatient surgery., Results: This study included 289,428 patients with ADRD undergoing surgery, of whom 21,754 (7.5%) had billed ACP within the 6 months before and after surgical admission. In a multivariable analysis, patients of white race, male sex, and residence in the Southern and Midwestern United States were at the highest risk of not receiving ACP. Of all patients who received ACP, 5960 (27.4%) did so before surgery while 12,658 (52.8%) received ACP after surgery. Timing of ACP after surgery was associated with an Elixhauser comorbidity index of 3 or higher (1.23, p = 0.045) and major postoperative complication or death (odds ratio 1.52, p < 0.0001)., Conclusions and Relevance: Overall ACP billing code use is low among Medicare patients with ADRD undergoing surgery. Billed ACP appears to have a reactive pattern, occurring most commonly after surgery and in association with postoperative mortality and complications. Additional study is warranted to understand barriers to use., (© 2021 The American Geriatrics Society.)

Background: Shared decision making and patient-centred communication have become part of pre-procedural decisions and perioperative care across medical specialties. However, gaps exist in patient communication about the implanted device received and the benefits in sharing information about their procedure and device., Objective: To understand the patients' knowledge of identifying information for their implanted devices and perspectives on sharing their implanted device information., Methods: Four focus groups were conducted with patients who had received a cardiac or vascular implanted device from one of the study sites within the previous 6 months. Data were transcribed and thematically analysed., Results: Five themes emerged: lack of awareness of identifying information on implanted devices; value of information on implanted devices; varying trust with sharing device information; perceived risk with sharing device information; and lack of consensus on a systematic process for tracking implanted devices., Discussion: Patients desire post-procedural information on their implanted device and a designated plan for longitudinal follow-up, but lack trust and perceive risk with broadly sharing their implanted device information., Conclusion: After receiving an implanted device, post-procedural patient communication needs to be expanded to include identifying information on the device including the unique device identifier, how long-term tracking will be supported and the process for notification in case of a problem with the device. This communication should also include education on how sharing device information supports patients' long-term health care, post-market safety surveillance and research., Patient or Public Contribution: The research team included members who were also patients with implanted devices., (© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Importance: Advance care planning (ACP) is intended to maximize the concordance of preferences with end-of-life (EOL) care and is assumed to lead to less intensive use of health care services. The Centers for Medicare & Medicaid Services began reimbursing clinicians for ACP discussions with patients in 2016., Objective: To determine whether billed ACP visits are associated with intensive use of health care services at EOL., Design Setting and Participants: This prospective patient-level cohort analysis of seriously ill patients included Medicare fee-for-service beneficiaries who met criteria for serious illness from January 1 to December 31, 2016, and died from January 1, 2017, to December 31, 2018. Analyses were completed from November 1, 2020, to March 31, 2021., Main Outcomes and Measures: Five measures of EOL health care services used (inpatient admission, emergency department visit, and/or intensive care unit stay within 30 days of death; in-hospital death; and timing of first hospice bill) and a measure of EOL expenditures. Analyses were adjusted for age, race and ethnicity, sex, Charlson Comorbidity Index, Medicare-Medicaid dual eligibility, and expenditure by hospital referral region (high, medium, or low). The primary exposure was receipt of a billed ACP service classified as none, timely (>1 month before death), or late (first ACP visit ≤1 month before death)., Results: Of the 955 777 Medicare beneficiaries who met criteria for serious illness in 2016 and died in 2017 or 2018, 522 737 (54.7%) were women, 764 666 (80.0%) were 75 years or older, and 822 684 (86.1%) were non-Hispanic White individuals. Among the study population, 81 131 (8.5%) had a timely ACP visit, and an additional 22 804 (2.4%) had a late ACP visit. After multivariable adjustment, compared with patients without any billed ACP visit, patients with a timely ACP visit experienced significantly less intensive EOL care on 4 of 5 measures, including in-hospital death (adjusted odds ratio [aOR], 0.85; 95% CI, 0.84-0.87), hospital admission (aOR, 0.84; 95% CI, 0.83-0.85), intensive care unit admission (aOR, 0.87; 95% CI, 0.85-0.88), and emergency department visit (OR, 0.83; 95% CI, 0.82-0.84). Only small or insignificant differences in late hospice use or mean total EOL expenditures were noted. Compared with patients without ACP, patients with late ACP experienced more intensive EOL care, including in-hospital death (aOR, 1.22; 95% CI, 1.19-1.26), hospital admission (aOR, 5.28; 95% CI, 5.07-5.50), intensive care unit admission (aOR, 1.57; 95% CI, 1.53-1.62), and emergency department visit (aOR, 3.87; 95% CI, 3.72-4.02)., Conclusions and Relevance: In this cohort study of US Medicare beneficiaries, billed ACP services during the EOL course of patients with serious illness were relatively uncommon, but if they occurred before the last month of life, they were associated with less intensive use of EOL services. Further research on the variables affecting hospice use and expenditures in the EOL period and the differential effect of late ACP is recommended to understand the relative role of ACP in achieving goal-concordant care., Competing Interests: Conflict of Interest Disclosures: Dr Weissman reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Gazarian reported receiving grants from the National Institute of Nursing Research (NINR) during the conduct of the study. Dr Kim reported receiving grants from the NIH for unrelated projects and personal fees from Alosa Health continuing medical educational material development outside the submitted work. Dr Rodgers reported receiving grants from Partners Health and consulting on the NIH grant that supported this work during the conduct of the study. Ms Manful reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported., (Copyright 2021 Weissman JS et al. JAMA Health Forum.)

Objective: Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum., Design, Setting, and Participants: Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method., Results: Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors., Conclusions: Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: For implanted devices, an effective postmarket surveillance system does not exist. For medications, the Food and Drug Administration's Sentinel Initiative plays that role, relying mainly on drug codes in insurance claims. Unique device identifiers (UDIs) could play an analogous role for implants, but there is no mandate for providers to include UDIs in claims or for payers to record them. Objections have been raised to incorporating UDIs into claims based on a potential burden on providers., Methods: To assess this purported barrier, we modified information systems at 2 provider-payer dyads to allow for the transmission of UDI data from provider to payer. In addition, to illustrate the potential benefit of including device data in claims, we used our data to compare rates of 90-day adverse events after implantation using the electronic health record (EHR) alone with the EHR plus claims., Results: The software system modifications were modest and performed as designed. Moreover, the level of difficulty of their development and implementation was comparable to that associated with a typical new release of an existing system. In addition, our data demonstrated the ability of claims-based data plus EHR data to reveal a larger percentage of postprocedure adverse events than data from EHRs alone., Conclusions: Modifying information systems to allow for the transmission of UDI data from providers to payers should not impose a substantial burden on either. Implementation of a postmarket surveillance system based on such data in claims will require, however, the development of a system analogous to Sentinel., Competing Interests: The other authors disclose no conflict of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Successful aging is a concept that has gained popularity and relevance internationally among gerontologists in recent decades. Examining lay older adults' perspectives on successful aging can enhance our understanding of what successful aging means. We conducted a systematic review of peer reviewed studies from multiple countries published in 2010-2020 that contained qualitative responses of lay older adults to open-ended questions such as "What does successful aging mean to you?" We identified 23 studies conducted in 13 countries across North America, Western Europe, the Middle East, Asia, and Oceania. We identified no studies meeting our criteria in Africa, South America, Eastern Europe, North Asia, or Pacific Islands. Across all regions represented in our review, older adults most commonly referred to themes of social engagement and positive attitude in their own lay definitions of successful aging. Older adults also commonly identified themes of independence and physical health. Least mentioned were themes of cognitive health and spirituality. Lay definitions of successful aging varied by country and culture. Our findings suggest that gerontology professionals in fields including healthcare, health psychology, and public health may best serve older adults by providing services that align with older adults' priority of maintaining strong social engagement as they age. Lay perspectives on successful aging acknowledge the importance of positive attitude, independence, and spirituality, in addition to physical and cognitive functioning.

Objective: Dementia has been associated with increased complications and mortality in orthopedics and other surgical specialties, but has received limited attention in vascular surgery. Therefore, we evaluated the association of dementia with surgical outcomes for elderly patients with Medicare who underwent a variety of open and percutaneous vascular surgery procedures., Methods: We reviewed claims data from the Centers for Medicare and Medicaid Services for beneficiaries enrolled in Medicare Part A fee-for-service insurance from January 1, 2011, to December 31, 2011, who underwent inpatient vascular surgery. Only the first surgery during the first admission was considered for analysis. Traditional outcomes (30- and 90-day mortality, intensive care admission, complications, length of stay) and patient-centered outcomes (discharge to home, extended skilled nursing facility [SNF] stay, time at home) were adjusted for patient and procedure characteristics using multilevel linear or logistic regression as appropriate. All analyses were performed using SAS (v9.4, SAS Institute Inc, Cary, NC)., Results: Our study included 210,918 patients undergoing vascular surgery, of whom 27,920 carried a diagnosis of dementia. The average age of the entire cohort was 75.74 years, and 55.43% were male. Patients with dementia were older and had higher rates of comorbidities compared with patients without a dementia diagnosis. The three most common defined classes of intervention excluding miscellaneous ones were cerebrovascular, peripheral arterial, and aortic cases, which jointly accounted for 53.15% of cases. Among all cases, 56.62% were open. Emergent/urgent cases were more frequent amongst those with dementia (60.66% vs 37.93%; P < .001). After adjustment, patients with dementia had increased odds of 30-day mortality (odds ratio [OR], 1.21; P < .0001) and 90-day mortality (OR, 1.63; P < .0001), extended SNF stay (OR, 3.47; P < .0001), and longer hospital length of stay (8.29 days vs 5.41 days; P < .001). They were less likely to be discharged home (OR, 0.31; P < .0001) and spent a lower fraction of time at home after discharge (63.29% vs 86.91%; P < .001). Intensive care admission and inpatient complications were similar between the two groups., Conclusions: Dementia is associated with poor traditional outcomes, including increased 30- and 90-day mortality and longer hospital lengths of stay in this large national patient sample. It is also associated with worse patient-centered outcomes, including substantially lower discharge rates to home, less time spent at home after discharge, and higher rates of extended stay in a SNF. These data should be used to counsel patients facing vascular surgery to provide goal-concordant care, particularly to patients with dementia., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Medicare beneficiaries with high medical needs can benefit from Advance Care Planning (ACP). Medicare reimburses clinical providers for ACP discussions, but it is unknown whether high-need beneficiaries are receiving this service., Objective: To compare rates of billed ACP discussions among a cohort of high-need Medicare beneficiaries with the non-high-needs Medicare population., Design: Retrospective analysis of Medicare Fee-for-Service (FFS) claims in 2017 comparing high-need beneficiaries (seriously ill, frail, ESRD, and disabled) with non-high need beneficiaries., Setting: Nationally representative FFS Medicare 20% sample., Participants: Medicare beneficiaries were assigned to one of the following classifications: seriously ill (65+), frail (65+), seriously ill & frail (65+); non-high need (65+); end stage renal disease (ESRD) or disabled (<65). All participants had data available for years 2016-2017., Exposure: Receipt of a billed ACP discussion, CPT codes 99497 or 99498., Main Outcome and Measure: Rates of billed ACP visits were compared between high-need patients and non-high-need patients. Rates were adjusted for the 65+ population for sex, age, race/ethnicity, Charlson comorbidity index, Medicare/Medicaid dual eligibility status, and Hospital Referral Region., Results: Among the 65+ groups, those most likely to have a billed ACP discussion included seriously ill & frail (5.2%), seriously ill (4.2%), and frail (3.3%). Rates remained consistent after adjusting (4.5%, 4.0%, 3.1%, respectively). Each subgroup differed significantly (p < .05) from non-high need beneficiaries (2.3%) in both unadjusted and adjusted analyses. Among the <65 high need groups, the rates were 2.7% for ESRD and 1.3% for the disabled (the latter p < .05 compared with non-high needs)., Conclusions and Relevance: While rates of billed ACP discussions varied among patient groups with high medical needs, overall they were relatively low, even among a cohort of patients for whom ACP may be especially relevant., Competing Interests: The authors have declared that no competing interests exist.

Youth can be valuable partners in community health improvement efforts. Latino youth from Lawrence, MA were engaged in research and health promotion over an 11-month period. Utilizing their knowledge of the community, youth assessed local parks and carried out evidence-based health promotion efforts to communicate community resources to encourage physical activity, nurture community ownership of parks, and advocate for park improvements. Health promotion efforts can engage youth in strategies to address critical public health issues by leveraging their unique perspective and distinct location within communities. The communications developed by the youth were distributed within the community, benefiting residents directly. Youth were motivated to engage in the project by a sense of civic obligation, and upon completing the project, they expressed that they had gained research and communication skills and were inspired to continue to support their community. Youth engagement in applied research and health promotion at the local level can provide a foundation for community health improvement efforts that are relevant for distinct communities, while fostering the positive development of youth, and nurturing community-driven efforts to help create a healthier environment.