Claire K. Ankuda

Measuring critical deficits in shared decision making before elective surgery

OBJECTIVE Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of deficiencies in informed surgical consent and shared decision-making in preoperative patients. METHODS Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings. RESULTS 13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits. CONCLUSION Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process. PRACTICE IMPLICATIONS Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.

Trends in Caregiving Assistance for Home-Dwelling, Functionally Impaired Older Adults in the United States, 1998-2012.

Trends in Caregiving Assistance for Home-Dwelling, Functionally Impaired Older Adults in the United States, 1998-2012 As more people in the United States age with chronic disease,1 needs for caregiving increase.2 Whether the source of caregiving for disabled older adults is changing is unknown. This study examined temporal trends in caregiving for homedwelling older adults with functional disability.

Healthcare Proxy Awareness of Suspected Infections in Nursing Home Residents with Advanced Dementia

To determine healthcare proxy involvement in decision‐making regarding infections in individuals with advanced dementia.

Association Between Spousal Caregiver Well-Being and Care Recipient Healthcare Expenditures

To measure the association between spousal depression, general health, fatigue and sleep, and future care recipient healthcare expenditures and emergency department (ED) use.

Provision of Palliative Care Services by Family Physicians Is Common

Objective: Provision of palliative care services by primary care physicians is increasingly important with an aging population, but it is unknown whether US primary care physicians see themselves as palliative practitioners. Methods: This study used cross-sectional analysis of data from the 2013 American Board of Family Medicine Maintenance of Certification Demographic Survey. Results: Of 10,894 family physicians, 33.1% (n = 3609) report providing palliative care. Those providing palliative care are significantly more likely to provide non–clinic-based services such as care in nursing homes, home visits, and hospice. Controlling for other characteristics, physicians reporting palliative care provision are significantly (P < .05) more likely to be older, white, male, rural, and practicing in a patient-centered medical home. Conclusion: One third of family physicians recertifying in 2013 reported providing palliative care, with physician and practice characteristics driving reporting palliative care provision.

Regional Variation in Primary Care Involvement at the End of Life

PURPOSE Variation in end-of-life care in the United States is frequently driven by the health care system. We assessed the association of primary care physician involvement at the end of life with end-of-life care patterns. METHODS We analyzed 2010 Medicare Part B claims data for US hospital referral regions (HRRs). The independent variable was the ratio of primary care physicians to specialist visits in the last 6 months of life. Dependent variables included the rate of hospital deaths, hospital and intensive care use in the last 6 months of life, percentage of patients seen by more than 10 physicians, and Medicare spending in the last 2 years of life. Robust linear regression analysis was used to measure the association of primary care physician involvement at the end of life with the outcome variables, adjusting for regional characteristics. RESULTS We assessed 306 HRRs, capturing 1,107,702 Medicare Part B beneficiaries with chronic disease who died. The interquartile range of the HRR ratio of primary care to specialist end-of-life visits was 0.77 to 1.21. HRRs with high vs low primary care physician involvement at the end of life had significantly different patient, population, and health system characteristics. Adjusting for these differences, HRRs with the greatest primary care physician involvement had lower Medicare spending in the last 2 years of life (

Caregiving for Older Adults with Obesity in the United States

65,160 vs

What Matters Most? A Mixed Methods Study of Critical Aspects of a Home-Based Palliative Program

69,030; P = .003) and fewer intensive care unit days in the last 6 months of life (2.90 vs 4.29; P <.001), but also less hospice enrollment (44.5% of decedents vs 50.4%; P = .004). CONCLUSIONS Regions with greater primary care physician involvement in end-of-life care have overall less intensive end-of-life care.

Association of Physician Specialty with Hospice Referral for Hospitalized Nursing Home Patients with Advanced Dementia

To determine the difference in receipt of activity of daily living (ADL) assistance between obese and normal‐weight older adults.

Association Between Purpose in Life and Glucose Control Among Older Adults

Background: Home-based palliative care programs have shown value in improving quality of care and lowering costs for seriously ill patients. It is unknown what specific elements of these programs matter most to patients and caregivers. Aim: To identify what services are critical and why they matter to patients in a home-based palliative program. Setting/Participants: A mixed methods study of 18 participants in the At Home Support (AHS) program in Southeast Michigan. Measurements: Two semistructured interviews were conducted for each participant, one while enrolled in AHS and another 3 months after the program ended to elicit the impact of AHS on their care. Qualitative theme data were merged with quantitative data on demographics, social and financial resources, symptoms, medical conditions, functional status, and utilization of health care while in AHS. Results: Four major themes of critical services reported by distinct populations of participants were described—medical support, endorsed by nearly every participant; emotional and spiritual support, endorsed by those with serious illness and symptom burden; practical assistance, endorsed by those with functional disability and isolation; and social services, endorsed by those in poverty. Medical monitoring was also described as critical but only by healthier participants. Conclusion: This study presents a conceptual model of the critical services in home-based palliative care and why these services are important to high-risk patients. This model may be used to guide further research and evaluation work on the benefits of home-based palliative care.