Elmer D. Abbo

Video decision support tool for advance care planning in dementia: randomised controlled trial

Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks. Design Randomised controlled trial conducted between 1 September 2007 and 30 May 2008. Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston. Participants Convenience sample of 200 older people (≥65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women. Intervention Verbal narrative alone (n=106) or with a video decision support tool (n=94). Main outcome measures Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care. Results Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (χ2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (κ=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (κ=0.79) (P<0.001 for difference). Conclusion Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time. Trial registration Clinicaltrials.gov NCT00704886.

Health Literacy not Race Predicts End-of-Life Care Preferences

BACKGROUND Several studies have reported that African Americans are more likely than whites to prefer aggressive treatments at the end of life. OBJECTIVE Since the medical information presented to subjects is frequently complex, we hypothesized that apparent differences in end-of-life preferences and decision making may be due to disparities in health literacy. A video of a patient with advanced dementia may overcome communication barriers associated with low health literacy. DESIGN Before and after oral survey. PARTICIPANTS Subjects presenting to their primary care doctors. METHODS Subjects were asked their preferences for end-of-life care after they heard a verbal description of advanced dementia. Subjects then viewed a 2-minute video of a patient with advanced dementia and were asked again about their preferences. For the analysis, preferences were dichotomized into comfort care and aggressive care. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM) and subjects were divided into three literacy categories: low (0-45, sixth grade and below), marginal (46-60, seventh to eighth grade) and adequate (61-66, ninth grade and above). Unadjusted and adjusted logistic regression models were fit using stepwise algorithms to examine factors related to initial preferences before the video. RESULTS A total of 80 African Americans and 64 whites completed the interview. In unadjusted analyses, African Americans were more likely than whites to have preferences for aggressive care after the verbal description, odds ratio (OR) 4.8 (95% confidence interval [CI] 2.1-10.9). Subjects with low or marginal health literacy were also more likely than subjects with adequate health literacy to have preferences for aggressive care after the verbal description, OR 17.3 (95% CI 6.0-49.9) and OR 11.3 (95% CI 4.2-30.8) respectively. In adjusted analyses, health literacy (low health literacy: OR 7.1, 95% CI 2.1-24.2; marginal health literacy OR 5.1, 95% CI 1.6-16.3) but not race (OR 1.1, 95% CI 0.3-3.2) was an independent predictor of preferences after the verbal description. After watching a video of advanced dementia, there were no significant differences in the distribution of preferences by race or health literacy. CONCLUSIONS Health literacy and not race was an independent predictor of end-of-life preferences after hearing a verbal description of advanced dementia. In addition, after viewing a video of a patient with advanced dementia there were no longer any differences in the distribution of preferences according to race and health literacy. These findings suggest that clinical practice and research relating to end-of-life preferences may need to focus on a patient education model incorporating the use of decision aids such as video to ensure informed decision-making.

The increasing number of clinical items addressed during the time of adult primary care visits.

BACKGROUNDPrimary care physicians report that there is insufficient time to meet patients’ needs during clinical visits, but visit time has increased over the past decade.OBJECTIVETo determine whether the number of clinical items addressed during the primary care visit has increased, and if so, whether this has been associated with changes in visit length and the pace of clinical work.DESIGNAnalysis of non-hospital-based adult primary care visits from 1997 to 2005, as reported in the National Ambulatory Medical Care Survey.PARTICIPANTSA total of 46,431 adult primary care visits.MEASUREMENTSWe assessed changes over time for the total number of clinical items addressed per visit (including diagnoses, medications, tests ordered, and counseling), visit duration, and average available time per clinical item. In adjusted analyses we controlled for patient and physician characteristics.RESULTSThe number of clinical items addressed per visit increased from 5.4 to 7.1 from 1997 to 2005 (p < 0.001). Visit duration concurrently increased from 18.0 to 20.9 min (p < 0.001). The increase in the number of clinical items outpaced the increase in duration, resulting in a decrease in time per clinical item from 4.4 to 3.8 (p = 0.04). These changes occurred across patient age and payer status and were confirmed in adjusted analyses.CONCLUSIONSThe volume of work associated with primary care visits has increased to a greater extent than has visit duration, resulting in less available time to address individual items. These findings have important implications for reimbursing physician time and improving the quality of care.

The time burden of overweight and obesity in primary care

BackgroundOverweight and obesity are associated with many conditions treated in primary care. Our objectives were: 1) to determine the frequency of weight-related conditions in a national sample of outpatient visits in the United States; 2) to establish the percentage of diagnosis codes and visit codes attributable to overweight and obesity; and 3) to estimate time spent to address these conditions, including time attributable to overweight and obesity itself.MethodsWe analyzed primary care visits from the 2005 and 2006 National Ambulatory Medical Care Survey (NAMCS) in the United States. Weight-related conditions included diabetes, hypertension, hyperlipidemia, obesity, cardiovascular disease, osteoarthritis, and low back pain. We used multivariable logistic regression to estimate an odds ratio for each weight-related condition, which we then converted to an attributable fraction (AF). The AF represents the percentage of diagnosis codes and visit codes attributable to excess weight for that condition. We then divided total visit time among all diagnoses and clinical items addressed at the primary care visit. Finally, to calculate the time attributable to overweight and obesity, we multiplied the AFs by the time spent on each weight-related condition.ResultsThe total number of clinical items (diagnoses + medications + tests + counseling) was estimated to be 7.6 per patient, of which 2.2 were weight-related. Of a total visit time of 21.77 minutes, time spent addressing weight-related conditions was 5.65 minutes (30%), including 1.75 minutes (8.0%) attributable to overweight and obesity.ConclusionsApproximately 8% of time from primary care visits is attributable to overweight and obesity. This estimate is conservative because the NAMCS only allows for coding of three diagnoses addressed per visit. Estimates of the time burden of overweight and obesity provide data to prioritize weight management for prevention and treatment.

Cardiopulmonary resuscitation outcomes in hospitalized community-dwelling individuals and nursing home residents based on activities of daily living

To determine whether poor functional status is associated with worse outcomes after attempted cardiopulmonary resuscitation (CPR).

Patient Preferences in Instructional Advance Directives

BACKGROUND Instructional advance directives (ADs) are traditionally written to apply in terminal illness. As such, they do not readily capture patient preferences for care in acute and chronic illness. OBJECTIVE To test whether patients prefer a modified AD that includes preferences to limit life-sustaining therapy (LST) for critical illness and advanced dementia over a traditional AD. METHODS A convenience sample of medically stable, hospitalized general medical patients were presented a traditional AD (the recommended Illinois statutory living will that limits LST in terminal illness) and a modified AD. The modified AD presents four conditional options: (1) to limit LST in terminal illness, (2) to limit LST in critical illness to a reasonable trial, (3) to refuse LST in advanced dementia (described in lay language), and (4) to refuse artificial hydration and nutrition (AHN) in advanced dementia. The primary outcome was the preferred AD to present to patients. Secondary outcomes included the AD choice of those who executed an AD and the options chosen by those executing the modified AD. RESULTS Seventy-two patients completed the survey. Eighty-six percent (95% confidence interval [CI], 76%-93%), preferred that the modified AD be presented to patients over the traditional AD. Twenty-one patients chose to execute an AD. Eighteen (86%; 95% CI, 64%-97%), executed the modified AD. Twelve executed all four options. CONCLUSIONS Traditional instructional ADs fail to capture important patient preferences. Future research should further validate these preferences and explore whether including these specific options in ADs can improve their efficacy.

Teaching Residents to Consider Costs in Medical Decision Making

The largest discrepancy detected by Goold and Stern (2006) in their study of resident and nonresident physicians’ attitudes towards areas of improved focus in residency ethics curriculum lay in the need to understand the ethical implications involved in healthcare resource allocation. The fact that residents failed to recognize the importance of this pervasive issue may appear ironic, but it should not be surprising. Residents are routinely faced with the burdens of practicing medicine in a world of limited resources. Their failure to recognize the ethical implications of their practice, however, stems from a general unwillingness among attending physicians to confront this problem. Unfortunately, traditional medical ethics has hampered rather than fostered such discussion. Despite the virtually unbounded demand for healthcare, the resources available for healthcare are inherently limited. Although there has long been recognition of this fact, there has been great ambivalence on multiple fronts about acknowledging this limitation. Patients simply want open access to the best in high quality care and sophisticated technology. Payers have only set limits on the margins of care. And physicians, at least historically and still commonly today, practice medicine almost in a state of denial of healthcare costs. Despite the fact that it is primarily through the orders of physicians that the actual decisions to consume healthcare resources are made, physicians have remained loathe to assume responsibility for considering costs in decision making. In fact, the dominant view espoused by physicians and medical ethicists is that the consideration of costs in a patient’s medical decisions is a violation of their trust to the patient (Hall 1997). Only a few physicians, most prominently Goold and Stern’s University of Michigan colleague, Peter Ubel, and a handful of ethicists have taken the contrarian view that physicians must consider costs in their medical decisions. Ubel (2000) correctly argues such costsensitive decisions nevertheless occur, but that physicians unconsciously mask their aversion to cost considerations by internalizing such calculations in what they define to be the standard of care. Such hidden behavior is unfortunate. Armed with expert knowledge, physicians are best situated to make reasonable, cost-sensitive, medical decisions calibrated to the unique particulars of a patient’s circumstances (Hall 1997; Ubel 2000). Because physicians essentially learn as residents how to practice medicine by observing the practice of their supervising attending physicians, opportunities to develop skills in making cost-sensitive medical decisions are obscured while the false notion of the physician as unswerving advocate is perpetuated. It is no surprise, then, that resident physicians do not readily recognize health care resource allocation as an ethical issue in their practice despite the fact that they are constantly making decisions that affect healthcare costs. In many ways, the traditional ideal of the uncorrupted physician is already obsolete. For example, hospitalists increasingly dominate the inpatient medical landscape. Compared with nonhospitalists, hospitalists tend to have shorter lengths of stay (Meltzer et al. 2002; Halasyamani et al. 2005). Length of stay is the primary driver of hospital costs, which account for approximately one third of all healthcare spending. While aiming to provide appropriate care, hospitalists are actively focused on prompt discharge and decreasing the length of stay for the hospital’s patients. Hospitals benefit from increasing overall capacity from the additional patient through-put achieved by the decreased length of stay. Because many hospitalists receive significant financial support from or are actually employed by the hospitals they serve, it is not surprising that hospitalists have embraced this dual allegiance to patient and hospital. Although there were certainly initial concerns about the effects of hospitalists on continuity of care and the

Malpractice Litigation and Nursing Home Quality of Care

OBJECTIVE To assess the potential deterrent effect of nursing home litigation threat on nursing home quality. DATA SOURCES/STUDY SETTING We use a panel dataset of litigation claims and Nursing Home Online Survey Certification and Reporting (OSCAR) data from 1995 to 2005 in six states: Florida, Illinois, Wisconsin, New Jersey, Missouri, and Delaware, for a total of 2,245 facilities. Claims data are from Westlaws Adverse Filings database, a proprietary legal database, on all malpractice, negligence, and personal injury/wrongful death claims filed against nursing facilities. STUDY DESIGN A lagged 2-year moving average of the county-level number of malpractice claims is used to represent the threat of litigation. We use facility fixed-effects models to examine the relationship between the threat of litigation and nursing home quality. PRINCIPAL FINDINGS We find significant increases in registered nurse-to-total staffing ratios in response to rising malpractice threat, and a reduction in pressure sores among highly staffed facilities. However, the magnitude of the deterrence effect is small. CONCLUSIONS Deterrence in response to the threat of malpractice litigation is unlikely to lead to widespread improvements in nursing home quality. This should be weighed against other benefits and costs of litigation to assess the net benefit of tort reform.