Katherine R. Courtright

Meeting the Milestones. Strategies for Including High-Value Care Education in Pulmonary and Critical Care Fellowship Training

Physician decision making is partially responsible for the roughly 30% of U.S. healthcare expenditures that are wasted annually on low-value care. In response to both the widespread public demand for higher-quality care and the cost crisis, payers are transitioning toward value-based payment models whereby physicians are rewarded for high-value, cost-conscious care. Furthermore, to target physicians in training to practice with cost awareness, the Accreditation Council for Graduate Medical Education has created both individual objective milestones and institutional requirements to incorporate quality improvement and cost awareness into fellowship training. Subsequently, some professional medical societies have initiated high-value care educational campaigns, but the overwhelming majority target either medical students or residents in training. Currently, there are few resources available to help guide subspecialty fellowship programs to successfully design durable high-value care curricula. The resource-intensive nature of pulmonary and critical care medicine offers unique opportunities for the specialty to lead in modeling and teaching high-value care. To ensure that fellows graduate with the capability to practice high-value care, we recommend that fellowship programs focus on four major educational domains. These include fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. In doing so, pulmonary and critical care educators can strive to train future physicians who are prepared to provide care that is both high quality and informed by cost awareness.

Rationale and Design of the Randomized Evaluation of Default Access to Palliative Services (REDAPS) Trial.

The substantial nationwide investment in inpatient palliative care services stems from their great promise to improve patient-centered outcomes and reduce costs. However, robust experimental evidence of these benefits is lacking. The Randomized Evaluation of Default Access to Palliative Services (REDAPS) study is a pragmatic, stepped-wedge, cluster randomized trial designed to test the efficacy and costs of specialized palliative care consultative services for hospitalized patients with advanced chronic obstructive pulmonary disease, dementia, or end-stage renal disease, as well as the overall effectiveness of ordering such services by default. Additional aims are to identify the types of services that are most beneficial and the types of patients most likely to benefit, including comparisons between ward and intensive care unit patients. We hypothesize that patient-centered outcomes can be improved without increasing costs by simply changing the default option for palliative care consultation from opt-in to opt-out for patients with life-limiting illnesses. Patients aged 65 years or older are enrolled at 11 hospitals using an integrated electronic health record. As a pragmatic trial designed to enroll between 12,000 and 15,000 patients, eligibility is determined using a validated, electronic health record-based algorithm, and all outcomes are captured via the electronic health record and billing systems data. The time at which each hospital transitions from control, opt-in palliative care consultation to intervention, opt-out consultation is randomly assigned. The primary outcome is a composite measure of in-hospital mortality and length of stay. Secondary outcomes include palliative care process measures and clinical and economic outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT02505035).

A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion

Background. Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge. Objective. This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients. Methodology. Outpatients (N = 316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive either the option to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. Patients in both groups could decline to complete an advance directive or take their selected version home. The primary outcome was a returned, completed advance directive. Secondary outcomes included whether patients wanted to complete an advance directive, decision satisfaction, quality of life at 3 months, and patient factors associated with advance directive completion. Results. Although offering more advance directive options was not significantly associated with increased rates of completion (13.1% in the standard group v. 12.2% in the expanded group, P = 0.80), it did significantly increase the proportion of patients who wanted to complete an advance directive and took one home (71.9% in standard v. 85.3% in expanded, P = 0.004). There was no difference in satisfaction (P = 0.65) or change in quality of life between groups (P = 0.63). A higher baseline quality of life was independently associated with advance directive completion (P = 0.006). Conclusions and Relevance. These results suggest that although an expanded choice set may initially nudge patients toward completing advance directives without restricting choice, increasing actual completion requires additional interventions that overcome downstream barriers.

Construct validity of five sentiment analysis methods in the text of encounter notes of patients with critical illness

Sentiment analysis may offer insights into patient outcomes through the subjective expressions made by clinicians in the text of encounter notes. We analyzed the predictive, concurrent, convergent, and content validity of five sentiment methods in a sample of 791,216 multidisciplinary clinical notes among 40,602 hospitalizations associated with an intensive care unit stay. None of these approaches improved early prediction of in-hospital mortality. However, positive sentiment measured by Pattern (OR 0.09, 95% Cl 0.04 – 0.17), sentimentr (OR 0.37, 95% Cl 0.25 – 0.63), and Opinion (OR 0.25, 95% Cl 0.07 – 0.89) were inversely associated with death on the concurrent day after adjustment for demographic characteristics and illness severity. Median daily lexical coverage ranged from 5.2% to 20.5%. While sentiment between all methods was positively correlated, their agreement was weak. Sentiment analysis holds promise for clinical applications, but will require a novel domain-specific method applicable to clinical text.

Willingness to participate in pragmatic dialysis trials: the importance of physician decisional autonomy and consent approach

BackgroundPragmatic clinical trials embedded in routine delivery of clinical care can lead to improvements in quality of care, but often have design features that raise ethical concerns.MethodsWe performed a discrete choice experiment and used conjoint analysis to assess how specific attributes of pragmatic dialysis trials influenced patients’ and physicians’ willingness to have their dialysis facility participate in a hypothetical trial of hypertension management. Electronic survey data were collected from 200 patients enrolled from 11 outpatient hemodialysis units and from 203 nephrologists. The three attributes studied were physicians’ treatment autonomy, participants’ research burden, and the approach to consent. The influence of each attribute was quantified using mixed-effects logistic regression.ResultsSimilar proportions of patients were willing to have their facilities participate in a trial with high vs. low physician autonomy (77% vs. 79%; p = 0.13) and research burden (76% vs. 80%; p = 0.06). Opt-in, opt-out, and notification-only consent approaches were acceptable to most patients (84%, 82%, and 81%, respectively), but compared to each of these consent approaches, fewer patients (66%) were willing to have their facility participate in a trial that used no notification (p < 0.001 for each 2-way comparison). Among the physicians, similar proportions were willing to participate in trials with high and low physician autonomy (61% and 61%, respectively, p = 0.96) or with low and high burden (60 and 61%, respectively, p = 0.79). However, as for the patients, the consent approach influenced trial acceptability with 77%, 69%, and 62% willing to participate using opt-in, opt-out, and notification-only, respectively, compared to no notification (36%) (p < 0.001 for each 2-way comparison).ConclusionsCurtailing physician’s treatment autonomy and increasing the burden associated with participation did not influence patients’ or physicians’ willingness to participate in the hypothetical research, suggesting that pragmatic dialysis trials are generally acceptable to patients and physicians. Both patients and physicians preferred consent approaches that include at least some level of patient notification, but the majority of patients were still willing to participate in trials that did not notify patients of the research.

Adaptation of the Acute Organ Failure Score for Use in a Medicare Population.

Objectives: Without widely available physiologic data, a need exists for ICU risk adjustment methods that can be applied to administrative data. We sought to expand the generalizability of the Acute Organ Failure Score by adapting it to a commonly used administrative database. Design: Retrospective cohort study. Setting: One hundred fifty-one hospitals in Pennsylvania. Patients: A total of 90,733 ICU admissions among 77,040 unique patients between January 1, 2009, and December 1, 2009, in the Medicare Provider Analysis and Review database. Measurements and Main Results: We used multivariable logistic regression on a random split cohort to predict 30-day mortality, and to examine the impact of using different comorbidity measures in the model and adding historical claims data. Overall 30-day mortality was 17.6%. In the validation cohort, using the original Acute Organ Failure Score model’s &bgr; coefficients resulted in poor discrimination (C-statistic, 0.644; 95% CI, 0.639–0.649). The model’s C-statistic improved to 0.721 (95% CI, 0.711–0.730) when the Medicare cohort was used to recalibrate the &bgr; coefficients. Model discrimination improved further when comorbidity was expressed as the COmorbidity Point Score 2 (C-statistic, 0.737; 95% CI, 0.728–0.747; p < 0.001) or the Elixhauser index (C-statistic, 0.748; 95% CI, 0.739–0.757) instead of the Charlson index. Adding historical claims data increased the number of comorbidities identified, but did not enhance model performance. Conclusions: Modification of the Acute Organ Failure Score resulted in good model discrimination among a diverse population regardless of comorbidity measure used. This study expands the use of the Acute Organ Failure Score for risk adjustment in ICU research and outcomes reporting using standard administrative data.

Suspect the Unexpected: A 45-Year-Old Man with Fevers, Rash, and Multiorgan Failure

A previously healthy 45-year-old man presented to the emergency department 1 week after the onset of myalgias, chills, and lethargy. At 3 days before presentation, his primary care physician initiated antibiotic therapy with amoxicillin/clavulanic acid by mouth. His symptoms persisted despite treatment, and he developed a nonpruritic rash on his lower extremities. He experienced progressive somnolence and confusion, thus prompting presentation to the emergency department. He was a nonsmoker, worked as a horse farmer, and owned several pets, including dogs, horses, and a turtle. Due to his work and hobbies, he spent a significant amount of time outside. He denied any known tick exposures. Neither family members nor co-workers had experienced recent illness. On physical exam, the patient appeared acutely ill. His vital signs were notable for a temperature of 103.28F, blood pressure of 76/36 mm Hg, heart rate of 118 beats/min, and respiratory rate 30 breaths/min. His oxygen saturation was 90% by pulse oximetry while receiving 100% oxygen via nonrebreather mask. He was somnolent and minimally responsive. Examination was otherwise notable for accessory muscle use, coarse breath sounds bilaterally, and a faint, diffuse petechial rash on his chest and Table 1. Laboratory data on initial presentation

Intensive care unit staffing and quality of care: challenges in times of an intensivist shortage

the responsibilities of critical care specialists (“intensivists”) now extend outside of the ICU, as they act as members of medical emergency teams and staff at long-term acute care hospitals. Thus, the gap between the demand for critical care and the supply of intensivists available to provide it continues to widen. It is difficult to know exactly how many are needed to meet the increasing critical care needs;

A Surreptitious Trip to the Lungs

A man underwent selective intra-arterial radioembolization therapy for unresectable hepatocellular carcinoma. At 3 months after completing therapy, he developed fever, dyspnea, and cough. A chest computed tomography (CT) demonstrated mild diffuse ground glass nodules. A follow-up CT 1 month later documented resolution of these abnormalities, but new, biapical, dense alveolar opacities with peripheral sparing.