Seo Yeon Hong

Identifying family members who may struggle in the role of surrogate decision maker.

&NA; Although acting as a surrogate decision maker can be highly distressing for some family members of intensive care unit patients, little is known about whether there are modifiable risk factors for the occurrence of such difficulties. Objectives: To identify: 1) factors associated with lower levels of confidence among family members to function as surrogates and 2) whether the quality of clinician–family communication is associated with the timing of decisions to forego life support. Methods: We conducted a prospective study of 230 surrogate decision makers for incapacitated, mechanically ventilated patients at high risk of death in four intensive care units at University of California San Francisco Medical Center from 2006 to 2007. Surrogates completed a questionnaire addressing their perceived ability to act as a surrogate and the quality of their communication with physicians. We used clustered multivariate logistic regression to identify predictors of low levels of perceived ability to act as a surrogate and a Cox proportional hazard model to determine whether quality of communication was associated with the timing of decisions to withdraw life support. Results: There was substantial variability in family members’ confidence to act as surrogate decision makers, with 27% rating their perceived ability as 7 or lower on a 10-point scale. Independent predictors of lower role confidence were the lack of prior experience as a surrogate (odds ratio 2.2, 95% confidence interval [1.04–4.46], p = .04), no prior discussions with the patient about treatment preferences (odds ratio 3.7, 95% confidence interval [1.79–7.76], p < .001), and poor quality of communication with the ICU physician (odds ratio 1.2, 95% confidence interval [1.09–1.35] p < .001). Higher quality physician–family communication was associated with a significantly shorter duration of life-sustaining treatment among patients who died (&bgr; = 0.11, p = .001). Conclusions: Family members without prior experience as a surrogate and those who had not engaged in advanced discussions with the patient about treatment preferences were at higher risk to report less confidence in carrying out the surrogate role. Better-quality clinician–family communication was associated with both more confidence among family members to act as surrogates and a shorter duration of use of life support among patients who died.

Anti-inflammatory Medication Adherence, Healthcare Utilization and Expenditures Among Medicaid and Children's Health Insurance Program Enrollees with Asthma

AbstractBackground: Underuse of controller therapy among Medicaid-enrolled children is common and leads to more emergency department (ED) visits and hospitalizations. However, there is little evidence about the relationship between medication adherence, outcomes and costs once controller therapy is initiated. Objective: This study examined the relationship between adherence to two commonly prescribed anti-inflammatory medications, inhaled corticosteroids (ICS) and leukotriene inhibitors (LI), and healthcare utilization and expenditures among children enrolled in Medicaid and the Children’s Health Insurance Program in Florida and Texas in the US. Methods: The sample for this retrospective observational study consisted of 18456 children aged 2–18 years diagnosed with asthma, who had been continuously enrolled for 24 months during 2004–7 and were on monotherapy with ICS or LI. State administrative enrolment files were linked to medical claims data. Children were grouped into three adherence categories based on the percentage of days per year they had prescriptions filled (medication possession ratio). Bivariate and multivariable regression analyses that adjusted for the children’s demographic and health characteristics were used to examine the relationship between adherence and ED visits, hospitalizations, and expenditures. Results: Average adherence was 20% for ICS-treated children and 28% for LI-treated children. Children in the highest adherence category had lower odds of an ED visit than those in the lowest adherence category (p < 0.001). We did not detect a statistically significant relationship between adherence and hospitalizations; however, only 3.7% of children had an asthma-related hospitalization. Overall asthma care expenditures increased with greater medication adherence. Conclusions: Although greater adherence was associated with lower rates of ED visits, higher medication expenditures outweighed the savings. The overall low adherence rates suggest that quality improvement initiatives should continue to target adherence regardless of the class of medication used. However, low baseline hospitalization rates may leave little opportunity to significantly decrease costs through better disease management, without also decreasing medication costs.

Investigating conflict in ICUs-is the clinicians' perspective enough?

Objective:Most studies have assessed conflict between clinicians and surrogate decision makers in ICUs from only clinicians’ perspectives. It is unknown if surrogates’ perceptions differ from clinicians’. We sought to determine the degree of agreement between physicians and surrogates about conflict and to identify predictors of physician-surrogate conflict. Design:Prospective cohort study. Setting:Four ICUs of two hospitals in San Francisco, California. Patients:Two hundred and thirty surrogate decision makers and 100 physicians of 175 critically ill patients. Measurements:Questionnaires addressing participants’ perceptions of whether there was physician-surrogate conflict, as well as attitudes and preferences about clinician-surrogate communication; &kgr; scores to quantify physician-surrogate concordance about the presence of conflict; and hierarchical multivariate modeling to determine predictors of conflict. Main Results:Either the physician or surrogate identified conflict in 63% of cases. Physicians were less likely to perceive conflict than surrogates (27.8% vs 42.3%; p = 0.007). Agreement between physicians and surrogates about conflict was poor (&kgr; = 0.14). Multivariable analysis with surrogate-assessed conflict as the outcome revealed that higher levels of surrogates’ satisfaction with physicians’ bedside manner were associated with lower odds of conflict (odds ratio, 0.75 per 1 point increase in satisfaction; 95% CI, 0.59–0.96). Multivariable analysis with physician-assessed conflict as the outcome revealed that the surrogate having felt discriminated against in the healthcare setting was associated with higher odds of conflict (odds ratio, 17.5; 95% CI, 1.6–190.1) while surrogates’ satisfaction with physicians’ bedside manner was associated with lower odds of conflict (0–10 scale; odds ratio, 0.76 per 1 point increase; 95% CI, 0.58–0.99). Conclusions:Conflict between physicians and surrogates is common in ICUs. There is little agreement between physicians and surrogates about whether physician-surrogate conflict has occurred. Further work is needed to develop reliable and valid methods to assess conflict. In the interim, future studies should assess conflict from the perspective of both clinicians and surrogates.

Discussion of treatment trials in intensive care

PURPOSE This study aimed to characterize whether and how the option of a treatment trial is discussed with surrogates in intensive care units. MATERIALS AND METHODS We audio-recorded 72 family conferences for 72 patients at high risk for death or severe functional impairment in 5 intensive care units in San Francisco, California. We analyzed transcripts to develop a coding framework for whether and how trials were discussed. RESULTS Trials were offered in 15% of conferences. We identified 2 types: (1) time-limited trials, defined as continuing all intensive, life-sustaining treatments, with a plan to reassess after a defined time period based on prespecified clinical milestones, and (2) symptom-limited trials, defined as using basic medical care aimed at survival (rather than purely comfort-focused treatment) once ventilatory support is withdrawn, with a plan to reassess based on patient symptoms. Clinicians frequently did not inform surrogates about key elements of the trial such as criteria by which the effectiveness of the trial would be evaluated and possible next steps based on trial results. CONCLUSIONS In this cohort of critically ill patients, trials were infrequently and incompletely discussed. Additional work is needed to improve communication about treatment trials and evaluate their impact on patient and family outcomes.