eCQ 11-4 Newsletter

Non-Symptom Factors Rated Highest for Quality Care of Older Adults

the following conditions: heart attack, heart disease, arthritis, diabetes, lung disease, dementia, and cancer. Investigators analyzed interview reports of bereaved proxies on care in the last month of life for participants from 2014 to 2016 (n = 477; weighted n = 1,123,887 participants) in the National Health and Aging Trends Study (NHATS), which has been following a nationally representative sample of more than 8,000 older Medicare beneficiaries yearly since 2011. Because more than 93% of American adults aged ≥ 65 years are covered under Medicare, their study can be considered to describe the last-month experiences of most community-dwelling older adults, the authors note. OVERALL FINDINGS • The majority of decedents were aged 65 to 84 years (60%), female (52%), and of white race (77%). • 24% had dementia; 48% had cancer. • 57% were enrolled in hospice. • Place of death was most often at home (44%) or in the hospital (33%). Rating of overall care quality was dichotomized as “excellent” or “not ex- cellent.” Proxy perception of each key quality domain (coordination, symptom management, shared decision making, respect, and spiritual and emotional sup-

port) was dichotomized as “positive” or “not positive.” Proxies rated overall care quality as “ex- cellent” for 54% of NHATS participants and “not excellent” for the remaining 46%. Participant characteristics associated with an “excellent” overall quality of care rating included being married at the time of death ( P = 0.007), hospice enrollment ( P = 0.04), and having a spouse as proxy ( P = 0.03). QUALITY OF OVERALL CARE WAS ASSOCIATED WITH: • Respect (adjusted odds ratio [aOR], 6.36; 95% confidence interval [CI], 3.23 to 12.52) • Care coordination (aOR, 4.49; 95% CI, 1.85 to 10.86) • Spiritual and emotional support (aOR, 2.02; 95% CI, 1.23 to 3.30) • Shared decision making (aOR, 1.97; 95% CI, 1.12 to 3.47) There was no significant association between symptom management and over- all care quality (aOR, 1.49; 95% CI, 0.81 to 2.71). The quality of overall care was negative- ly associated with dying in a setting other than home or hospital, such as a nursing home (aOR, 0.55; 95% CI, 0.034 to 0.88). Within the care coordination domain, dying in a setting other than home or hospital was perceived as significantly negative (aOR, 0.31; 95% CI, 0.11 to 0.90). Source: “Non-Symptomatic FactorsMore Strongly Associated with High-Quality End-of-Life Care Than Symptomatic Factors for Community- Dwelling Older Adults with Multiple Chronic Conditions,” Journal of Palliative Medicine; May 2019; 22(5):522–531. Kricke G, Woods D, Jordan N; Division of Quality, Northwestern Memorial HealthCare, Chicago; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago; Division of Geriatric Medicine and Gerontology, Department of Medicine, Center for Transformative Geriatrics Research, Baltimore; Armstrong Institute Center for Health Care Human Factors, Johns Hopkins University School of Medicine, Baltimore; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago; and Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Chicago.

Proxies forMedicare beneficiaries living in the community with multiple chronic conditions (MCC) near the end of life gave higher ratings to care domains such as respect, care coordination, and emotional support than to symptommanagement, ac- cording to a report published in the Journal of Palliative Medicine. “Our findings suggest that end-of-life care providers should consider non- symptomatic domains...in addition to symptom management when providing end-of-life care, particularly respect and shared decisionmaking,” write the authors. “Prognostic uncertainty may lead older adults with MCC to receive fragmented end-of-life care in a general healthcare system focused on stabilization rather than end-of-life specific needs. “Enhancing palliative care may be one approach for addressing dying individuals’ care coordination, shared decision mak- ing, respect, and spiritual and emotional support needs while also attending to their symptoms.” MCC is defined by the National Quality Forum as “two or more concurrent chronic conditions that collectively have an adverse effect on health status, function, or quality of life, and that require complex healthcare management, decision making, or coordi- nation.” For the current study, MCC was defined as the presence of two or more of

Rate of Unplanned Hospitalizations (from page 2)

same-day appointments, and using navigators to provide additional sup- port and connect patients and caregiv- ers with community resources. Source: “Unplanned Hospitalizations Among Individuals with Cancer in the Year after Diagnosis,” Journal of Oncology Practice; January 2019; 15(1):e20–e29. Whitney RL, Bell JF, Tancredi DJ, Romano PS, Bold RJ, Wun T, Joseph JG; University of California San Francisco, Fresno; and University of California Davis, Sacramento.

the authors, by addressing patients’ urgent care needs through: • Community-based palliative care • After-hours telephone support • Evidence-based treatment guidelines • Out-of-hospital emergency teams Other suggested strategies for reducing unplanned hospitalizations include having oncology nurses tri- age patient symptoms and arrange for

Volume 11, Issue 4

Page 3

© 2019 by Quality of Life Publishing Co. May not be reproduced without permission of the publisher. 877-513-0099