An Evaluation of the Physician Orders for Life-Sustaining Treatment (POLST) Program

The number of elderly in the U.S. (i.e., individuals age 65 years or older) is growing at a rapid rate. While the current proportion of elderly persons living in U.S. is estimated to be little over 14%, it will soon reach up to 20% in next 10 years. In addition, it is anticipated that the elderly population will soon outnumber the younger generations, for the first time in U.S. history. With the rapid shift we are witnessing in the U.S. population, the World Health Organization (WHO) informs that the leading cause of death in U.S. has also shifted: from infections to chronic illnesses. The majority of elderly individuals will suffer from at least one chronic illness, and many will live longer than ever, with complex multiple healthcare needs. The demands for specialized end of life (EoL) care among frail elderly will continue to rise, and it is among the top research priorities to identify best practices in EoL care and understand how best to facilitate patient-centered care in healthcare settings. In order to increase awareness in the importance of quality care provided to those who are near EoL, the Institute of Medicine (IOM; now the National Academy of Medicine) recommended a nation-wide implementation of an advance care planning tool, the POLST (Physician Orders for Life-Sustaining Treatment). Designed specifically for frail individuals living with serious illnesses, the POLST program is used to elicit care preferences and deliver goal-concordant care. Making patients’ specific care wishes actionable and transferrable, it aims to preserve one’s autonomy, and to allow them to die with dignity. This dissertation aims to evaluate the POLST program, from its effectiveness, dissemination, to outcomes associated with its maturity status. The first chapter provides background information on the aging population the importance of advance care planning among frail elderly persons. The POLST program is introduced and I lay out the three research aims and the significance of each topic. Chapter 2 contains a systematic review of scientific evidence on the concordance between documented care wishes and actual care delivered to the POLST users. It explains specific care interventions that yielded high concordant care, as well as ones that had mixed results. In chapter 3, an environmental scan of a state-specific POLST program across all U.S. states and Washington D.C. is presented; the scan examined maturity status, specific care options mentioned/ absent as well as descriptive statistics on the association between presence of infection/pain-related care options and the POLST program maturity status. In chapter 4, a quantitative analysis aimed at examining the impacts of the POLST program maturity status on a patient-level outcome (i.e., nursing home death) is presented. In it, multiple large datasets were used to generate a representative sample of the U.S. nursing home population. I then applied multivariate logistic regression modeling to estimate associations. Lastly, chapter 5 synthesizes the findings of this dissertation as well as strengths and limitations. It then shares recommendations for policy, clinical practice and future research

Informal caregiver decision-making factors associated with technology adoption and use in home health care: A systematic scoping review

Technology systems to alleviate the burden of managing patient’s health at home are increasing. The home is a unique place where chronic disease self-management is often performed by informal caregivers. Informal caregivers provide up to 80% of in‐home care to dementia patients. Yet, how caregivers make decisions about adopting a specific technology has not been thoroughly explored. This review mapped evidence on decision-making factors associated with technology adoption and use by caregivers for patients at home. This study followed the recommendations for performing systematic scoping reviews that were developed by members of the Joanna Briggs Institute. Four electronic databases (PubMed, Medline, CINAHL, and Embase) were searched using both medical subject headings (MeSH terms) and key words. A total of 6 papers were included for data synthesis. The scope of the technology types and patient diagnoses explored in the included studies has been mapped. Factors such as information, comprehension, motivation, time, perceived burden, and perceived caregiving competency were found to affect whether to adopt caregiver decision-making regarding on the use of technology when caring for patients at home. There are other factors uniquely springing from the patient and technology as well as shared issues between caregivers and patient or caregivers and technology. Informal caregiver decision-making on technology adoption can have a considerable impact on patient care at home. This systematic scoping review found that although some factors depend on technology type and patient diagnosis, there were some common factors across the research. Those factors can be carefully considered in referring technology use for caregivers. Further, more focused study in this under-investigated area is much needed

Do caregivers’ involvement in Type 2 diabetes education affect patients’ health outcomes?: A systematic review and meta-analysis

Introduction: The prevalence of Type 2 diabetes mellitus (T2DM) is rising worldwide. Patients frequently struggle with controlling their diabetes and need the assistance of caregivers for effective self-management because managing diabetes requires a variety of strategies, including diet, glucose monitoring, and exercise. This study aimed to examine the effect of caregiver involvement in T2DM education within a community on patients’ diabetes care outcomes. Methods: Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of all published studies from the earliest record to May 2022 that reported adult caregivers of T2DM patients who participated in educational interventions concerning diabetes management and that reported one or more outcomes of the interventions were conducted. Four databases were used, including PubMed, Cochrane Library, EMBASE, and CINAHL. The meta-analysis focused on glycated hemoglobin (HbA1c) levels among randomized controlled trials (RCTs), with additional attention to lipid levels. Review Manager 5.4 was used to perform this meta-analysis. Results: A total of 17 out of 683 studies were synthesized. Involvement of caregivers in T2DM education is shown to reduce body mass index and HbA1c. This involvement also improves patients’ knowledge, physical activity, and self-efficacy, but the effect on medication adherence varies. A meta-analysis of six RCT studies shows that caregiver involvement in T2DM education reduced pooled HbA1c levels by 0.83 (95% Confidence interval: −1.27–−0.38) compared to involvement (p = 0.0003). Meta-analysis of three types of lipids (low-density lipoprotein, total cholesterol, and high-density lipoprotein) showed no strong evidence that caregiver participation in diabetes education improved lipid levels. Conclusions: Caregivers play key roles in diabetes management and can contribute to improving patient HbA1c levels. Future research should focus on enhancing caregiver participation in T2DM education

sj-pdf-1-pmj-10.1177_02692163221122268 – Supplemental material for Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies

Supplemental material, sj-pdf-1-pmj-10.1177_02692163221122268 for Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies by Aluem Tark, Leah V Estrada, Patricia W Stone, Marianne Baernholdt and Harleah G Buck in Palliative Medicine</p

sj-pdf-3-pmj-10.1177_02692163221122268 – Supplemental material for Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies

Supplemental material, sj-pdf-3-pmj-10.1177_02692163221122268 for Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies by Aluem Tark, Leah V Estrada, Patricia W Stone, Marianne Baernholdt and Harleah G Buck in Palliative Medicine</p

sj-pdf-2-pmj-10.1177_02692163221122268 – Supplemental material for Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies

Supplemental material, sj-pdf-2-pmj-10.1177_02692163221122268 for Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies by Aluem Tark, Leah V Estrada, Patricia W Stone, Marianne Baernholdt and Harleah G Buck in Palliative Medicine</p

Detecting Language Associated With Home Healthcare Patient&apos;s Risk for Hospitalization and Emergency Department Visit

Background About one in five patients receiving home healthcare (HHC) services are hospitalized or visit an emergency department (ED) during a home care episode. Early identification of at-risk patients can prevent these negative outcomes. However, risk indicators, including language in clinical notes that indicate a concern about a patient, are often hidden in narrative documentation throughout their HHC episode. Objective The aim of the study was to develop an automated natural language processing (NLP) algorithm to identify concerning language indicative of HHC patients&apos; risk of hospitalizations or ED visits. Methods This study used the Omaha System-a standardized nursing terminology that describes problems/signs/symptoms that can occur in the community setting. First, five HHC experts iteratively reviewed the Omaha System and identified concerning concepts indicative of HHC patients&apos; risk of hospitalizations or ED visits. Next, we developed and tested an NLP algorithm to identify these concerning concepts in HHC clinical notes automatically. The resulting NLP algorithm was applied on a large subset of narrative notes (2.3 million notes) documented for 66,317 unique patients (n = 87,966 HHC episodes) admitted to one large HHC agency in the Northeast United States between 2015 and 2017. Results A total of 160 Omaha System signs/symptoms were identified as concerning concepts for hospitalizations or ED visits in HHC. These signs/symptoms belong to 31 of the 42 available Omaha System problems. Overall, the NLP algorithm showed good performance in identifying concerning concepts in clinical notes. More than 18% of clinical notes were detected as having at least one concerning concept, and more than 90% of HHC episodes included at least one Omaha System problem. The most frequently documented concerning concepts were pain, followed by issues related to neuromusculoskeletal function, circulation, mental health, and communicable/infectious conditions. Conclusion Our findings suggest that concerning problems or symptoms that could increase the risk of hospitalization or ED visit were frequently documented in narrative clinical notes. NLP can automatically extract information from narrative clinical notes to improve our understanding of care needs in HHC. Next steps are to evaluate which concerning concepts identified in clinical notes predict hospitalization or ED visit.N