Feasibility of a physician-extender approach to increase advance care planning uptake.

8 Background: Advanced care planning (ACP) for people with life-limiting cancer has been associated with improved patient quality of life and care more consistent with patient wishes. Nevertheless, even though approximately 70% of patients with a life-limiting illness will require the substituted judgment of a proxy, fewer than 25% of patients have documented goals of care. This poor uptake has been attributed to limits in physician time and ACP training. The current study evaluated the feasibility of utilizing a physician-extender trained in ACP best practices to overcome these barriers and improve ACP uptake. Methods: Patients who met criteria for a life-limiting cancer diagnosis were identified by support staff in Medical Oncology offices and the Emergency Department (ED) in a large North East community health care system. Pending physician approval, a Licensed Clinical Social Worker (LCSW) with training and experience in ACP was available to provide support and assistance to patients, which included but was not limited to ACP. The LCSW initially met patients in clinic and subsequently in whatever way was most convenient for the patient (at future appointments, by phone, inpatient, or at the patient’s home). The program was approved by the Medical Oncology section and the Emergency Department. Results: ACP uptake, calculated as the percentage of eligible patients who participated in the program, was 14.6% in the Medical Oncology practices (60/140) and 44.6% (41/92) in the ED. The difference in uptake between the two sites was significant, χ2(1, N = 502) = 41.88, p < .01, and was primarily the result of Medical Oncologists determining that ACP was not appropriate for a subset of eligible patients. Conclusions: The results of this feasibility evaluation suggest that limits in time and ACP training are not the primary barriers to ACP uptake in oncology. Instead, the type of physician and setting proved to be important correlates of uptake. We consider the implications of these findings and identify next steps to better understand the factors that influence physician participation in ACP.

The Effect of a Disease Management Algorithm and Dedicated Postacute Coronary Syndrome Clinic on Achievement of Guideline Compliance

BackgroundThe application of disease management algorithms by physician extenders has been shown to improve therapeutic adherence in selected populations. It is unknown whether this strategy would improve adherence to secondary prevention goals after acute coronary syndromes (ACSs) in a largely indigent county hospital setting.MethodsPatients admitted for ACS were randomized at the time of discharge to usual follow-up care versus the same care with the addition of a physician extender visit. Physician extender visits were conducted according to a treatment algorithm based on contemporary practice guidelines. Groups were compared using the primary end point of achievement of low-density lipoprotein treatment goals at 3 months after discharge and achievement of additional evidence-based practice goals.ResultsOne hundred forty consecutive patients were randomized. A similar proportion of patients returned for study follow-up in both groups at 3 months (54 [79%]/68 in the usual care group vs 57 [79%]/72 in the intervention group; P = 0.97). Among those completing the 3-month visit, a low-density lipoprotein cholesterol level less than 100 mg/dL was achieved in 37 (69%) of the usual care patients compared with 35 (57%) of those in the intervention group (P = 0.43). There was no statistical difference in implementation of therapeutic lifestyle changes (smoking cessation, cardiac rehabilitation, or exercise) between groups. Prescription rates of evidence-based therapeutics at 3 months were similar in both groups.ConclusionThe implementation of a post-ACS clinic run by a physician extender applying a disease management algorithm did not measurably improve adherence to evidence-based secondary prevention treatment goals. Despite initially high rates of evidence-based treatment at discharge, adherence with follow-up appointments and sustained implementation of evidence-based therapies remains a significant challenge in this high-risk cohort.