A program encouraging physicians and other providers to discuss with patients their preferences regarding end-of-life care significantly increased the documented incidence of such conversations and the number of patients with late-stage disease who were discharged to hospice. In a Journal of General Internal Medicine paper that has been released online, a team led by Massachusetts General Hospital (MGH) investigators describes the pilot program, which is part of a larger initiative to transform medical care for serious illness in the state of Hawaii. The program included video decision aids in 10 languages and was carried out in the city of Hilo, Hawaii.
"By collaborating with the people of Hawaii and recognizing the diversity of the community, we were able to honor and respect patients' individual choices when it came to medical care," says Angelo Volandes, MD, MPH, of the MGH Department of Medicine, lead author of the report. "Doctors are often uncomfortable having end-of-life conversations and have rarely been trained in advance care planning. The videos can be a valuable supplement to, not a replacement for, the doctor-patient relationship."
Advance care planning - conversations with patients regarding the type of care they would like to receive, or not receive, if they become seriously or terminally ill and cannot speak for themselves - has been the subject of considerable attention in recent years. Earlier this year Medicare began reimbursing clinicians for advance care planning discussions with patients, and the process was mentioned in, but not funded by, the Affordable Care Act. But there have been few studies examining the impact of advance care planning efforts on medical documentation of such conversations, on the care actually delivered or on costs.
A broad coalition of stakeholders, led by Hawaii Medical Service Association (HMSA), an independent Blue Cross/Blue Shield licensee, has been working since 2012 to improve advance care planning rates statewide through innovative collaborations, including implementation of educational videos. Hilo Medical Center, a 276-bed hospital, was the first in the state to make advance care planning the standard of care for patients, and the JGIM paper reports on the first 21 months of the program's implementation in the city of more than 43,000.
Beginning in early 2013, Hilo Medical Center clinicians, Hospice of Hilo staff and 30 primary care physicians in the city were offered a one- to four-hour training program and access to advance care planning video decision aids in English, Japanese, Cantonese, Vietnamese, Samoan, Korean, Ilocano, Tagalog, Spanish and Marshallese. Less than 10 minutes long, the videos are designed to be accessible to general audiences and include broad questions that patients should consider regarding their individual preferences and how they could affect future medical interventions. How or whether providers used the videos in subsequent advance care planning discussions was neither required nor tracked.
The primary study outcome for Hilo Medical Center was any change in the rate at which advance care planning conversations were documented in medical records of patients with late-stage disease. For outpatient care, any difference between the rates of advance care planning in Hilo and in a control group of similar Hawaii communities was analyzed. The researchers also compared the number of hospice admissions for late-stage patients before and after the program was implemented - compared with the control communities - as well as the rate of in-hospital deaths. Any impact on health costs was determined by analyzing HMSA claims data.
Prior to implementation of the training program, the rate of advance care planning documentation for late-stage patients at Hilo Medical Center was 3.2 percent, but during the 21 months after training was offered, the rate increased to almost 40 percent. Among almost 4,000 HMSA patients over age 75 in Hilo who saw a primary care physician during 2014, the year following primary care physician training, 37 percent received advance care planning, compared with 25.6 percent in the control communities.
The percentage of late-stage Hilo Medical Center patients who were discharged to hospice, which was 5.7 percent before the training, rose to 13.8 percent. Overall Hospice of Hilo admissions increased 28 percent in 2013 and 51 percent in 2014, compared with 2012. While average HMSA reimbursements for care during the last month of life increased from 2012 to 2013 in both Hilo and the control area, the increase for Hilo was only 5.5 percent, compared with more than 22 percent in the control area, reflecting an average per-patient savings of $3,458 for the last month of life.
Although this study was conducted in a relatively small region, the authors note that the diversity of the Hawaiian population may offset that limitation. The program has now expanded to all hospitals in Hawaii, 10 hospices, military facilities and many other providers; and Volandes expresses the hope that this study's results will renew calls for continuing innovation in advance care planning, including certification and reimbursement for patient decision aids.
"Advance care planning videos and other decision aids offer cost-efficient and broadly applicable methods of placing patients at the center of their care," he says. "They also allow doctors and other health providers to have critical conversations with patients that were rarely encouraged during their training. Making these decision aids widely available could be a real health care game-changer."
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A physician and researcher at Harvard Medical School, Volandes is also the co-founder and president of Advance Care Planning Decisions, a nonprofit foundation that creates and distributes advance care planning videos and provided the videos used in the study. He is also the author of the 2015 book, The Conversation: A Revolutionary Plan for End-of-Life Care. Additional co-authors of the study are Rae Seitz, MD, and Robert Eubanks, Hawaii Medical Service Association; Areej El-Jawahri, MD, MGH Cancer Center; and Michael K. Paasche-Orlow MD, MA, MPH, and Aretha Delight Davis, MD, JD, ACP Decisions.
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $800 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, transplantation biology and photomedicine. In July 2015, MGH returned into the number one spot on the 2015-16 U.S. News & World Report list of "America's Best Hospitals."
Journal
Journal of General Internal Medicine