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IIR 02-292 – HSR&D Study

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IIR 02-292
Improving the Quality of End-of-Life Communication for Patients with COPD
David H. Au MD MS
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: January 2004 - December 2007

BACKGROUND/RATIONALE:
Chronic Obstructive Pulmonary Disease (COPD) affects 19 million Americans and is the 4th leading cause of death in the U.S. Age-adjusted mortality from COPD is increasing while most other major causes of death are declining. COPD is a common problem in the VA setting with more than a million outpatient and 127,000 inpatient primary or secondary ICD-9 diagnoses in 1996. During that period, COPD contributed to 33% of admissions to VA medical facilities and 16% of all hospital admissions. In addition, treatment of COPD is expensive with an estimated 32 billon dollars spent in the US in 2002. Discussing treatment preferences in the context of the burden of treatment and the likelihood of a desirable outcome is an essential part of providing quality end-of-life care and increases the probability that care is in general agreement with a patient's wishes. Despite evidence that suggests patients with COPD would like to have end-of-life discussions, communication with COPD patients about end-of-life care occurs infrequently.

OBJECTIVE(S):
The objective of the study is to evaluate an intervention to improve the quality of end-of-life discussions between patients with COPD and their primary care providers. Because primary care clinicians and pulmonologists treat most patients with COPD, interventions that are designed to improve communication about end-of-life care and treatment preferences for COPD patients will have to address factors that serve as obstacles to communication about end-of-life care. The primary objective of this study is to assess, in a randomized fashion, whether an intervention can improve the quality of communication for patients with COPD. The intervention is based on self-efficacy theory and includes provider education, local champions and role models, determination of patients' individual barriers and facilitators regarding communication about end-of-life care, preferences for communication about end-of-life care and preferences for end-of-life care and using this information to activate patients, family members, and healthcare providers.

As secondary aims, we will 1) assess whether the intervention resulted in an increase in provider-patients discussions about end-of-life care, patient-surrogate discussion about end-of-life care or improved patient's satisfaction with COPD care; 2) assess the desire of COPD patients to discuss preferences about end-of-life care, preferences about dying and death, and the quality of patient-clinician communication about end-of-life care; 3) assess barriers and facilitators to high quality end-of-life communication for patients with COPD and their providers; 4) examine the utilization of VA services by these patients for up to ten years after the study start date to describe whether the intervention influenced the care actually received.

METHODS:
This is a multifaceted randomized trial that is grounded in self-efficacy theory and is designed to improve the quality of communication of end-of-life care for patients with COPD. The intervention will be evaluated using a randomized controlled trial design with the providers as the unit of randomization and the primary outcome being a previously developed and validated questionnaire assessing the occurrence and quality of communication about end-of-life care. We will enroll approximately 120 providers and 450 patients from General Internal Medicine, Geriatrics and Pulmonary clinics at the VA Puget Sound Health Care System. Eligible subjects must have a future visit scheduled in a participating clinic and have airflow limitation on spirometry or pulmonary function testing.

FINDINGS/RESULTS:
In the past 12 months, we have completed the development and testing of our data system infrastructure. We have tested and implemented new recruitment strategies. To date, we have enrolled 167 providers and 336 patients.

IMPACT:
Providers and patients may benefit from having a better understanding of the patient's end-of-life treatment and communication preferences. The study will facilitate discussion of topics that are often awkward for providers and patients to approach. Furthermore, patients will provide individualized information about their preferences to a person that they designate as a surrogate decision maker. This will engender communication at a practical, personal level, which is intended facilitate the communication about preferences for care. We have designed the intervention so that it can be implemented throughout the VA without effecting clinical load. The model developed may also be applicable to other medical conditions where end of life care is a concern.

PUBLICATIONS:

Journal Articles

  1. Reinke LF, Uman J, Udris EM, Moss BR, Au DH. Preferences for death and dying among veterans with chronic obstructive pulmonary disease. The American journal of hospice & palliative care. 2013 Dec 1; 30(8):768-72.
  2. Cecere LM, Slatore CG, Uman JE, Evans LE, Udris EM, Bryson CL, Au DH. Adherence to long-acting inhaled therapies among patients with chronic obstructive pulmonary disease (COPD). COPD. 2012 Jun 1; 9(3):251-8.
  3. Au DH, Udris EM, Engelberg RA, Diehr PH, Bryson CL, Reinke LF, Curtis JR. A randomized trial to improve communication about end-of-life care among patients with COPD. Chest. 2012 Mar 1; 141(3):726-35.
  4. Cecere LM, Littman AJ, Slatore CG, Udris EM, Bryson CL, Boyko EJ, Pierson DJ, Au DH. Obesity and COPD: associated symptoms, health-related quality of life, and medication use. COPD. 2011 Aug 2; 8(4):275-84.
  5. Janssen DJ, Curtis JR, Au DH, Spruit MA, Downey L, Schols JM, Wouters EF, Engelberg RA. Patient-clinician communication about end-of-life care for Dutch and US patients with COPD. European Respiratory Journal. 2011 Aug 1; 38(2):268-76.
  6. Reinke LF, Slatore CG, Uman J, Udris EM, Moss BR, Engelberg RA, Au DH. Patient-clinician communication about end-of-life care topics: is anyone talking to patients with chronic obstructive pulmonary disease? Journal of palliative medicine. 2011 Aug 1; 14(8):923-8.
  7. Reinke LF, Slatore CG, Udris EM, Moss BR, Johnson EA, Au DH. The association of depression and preferences for life-sustaining treatments in veterans with chronic obstructive pulmonary disease. Journal of pain and symptom management. 2011 Feb 1; 41(2):402-11.
  8. Curtis JR, Engelberg RA, Wenrich MD, Au DH. Communication about palliative care for patients with chronic obstructive pulmonary disease. Journal of palliative care. 2005 Oct 12; 21(3):157-64.
Book Chapters

  1. Au DH, Curtis JR. Providing Palliative and End of Life Care for Patients with COPD. In: Lung Biology in Health and Disease. New York, NY: Informa Healthcare, USA 2nd Edition; 2007. 515-530 p.
Conference Presentations

  1. Collins BF, Feemster LC, Uman J, Au DH. Obesity And Smoking Status: COPD Patient Ratings Of Quality Of Care. Poster session presented at: American Thoracic Society Annual International Conference; 2014 May 16; San Diego, CA.
  2. Au DH. Challenges Affecting Diagnosis, Treatment and Health Outcomes, Session Chair. Presented at: American Thoracic Society Annual International Conference; 2013 May 18; San Francisco, CA.
  3. Reinke LF, Au DH. Dyspnea Crisis Symposium: Communication and Coordination of Care. Presented at: American Thoracic Society Annual International Conference; 2011 May 15; Denver, CO.
  4. Cooke CR, Joo M, Udris EM, Johnson E, Au DH. Using Administrative Data to Accurately Identify Patients with Chronic Obstructive Pulmonary Disease (COPD). Poster session presented at: American Thoracic Society Annual International Conference; 2009 May 19; San Diego, CA.
  5. Au DH, Udris EM, Diehr PK, Engelberg RA, Curtis JR. A Randomized Trial to Improve the Occurrence and Quality of Communication about End-of-Life Care among Patients with COPD - Mini Symposium. Presented at: American Thoracic Society Annual International Conference; 2009 May 18; San Diego, CA.
  6. Cecere LM, Udris EM, Slatore C, Bryson CL, Au DH. The Effect of Obesity on Symptoms of Dyspnea, Health-related Quality of Life, and Medication Use in Veterans with COPD. Poster session presented at: American Thoracic Society Annual International Conference; 2009 May 18; San Diego, CA.
  7. Fan VS, Udris EM, Au DH. Factors Associated with Efficacy in COPD. Poster session presented at: American Thoracic Society Annual International Conference; 2009 May 17; San Diego, CA.
  8. Au DH, Udris EM, Diehr P, Engelberg RA, Curtis JR. A Randomized Trial to Improve the Occurrence and Quality of Communication about End-of-Life Care among Patients with COPD. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Washington, DC.
  9. Slatore CG, Littman AJ, Au DH, Satia JA, White ME. Lung Cancer: Association with NSAIDs in a Large Cohort. Poster session presented at: American Thoracic Society Annual International Conference; 2008 May 17; Toronto, Canada.
  10. Au DH. Defining COPD, time for a new paradigm? Paper presented at: American Thoracic Society Annual International Conference; 2007 May 22; San Francisco, CA.


DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Epidemiology, Treatment - Observational
Keywords: Chronic lung disease, Communication -- doctor-patient, End-of-life
MeSH Terms: none

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