Faculty Bibliography

CONTEXT/BACKGROUND:Understanding the dynamics of goals of care conversations between patients, nurses, and social workers in an outpatient setting may reveal benefits and opportunities for improvement. OBJECTIVES/OBJECTIVE:Assess goals of care conversations between the healthcare team and Veterans with chronic heart and lung diseases to better understand patient's perspectives on care goals. METHODS:In the intervention arm of a clinical trial, a nurse or social worker conducted telephone-based outpatient goals of care conversations using a semi-structured, 7-question communication guide. Inductive thematic qualitative analysis was applied to audio recordings of 27 conversations. Three independent coders iteratively developed emerging themes, which were further refined through team consensus. RESULTS:Participants mean age was 66 years (SD 6), 93% male, and 70% self-identified non-Hispanic white. The mean length of conversation was 51 minutes (SD 14). Four themes emerged: (1) participants appreciated the discussions and found them meaningful; 2) participant readiness to engage varied and often evolved; (3) goals were highly individualized and ranged from health care to personal; and (4) participants confused medical and legal terminology. CONCLUSION/CONCLUSIONS:In goals of care conversations with Veterans with cardiopulmonary disease, goals evolved, revealing personalized insights that could shape their treatment plans. Variations in participant readiness and challenges in terminology emerged and progressed within single encounters.

CONTEXT/BACKGROUND:In a multi-site randomized clinical trial, a nurse and social worker telecare team intervention (ADAPT) improved quality of life, disease-specific health status, depression, and anxiety among high-risk patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), or interstitial lung disease (ILD). OBJECTIVES/OBJECTIVE:Examine the content, processes, and cost of delivering the ADAPT intervention. METHODS:Analysis of prospectively collected data from the ADAPT randomized clinical trial, including intervention session frequency/duration, team recommendations, and per-patient cost to deliver the intervention using time-driven activity-based costing. RESULTS:Mean length of the intervention was 115.1 (SD 33.4) days. Participants (n=153) averaged 10.0 (SD 3.3) sessions with the nurse and 9.5 (SD 3.4) sessions with the social worker; 80.4% completed all required social work sessions and all required nurse sessions. The team discussed each participant an average of 3.7 (SD 1.8) times and made 7 (SD 3.8) recommendations per participant. Common recommendations included referrals/consults (79.7%, e.g., mental health, sleep, PT/OT, other specialists), medication additions (58.1%) or changes (31.8%), and tests (33.1%) The mean cost to implement and deliver the intervention per patient was $1,139.68 (SD $368.15). CONCLUSION/CONCLUSIONS:In a successful nurse and social work telecare team intervention, there was high participation in nurse and social worker sessions, individualized medical and behavioral interventions, and connecting of participants to existing medical and community resources. The intervention produced clinically meaningful changes in multiple quality of life outcomes for a relatively low cost.

OBJECTIVES/OBJECTIVE:This study examined whether cognitive function influenced the benefits of multicomponent team interventions designed to improve quality of life. DESIGN/METHODS:Data from 2 multisite randomized trials of multicomponent interventions were pooled. The interventions involved symptom management by a nurse, psychosocial counseling by a social worker, and collaboration among palliative care, primary care, and specialists. SETTING AND PARTICIPANTS/METHODS:Patients with chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), and heart failure (HF) enrolled in 2 multisite randomized trials. METHODS:Cognitive function was assessed using the Telephone Interview for Cognitive Status (TICS) and analyzed continuously and dichotomously (<36 on TICS indicating cognitive dysfunction). Mixed-effects linear regression models assessed whether cognitive function modified the effect of the interventions on quality of life and related outcomes. We also explored whether cognitive function was associated with the number of intervention visits, intervention staff time, and completed study team recommendations (consults, tests, behavior changes). RESULTS:A total of 610 participants across both trials had a mean age of 67 years, nearly all had HF or COPD, and a small proportion had ILD; 83% of participants screened positive for cognitive dysfunction. Cognitive function did not influence the benefits of the interventions across outcomes (P > .10). In exploratory analyses, lower TICS scores were associated with fewer completed intervention visits (P = .007). Total staff time, consults, tests, and behavior change recommendations were similar across TICS scores. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:Cognitive dysfunction is prevalent among patients with chronic cardiopulmonary illnesses. Intervention benefits were not affected by cognitive status. Exploratory analyses found an association between worse cognitive function and fewer intervention visits but no difference in intervention time, tests, or behavior change recommendations. Increased effort to identify cognitive dysfunction in this population and engage them in interventions to improve quality of life should be considered.

BACKGROUND:Rapid eye movement sleep behavior disorder occurs with idiopathic Parkinson's disease (PD) and often precedes PD. Its frequency in LRRK2-PD and utility as a preclinical marker has not been established. METHODS:One hundred forty-four idiopathic PD, 142 LRRK2 G2019S mutation PD, 117 non-manifesting carriers, 93 related noncarriers, and 40 healthy controls completed the Rapid eye movement sleep Behavior Disorder Screening Questionnaire. RESULTS:Cut scores were met by 30.6% idiopathic PD, 19.7% LRRK2-PD, 6% nonmanifesting carriers, 20.4% related noncarriers, and 15% controls. The likelihood of abnormal scores was decreased in LRRK2-PD versus idiopathic PD (odds ratio = 0.55, P = 0.03), nonmanifesting carriers versus related noncarriers (OR = 0.25, P < 0.01), and PD of less than 3 years' duration, 1 of 19 LRRK2-PD versus 14 of 41 idiopathic PD (P < 0.05). CONCLUSIONS:A lower frequency of abnormal questionnaire scores is seen in LRRK2-PD, especially in early LRRK2-PD, and in nonmanifesting carriers. Therefore, the Rapid eye movement sleep Behavior Disorder Questionnaire is unlikely to serve as a preclinical marker for phenoconversion to PD.