Faculty Bibliography

IMPORTANCE/UNASSIGNED:Goal-concordant care (GCC) is recognized as the highest quality of care and most important outcome measure for serious illness research, yet practical methods for measuring it are lacking. OBJECTIVE/UNASSIGNED:To measure GCC using clinical notes in patients' medical records. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This longitudinal cohort study involved a retrospective medical record review in 3 urban hospitals in a single health system. Participants included adults with a hospital encounter of 3 or more days between April 1 and July 31, 2019, and 50% or higher predicted 6-month mortality risk. Data abstraction occurred from July 2021 through June 2022. EXPOSURE/UNASSIGNED:Acute care hospitalization and a 50% or higher predicted 6-month mortality risk. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Pairs of clinicians independently reviewed clinical notes from admission through 6 months or death to classify the care received during each epoch between patients' documented goals of care (GOC) discussions, into 1 of 4 categories: (1) comfort focused, (2) maintain or improve function, (3) life extension, or (4) unclear. The GOC discussions had been previously classified using the same 4 categories. The primary study outcome was GCC, defined as the alignment of classification of care received and GOC. Secondary outcomes included goal-discordant care, if GOC and care-received classifications were misaligned, and uncertain concordance, if either care received or GOC was classified as unclear or GOC were not documented. Interrater reliability for classification of care received was assessed using Cohen κ statistics. RESULTS/UNASSIGNED:Among 109 patients (53 female [49%]), the median (IQR) age was 70 (63-79) years. The most common serious illnesses were cardiac disease (76 patients [70%]), metastatic cancer (50 patients [45%]), and chronic kidney disease (42 patients [39%]). Interrater reliability for care-received classification was almost perfect (95% interrater agreement, Cohen κ = 0.92; 95% CI, 0.86-0.99). A total of 398 epochs of care were identified, 198 (50%) of which were classified as goal concordant. Of the remaining 200 epochs, 74 (19%) were classified as goal discordant and 126 (32%) of uncertain concordance. During at least 1 epoch of care over the 6-month follow-up, 85 patients (78%) received care of uncertain concordance and 43 (39%) received goal-discordant care. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cohort study of seriously ill adults, GCC was measured using clinical notes alone. These findings can inform automated text-based classification methods to improve the efficiency and scalability of this method and facilitate pragmatic and reliable measurement of GCC in serious illness research and quality improvement efforts.

BACKGROUND:Risk of early-stage lung adenocarcinoma (LUAD) recurrence after surgical resection is significant, and post-recurrence median survival is approximately two years. Currently there are no commercially available biomarkers that predict recurrence. Here, we investigated whether microbial and host genomic signatures in the lung can predict recurrence. METHODS:In 91 early-stage (Stage IA/IB) LUAD-patients with extensive follow-up, we used 16s rRNA gene sequencing and host RNA-sequencing to map the microbial and host transcriptomic landscape in tumor and adjacent unaffected lung samples. RESULTS:23 out of 91 subjects had tumor recurrence over 5-year period. In tumor samples, LUAD recurrence was associated with enrichment with Dialister, Prevotella, while in unaffected lung, recurrence was associated with enrichment with Sphyngomonas and Alloiococcus. The strengths of the associations between microbial and host genomic signatures with LUAD recurrence were greater in adjacent unaffected lung samples than in the primary tumor. Among microbial-host features in the unaffected lung samples associated with recurrence, enrichment with Stenotrophomonas geniculata and Chryseobacterium were positively correlated with upregulation of IL-2, IL-3, IL-17, EGFR, HIF-1 signaling pathways among the host transcriptome. In tumor samples, enrichment with Veillonellaceae Dialister, Ruminococcacea, Haemophilus Influenza, and Neisseria were positively correlated with upregulation of IL-1, IL-6, IL17, IFN, and Tryptophan metabolism pathways. CONCLUSIONS:Overall, modeling suggested that a combined microbial/transcriptome approach using unaffected lung samples had the best biomarker performance (AUC=0.83). IMPACT/CONCLUSIONS:This study suggests that LUAD recurrence is associated with distinct pathophysiological mechanisms of microbial-host interactions in the unaffected lung rather than those present in the resected tumor.

BACKGROUND:The ability to classify patients' goals of care (GOC) from clinical documentation would facilitate serious illness communication quality improvement efforts and pragmatic measurement of goal-concordant care. Feasibility of this approach remains unknown. OBJECTIVE:To evaluate the feasibility of classifying patients' GOC from clinical documentation in the electronic health record (EHR), describe the frequency and patterns of changes in patients' goals over time, and identify barriers to reliable goal classification. DESIGN/METHODS:Retrospective, mixed-methods chart review study. PARTICIPANTS/METHODS:Adults with high (50-74%) and very high (≥ 75%) 6-month mortality risk admitted to three urban hospitals. MAIN MEASURES/METHODS:Two physician coders independently reviewed EHR notes from 6 months before through 6 months after admission to identify documented GOC discussions and classify GOC. GOC were classified into one of four prespecified categories: (1) comfort-focused, (2) maintain or improve function, (3) life extension, or (4) unclear. Coder interrater reliability was assessed using kappa statistics. Barriers to classifying GOC were assessed using qualitative content analysis. KEY RESULTS/RESULTS:Among 85 of 109 (78%) patients, 338 GOC discussions were documented. Inter-rater reliability was substantial (75% interrater agreement; Cohen's kappa = 0.67; 95% CI, 0.60-0.73). Patients' initial documented goal was most frequently "life extension" (N = 37, 44%), followed by "maintain or improve function" (N = 28, 33%), "unclear" (N = 17, 20%), and "comfort-focused" (N = 3, 4%). Among the 66 patients whose goals' classification changed over time, most changed to "comfort-focused" goals (N = 49, 74%). Primary reasons for unclear goals were the observation of concurrently held or conditional goals, patient and family uncertainty, and limited documentation. CONCLUSIONS:Clinical notes in the EHR can be used to reliably classify patients' GOC into discrete, clinically germane categories. This work motivates future research to use natural language models to promote scalability of the approach in clinical care and serious illness research.

We examined whether hospitals participating in Medicare's Shared Saving Program increased the use of highly rated skilled nursing facilities (SNFs) or decreased the use of low-rated SNFs hospital-wide after initiation of their accountable care organization (ACO) contracts compared with non-ACO hospitals. Using a difference-in-differences design, we estimated the change in the probability of discharge to 5-star and 1-star SNFs among all beneficiaries discharged from ACO-participating hospitals after the hospital initiated ACO participation. After joining an ACO, the percentage of hospital discharges going to a high-quality SNF increased by 3.4 percentage points on a base of 15.4% (95% confidence interval [CI] 1.3-5.5, P = .002) compared with non-ACO-participating hospitals. The probability of discharge from an ACO-participating hospital to low-quality SNFs did not change significantly compared with non-ACO-participating hospitals. Our findings indicate that ACO-participating hospitals were more likely to discharge patients to highly rated SNFs after they began their ACO contract but did not change the likelihood of discharge to lower rated SNFs in comparison with non-ACO hospitals.

PURPOSE:To describe the most prevalent and costly inpatient hospitalizations in a national cohort of privately insured young adults since the Affordable Care Act. METHODS:Cross-sectional study of a national administrative data set of privately insured young adult (18-30 years) beneficiaries hospitalized from January 2012 to June 2013. The most prevalent diagnosis categories for young adult hospitalizations are presented as percentages of all young adult hospitalizations by gender and age group (18-21, 22-25, and 26-30 years). Mean and median out-of-pocket costs by diagnosis category and gender are calculated based on deductible, copay and coinsurance payments. RESULTS:We analyzed 158,777 hospitalizations among 4.7 million young adult beneficiaries; young adults accounted for 18.3% of privately insured hospitalizations across all ages. Top diagnoses for young adult female hospitalizations were pregnancy related (71.9%) and mental illness (8.9%). Top diagnoses for young adult male hospitalizations were mental illness (39.3%) and injuries and poisoning (14.0%). Mean and median total out-of-pocket costs for any young adult hospitalization were $1,034 and $700, respectively (mean deductible payment = $411). The most expensive out-of-pocket hospitalizations were for dermatologic diseases (e.g., skin infections) with means of $1,306 for females and $1,287 for males. CONCLUSIONS:This study establishes a baseline for the ongoing assessment of the most common and costly hospitalizations among privately insured young adults in the United States under the Affordable Care Act. The substantial burden of potentially avoidable hospitalizations (e.g., mental health, injury, and poisonings) supports resource allocation to improve outpatient services, mental health access, and public health prevention strategies for young adults.