Although the use of palliative and hospice care for terminally ill Medicare patients is growing, large numbers of Americans die following intensive, non-curative, burdensome treatments. Available evidence suggests that advanced care planning (ACP) discussions are associated with less aggressive end-of-life (EOL) care, greater concordance between the care patients prefer and the care they receive, and perhaps improved bereavement outcomes for caregivers. However, national data on the uptake and impact of ACP are lacking. As a result of a new policy from the Centers for Medicare & Medicaid Services (CMS), effective January 1, 2016, clinicians may now bill for having ACP discussions with their patients. This provides an unprecedented opportunity to study the use and impact of these discussions on a national population basis. Importantly, these services are reimbursable whether they are provided by physicians or nurses in any setting. The proposed study will use both quantitative and qualitative methods to provide a unique scientific examination of the use of ACP discussions and their impact on the intensity and outcomes of care received by seriously ill patients nearing the end of life. We propose the following aims:
Aim 1) To identify trends in use and factors associated with Medicare ACP discussions. Using Medicare claims files, we will examine the number and types of patients who have ACP discussions documented by their clinicians, factors associated with ACP use, and trends over time in ACP uptake.
Aim 2) To examine the impact of ACP discussions on EOL intensity among seriously ill patients. Using Medicare claims files, we will build a prospective cohort of seriously ill patients and examine the effect of ACP conversations on patients' EOL intensity.
Aim 3) To identify barriers and facilitators of conducting ACP discussions in clinical settings. Using qualitative methods (case studies, focus groups, semi-structured interviews), we will examine patients', clinicians', and other stakeholders' perceived barriers and facilitators to the use of ACP, as well as explore implications of ACP conversations with respect to clinical workflow. It is hoped that by further understanding utilization patterns of ACP use and accompanying barriers and facilitators to implementation may influence patient care. We expect that the findings of the proposed analyses will serve to advise health systems and policymakers on how best to direct resources and address potential inequities relating to ACP conversations and, more broadly, inform the viability of targeting ACP as a primary vehicle for change, as opposed to other aspects of the EOL care delivery system.
Small studies suggest that advance care planning (ACP) conversations may improve quality of care at the end of life (EOL), but national data regarding the uptake and impact of ACP on EOL intensity are lacking. A recent decision by the Centers for Medicare & Medicaid Services to pay clinicians to have these discussions with their patients provides an unprecedented opportunity to study the use and impact of these discussions, and new impetus for understanding stakeholders' views of ACP. Our proposed research study will inform clinical practice by 1) identifying factors associated with the provision of billed ACP discussions; 2) assessing the impact of ACP discussions on the intensity and outcomes of care delivered to seriously ill patients; and 3) assessing facilitators and barriers to receipt and provision of these ACP discussions.
