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An advance directive (AD) document allows a patient to indicate their health care preferences and identify an agent to make decisions on their behalf if they lose their ability to communicate. Due to the substantially elevated risk of acute respiratory failure and death during the COVID-19 pandemic, ADs were especially relevant. The objective of this study was to describe AD completed prior to COVID-19 infection (COVID-19) among patients receiving care in a national healthcare system. We conducted a cohort study of United States Veterans Health Administration (VA) patients with COVID-19 between March 2020 and December 2022. AD completion before COVID-19 was ascertained by progress note titles in the electronic health record. Covariates included age, sex, race/ethnicity, marital status, geographic region, health care utilization, calendar quarter of COVID-19, and VA COVID-19 (VACO) 30-day mortality index score. Among 422,028 COVID-19 patients (median age = 62 years; 88.5% male; 58.6% non-Hispanic White (NH-White), 23.3% non-Hispanic Black (NH-Black), 9.2% Hispanic), 67,970 (16.1%) had AD documentation which varied substantially across all covariates. AD completion increased with VACO Index quintiles ranging from 8.2 to 31.0%. In a model adjusted for covariates, relative to NH-White, NH-Black and Hispanic groups had decreased odds for AD (NH-Black odds ratio (OR)=0.77 (95% confidence interval 0.76-0.79); Hispanic OR=0.85 (0.82-0.87)). VACO index includes age, and both were strongly associated with AD completion. Women compared to men, and those who were widowed, separated/divorced and never married relative to people who were married, had increased AD completion. AD completion was overall low, including among patients at high risk of mortality due to COVID-19. When controlling for age, risk for mortality and other covariates, men and people who identify as Black or Hispanic were less likely to have completed an AD. Investment in interventions to facilitate AD completion are needed, particularly among historically underrepresented populations.

Background Black patients with non‐small cell lung cancer (NSCLC) are more often diagnosed at a later stage and receive inadequate evaluation and treatment compared to White patients. We aimed to identify factors representing exposure to structural racism that mediate the association between race and NSCLC care. Methods We queried Surveillance, Epidemiology, and End Results–Medicare for non‐Hispanic Black and White patients ≥ 67 years diagnosed with NSCLC from 2013 to 2019. Our outcomes were localized diagnosis stage, receipt of stage‐appropriate evaluation, receipt of stage‐appropriate treatment, two‐year survival, and receipt of “optimal” care, an aggregate metric comprising the first three listed outcomes. We estimated indirect effects of mediators on the association between race and outcomes. Results Of 69,130 patients, 8.2% were Black. Medicare–Medicaid dual eligibility, a marker of individual‐level socioeconomic status (SES), accounted for the largest proportion of mediating effects for most outcomes, ranging from 13.6% (p < 0.001) for localized diagnosis stage to 25.0% (p < 0.001) for two‐year survival. Receipt of an influenza vaccine, a marker of health care access, had the second largest mediating effects on the associations between race and diagnosis stage (9.5%, p < 0.001), treatment (15.3%, p < 0.001), and optimal care (11.4%, p < 0.001). Neighborhood‐level SES accounted for the third largest proportion of the effects of race on each outcome, explaining between 9% and 16% of the racial inequities at each phase (all p < 0.001). Conclusions Individual‐ and neighborhood‐level structural factors partly explain inequities in NSCLC care, and their effects vary based on the phase of care. Interventions should be adapted to the phase of care. Individual‐ and neighborhood‐level factors mediate the observed racial inequities in the quality of non‐small cell lung cancer (NSCLC) care, and their effects vary based on the phase of cancer care. The design of interventions addressing these structural drivers of inequitable care should be tailored based on the phase of NSCLC care.

INTRODUCTION After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions. METHODS We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner‐completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi‐structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations. RESULTS Care partners’ mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: (1) unique care considerations while in the ED setting impact the perceived success of the care transition, (2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, (3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and (4) navigating the health care system after an ED encounter was perceived as difficult by care partners. DISCUSSION Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner‐reported outcome measures as well as ED discharge care transition interventions targeting care partners.

Background/objectives: High-quality pediatric critical care includes supporting children nearing the end-of-life (EOL) and their families. Cataloging existing interventions for children dying in the neonatal or pediatric intensive care unit (NICU, PICU) establishes critical areas for future research. In this scoping review, we evaluated characteristics of PICU EOL interventions. Methods: A librarian guided a search of OVID Medline, CINAHL, OVID PsycINFO, OVID Embase, Cochrane Central, and Web of Science, plus backwards and forwards reference searching. We included interprofessional interventions, defined as any systematic change (e.g., educational programs, symptom management, electronic medical record, etc.), for children dying from any cause. Studies were independently screened by two reviewers. Data were extracted by one team member and reviewed by a second. We extracted intervention elements, contextual factors, implementation barriers/facilitators, and generated frequencies from qualitative coding. Results: Of 11,643 screened articles, 44 met the inclusion criteria. Most were in neonatal ICUs (n = 28/44, 64%) and general PICUs (n = 10/44, 23%). Most interventions aimed to improve clinician knowledge (25/44, 57%), augment clinical structures and processes (n = 11/44, 25%), or enhance communication (n = 8/44, 18%). Common delivery methods included clinical practice changes (n = 25/44, 57%; e.g., protocols, order sets [n = 12]), and educational sessions (n = 20/44, 45%). Outcomes included clinician knowledge (n = 17/44, 39%), qualitative feedback (n = 18/44, 41%), feasibility/acceptability (n = 12/44, 27%), or treatment utilization (n = 11/44, 25%). Few examined families’ mental health (n = 3, 7%) or bereavement (n = 2, 5%). Few reported implementation facilitators or barriers. Conclusions: Most included studies targeted clinician outcomes through education. Designing, testing, and implementing interventions focused on family outcomes is a critical next step.

Aim The purpose of this study was to explore the latent conditions of cooperation and conflict in intra‐hospital patient transfers (i.e. transfers of patients between units in a hospital). Design Secondary qualitative analysis of 28 interviews conducted with 29 hospital staff, including physicians (N = 13), nurses (N = 10) and support staff (N = 6) from a single, large academic tertiary hospital in the Northeastern United States. Methods A two‐member multidisciplinary team applied a directed content analysis approach to data collected from semi‐structured interviews. Results Three recurrent themes were generated: (a) patient flow policies created imbalances of power; (b) relationships were helpful to facilitate safe transfers; and (c) method of admission order communication was a source of disagreement. Hospital quality improvement efforts could benefit from a teaming approach to minimize unintentional power imbalances and optimize communicative relationships between units.

Substance use, a significant public health concern, may be associated with worsening social connections and feelings of loneliness among adult populations. This study examined the associations between substance use (i.e., binge alcohol, e-cigarette, and traditional cigarette use) and loneliness among adults aged ≥50 years residing in the US. We conducted a secondary analysis of cross-sectional data from the 2023 Behavioral Risk Factor Surveillance System Social Determinant of Health Equity module. The sample included 138,614 adults aged ≥50 years, representing approximately 55.4 million individuals in this age group. Substance use was the key independent variable and categorized into two groups: no substance use and substance use—participants who reported current use of ≥1 of three substances (i.e., binge alcohol, e-cigarette, and traditional cigarette use). Overall, 19.0% of participants reported using ≥1 substance use, 21.0% reported feeling lonely sometimes, and 5.1% feeling lonely always/usually. Participants who reported using ≥1 substance had a 17.0% higher relative risk of feeling lonely always/usually (compared to feeling never/rarely lonely) than adults who did not report substance use, after adjusting for all covariates (RRR 1.17; 95% CI 1.10–1.35; p = 0.029). These findings underscore the strong link between substance use and loneliness among midlife and older adults.

Palliative care (PC) is recommended for patients with heart failure (HF) and for patients with the human immunodeficiency virus (HIV) as a means of reducing symptom burden, facilitating advance care planning, and improving quality of life.1-3 However, PC research in these populations is limited and the extent to which these patients receive PC is not known. 1-3 Therefore, the purpose of this dissertation was to examine the frequency with which patients hospitalized with HF, with and without HIV, receive PC and the factors that contribute to PC use during hospitalization. The findings of this dissertation encompass three papers. The first paper is a review of methods of data quality appraisal for research utilizing electronic health records (EHR), entitled \"Data Quality in Electronic Health Records Research: Quality Domains and Assessment Methods\" in press with the Western Journal of Nursing Research. This paper informed the analytic work of the two data-based papers in this dissertation, both of which used data from the Veterans Aging Cohort Study (VACS).4-5 In the second paper, we report the findings of a validation study of the International Classification of Diseases Ninth Edition (ICD-9) diagnostic code for PC, v66.7, entitled \"Validation of the ICD-9 Code for Palliative Care in Patients Hospitalized with Heart Failure.\" In the third paper we applied the PC ICD-9 code to examine the prevalence of PC among patients hospitalized with HF and the HIV-specific, demographic, clinical and health care utilization factors that predict PC use, entitled \"Demographic and Clinical Correlates of Palliative Care in HIV-Infected and Uninfected Patients Hospitalized with Heart Failure.\" The results of this three-paper dissertation provide guidance for appraising the quality of data derived from the EHR, support the validity of the ICD-9 diagnostic code as an indicator of specialist PC within administrative data, and highlights the limited use of PC for patients hospitalized with HF and factors associated with PC referral. This dissertation provides important, foundational findings that underscore the pressing need for future research and interventions aimed at removing barriers and increasing access to PC for patients with HF, including those with and without HIV.

INTRODUCTION: After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions. METHODS: We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner-completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi-structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations. RESULTS: Care partners mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: 1) unique care considerations while in the ED setting impact the perceived success of the care transition, 2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, 3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and 4) navigating the health care system after an ED encounter was perceived as difficult by care partners. DISCUSSION: Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner-reported outcome measures as well as ED discharge care transition interventions targeting care partners. Competing Interest Statement The authors have declared no competing interest. Funding Statement Dr. Gettel is a Pepper Scholar with support from the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (P30AG021342), the National Institute on Aging (NIA) of the National Institutes of Health (R03AG073988), the Alzheimers Association (ARCOM-22-878456), and the NIA Imbedded Pragmatic Alzheimers and AD-Related Dementias Clinical Trials Collaboratory (NIA IMPACT Collaboratory; U54AG063546). Dr. Venkatesh is supported by the American Board of Emergency Medicine National Academy of Medicine Anniversary fellowship and previously by the Yale Center for Clinical Investigation (KL2TR000140) from the National Center for Advancing Translational Science. Dr. Cohen is supported by the NIA (K76AG059987). Dr. Monin is supported by the NIA (U54AG063546, R01AG058565). Dr. Feder received funding from the National Heart Lung and Blood Institute (K12HL138037) of the NIH and the Yale Center for Implementation Science. Dr. Hwang is supported by the NIA (R33AG058926, R61AG069822), by the John A Hartford Foundation, and the West Health Institute. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation or approval of the manuscript. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The IRB of Yale University gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data Availability All data produced in the present study are available upon reasonable request to the authors.