Elizabeth Chen, PhD, MBA, MPH

Reported discharged to ICU after a "code blue" and discharged to hospice rates from 2010 to 2015 overlaid with process and policy improvements over the same period targeted toward improving quality of end-of-life care for a severely ill patient population. Data show a reduction in discharges to the ICU from an average 2.3% to 0.7% and an increase in discharges to hospice from an average 1.3% to 1.7% while case mix index rose over the period.

Allocating sufficient time for goals of care conversations is difficult. Better understanding for patient characteristics that influence their decisions to avoid aggressive end-of-life care could help physicians and their care teams identify patients for these critical conversations.

The objective of this study was to quantify the role of age, proxy decision-makers, and type and extent of disease in decisions to forego aggressive end-of-life interventions. 288 Medical Orders for Life… Show more

Allocating sufficient time for goals of care conversations is difficult. Better understanding for patient characteristics that influence their decisions to avoid aggressive end-of-life care could help physicians and their care teams identify patients for these critical conversations.

The objective of this study was to quantify the role of age, proxy decision-makers, and type and extent of disease in decisions to forego aggressive end-of-life interventions. 288 Medical Orders for Life Sustaining Treatment (MOLST) forms completed by physicians with patients or proxies at a long-term acute care hospital after goals of care conversations indicate preferences for or against resuscitation, intubation, and hospital transfer. Patients�� Charlson Scores and demographics come from electronic health records. Logistic regression models tested the independent roles of age, illness severity, along with the use of proxies on the odds of limiting life-sustaining treatments.

One-third chose to limit life-sustaining treatments. Patients’ age 60-79 were 2.5 times (OR=2.51;p=0.02), and those age >80 were 5 times, more likely (OR=5.05;p<0.001) than those age <60 to limit life-sustaining treatments. Each one-point increase (16%) in Charlson Score (range 0-12) raised the likelihood of limiting life-sustaining treatment by 14% (OR=1.14;p=0.01). Surprisingly, proxy decision-makers were twice as likely (OR=1.92;p=0.02) as patients not to opt for aggressive treatments controlling for health status.

Older, sicker patients strongly prefer to avoid aggressive life-sustaining treatments even after referral to a high-tech facility. Clinicians may want to use age and Charlson Score to identify patients for goals of care conversations. That proxy decision makers are more likely than patients to limit treatment calls for further research.
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The Medical Orders for Life-Sustaining Treatment (MOLST) is a portable medical order that documents patient wishes for life-sustaining treatments. We describe Plan-Do-Study-Act Cycles 1 and 2 for incorporating goals of care conversations and documenting patient wishes on MOLST, a new statewide public health effort spurred by regulation. The MOLST is indicated for patients with life limiting or advancing chronic illness.

Approximately 35% of discharges had a completed MOLST in Cycle 1… Show more

The Medical Orders for Life-Sustaining Treatment (MOLST) is a portable medical order that documents patient wishes for life-sustaining treatments. We describe Plan-Do-Study-Act Cycles 1 and 2 for incorporating goals of care conversations and documenting patient wishes on MOLST, a new statewide public health effort spurred by regulation. The MOLST is indicated for patients with life limiting or advancing chronic illness.

Approximately 35% of discharges had a completed MOLST in Cycle 1. The end of patient interviewing for research marked the beginning of Cycle 2, also accompanied by a decline in numbers. A plan for Cycle 3 has been implemented, which adds social workers to the process and a 50% goal.
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Most individuals prefer to die at home, yet large numbers die in a hospital. This study examines the relationship between enrollment in a capitated plan (Medicare Advantage) on the odds of dying in a hospital setting. Data from the 2008 and 2010 waves of the Health and Retirement Study (HRS), including enrollment in Medicaid, health status, social, and advance planning variables, were analyzed. We hypothesize that enrollees in capitated plans are more likely to die outside a hospital setting… Show more

Most individuals prefer to die at home, yet large numbers die in a hospital. This study examines the relationship between enrollment in a capitated plan (Medicare Advantage) on the odds of dying in a hospital setting. Data from the 2008 and 2010 waves of the Health and Retirement Study (HRS), including enrollment in Medicaid, health status, social, and advance planning variables, were analyzed. We hypothesize that enrollees in capitated plans are more likely to die outside a hospital setting because Medicare Advantage contracts incentivize insurers to move eligible patients to the Medicare Hospice Benefit. We examine a broader set of variables than previous studies that rely on Medicare Administrative data.

The analytic sample (N=1047) comprised individuals in the HRS, who died from 2008-2010, and were enrolled in Medicare at the time of death. Logistic regression analyses estimated the impact of enrollment in capitated vs. fee-for-service Medicare and the likelihood of dying in a hospital, controlling for other characteristics.

Enrollees in capitated plans were less likely to die in a hospital (OR=.64) than those in fee-for-service plans. The same was true when death was expected (OR=.54) or if decedents lived in a nursing home (OR=.40). Males were more likely to die in a hospital (OR=1.44) than females. Deaths due to respiratory (OR=1.98) or digestive (OR=1.92) diseases had higher odds of occurring in a hospital than deaths from cancer.

Findings suggest that financial incentives in capitated contracts are more likely to spur alternatives to hospitals as the site of death than fee-for-service.
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The aim of this poster is to advocate for advance care planning (ACP) as part of healthy aging. We describe types of ACPs and explain their importance using the Leutz Model of Healthy Aging (Doonan, 2010). As we age, purposeful engagement in health care should include expressing our own preferences for various life-saving medical interventions. Conveying our wishes through written advance directives will help communities support individual health care goals at times when we are unable to make… Show more

The aim of this poster is to advocate for advance care planning (ACP) as part of healthy aging. We describe types of ACPs and explain their importance using the Leutz Model of Healthy Aging (Doonan, 2010). As we age, purposeful engagement in health care should include expressing our own preferences for various life-saving medical interventions. Conveying our wishes through written advance directives will help communities support individual health care goals at times when we are unable to make, or communicate health care decisions. The poster will describe tools to facilitate ACP, such as “living wills”, efforts by “The Conversation Project”, considerations in “The Five Wishes”, and a newly recognized tool in Massachusetts “The Medical Orders for Life Sustaining Treatment (MOLST)”. We conclude by recommending that all adults engage in ACP, and that individuals review plans annually with physicians at regular preventive care visits. Show less

We report preliminary results from a pilot implementation of the Medical Orders for Life Sustaining Treatment (MOLST) in a long-term acute care hospital (LTAC). Patients in LTACs are primarily Medicare insured, typically experiencing decline from at least one of multiple co-morbidities, recently discharged from acute care hospitals, but in need of substantial hospital-level care before transfer to lower care intensity settings. Length of stay is approximately 25 days in the 400+ LTACs across… Show more

We report preliminary results from a pilot implementation of the Medical Orders for Life Sustaining Treatment (MOLST) in a long-term acute care hospital (LTAC). Patients in LTACs are primarily Medicare insured, typically experiencing decline from at least one of multiple co-morbidities, recently discharged from acute care hospitals, but in need of substantial hospital-level care before transfer to lower care intensity settings. Length of stay is approximately 25 days in the 400+ LTACs across the U.S.
Our study collects data from patients, their physicians, and medical records. High agreement amongst clinicians (72%) that MOLST was appropriate for over 90% of this patient population suggests limited clinician bias in patient selection. 75 MOLSTs were reviewed. Patients signed 69%; health care proxies and guardians signed the remainder. 33% specified no resuscitation (DNR), 28% no intubation (DNI); and 7% chose not to be transferred back to an acute care hospital. Preferences about length of time for these and various other forms of mechanical life support, as well as group differences for age, sex, and decision-maker, are established.
The proportions of patients selecting DNR in this population is approximately two times those reported in a cancer intensive care population (15%) or a national nursing home sample (18%).
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The purpose of this paper is to characterize optometrists in the United States based on race and ethnicity. A 40-year record of students enrolled in doctor of optometry programs in the United States was used to estimate proportions, which were then compared with Census 2010 data. Black and Hispanic optometrists comprise a substantially lower proportion when compared with the population. Non-Hispanic White and Asian optometrists are a higher proportion than the population. This is the first… Show more

The purpose of this paper is to characterize optometrists in the United States based on race and ethnicity. A 40-year record of students enrolled in doctor of optometry programs in the United States was used to estimate proportions, which were then compared with Census 2010 data. Black and Hispanic optometrists comprise a substantially lower proportion when compared with the population. Non-Hispanic White and Asian optometrists are a higher proportion than the population. This is the first effort to estimate the racial and ethnic mix of the profession. Show less