Search

Despite efforts to enhance serious illness communication, patients with advanced heart failure (HF) lack prognostic understanding.To determine rate of concordance between HF patients' estimation of their prognosis and their physician's estimate of the patient's prognosis, and to compare patient characteristics associated with concordance.Cross-sectional analysis of a cluster randomized controlled trial with 24-month follow-up and analysis completed on 09/01/2020. Patients were enrolled in inpatient and outpatient settings between September 2011 to February 2016 and data collection continued until the last quarter of 2017.Six teaching hospitals in the U.S.Patients with advanced HF and implantable cardioverter defibrillators (ICDs) at high risk of death. Of 537 patients in the parent study, 407 had complete data for this analysis.A multi-component communication intervention on conversations between HF clinicians and their patients regarding ICD deactivation and advance care planning.Patient self-report of prognosis and physician response to the "surprise question" of 12-month prognosis. Patient-physician prognostic concordance (PPPC) measured in percentage agreement and kappa. Bivariate analyses of characteristics of patients with and without PPPC.Among 407 patients (mean age 62.1 years, 29.5% female, 42.4% non-white), 300 (73.7%) dyads had non-PPPC; of which 252 (84.0%) reported a prognosis1 year when their physician estimated1 year. Only 107 (26.3%) had PPPC with prognosis of ≤ 1 year (n=20 patients) or1 year (n=87 patients); (Κ = -0.20, p = 1.0). Of those with physician estimated prognosis of1 year, non-PPPC was more likely among patients with lower symptom burden- number and severity (both p ≤.001), without completed advance directive (p=.001). Among those with physician prognosis estimate1 year, no patient characteristic was associated with PPPC or non-PPPC.Non-PPPC between HF patients and their physicians is high. HF patients are more optimistic than clinicians in estimating life expectancy. These data demonstrate there are opportunities to improve the quality of prognosis disclosure between patients with advanced HF and their physicians. Interventions to improve PPPC might include serious illness communication training.

Background Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function. Objectives The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation. Methods In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion. Results A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. Secondary outcomes: Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives. Conclusions The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients’ severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744 )

This article summarizes results from four research studies (n = 902) that examined the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring disorders (most with severe mental disorders). Significantly better outcomes for MTC were found across four experimental versus control comparisons on 23.1% (12 of 52) of primary outcome measures of substance use, mental health, crime, HIV risk, employment, and housing. Study limitations included the potential for selection bias, limited measurement of program fidelity, and insufficient examination of the relationship between treatment dose and outcome. Future research should emphasize clinical trial replications, multiple outcome domains, and further development of continuing care models. Given the need for research-based approaches, the MTC warrants consideration when program and policy planners are designing programs for co-occurring disorders.

This study, which was conducted in an outpatient substance abuse treatment program, randomly assigned clients with mental health symptoms to either a control group, which received basic program services, or an experimental group, which was configured as a modified therapeutic community (TC) track, with the addition of modified TC features and three specific elements-psychoeducational seminar, trauma-informed addictions treatment, and case management. The experimental group had significantly better outcomes as compared with the control group on measures of psychiatric severity and on the key measure of housing stability; no difference was observed for substance use, crime, and employment. The findings must be qualified because (a) only 3 of 34 representative measures (

This paper estimates and compares the economic benefits and costs of modified therapeutic community (modified TC) treatment for homeless mentally ill chemical abusers (MICAs) relative to a ‘treatment-as-usual’ (TAU) comparison group. Data from the period 12 months pre-admission to the modified TC were compared to data from 12 months post-admission across three outcome categories: employment, criminal activity, and utilization of health care services. The economic cost of the average modified TC treatment episode was $20,361. The economic benefit generated by the average modified TC client was $305,273. The incremental economic benefit per modified TC client (relative to TAU) was $273,698, resulting in a net benefit per modified TC client of $253,337 and a benefit–cost ratio of 13:1. Adjusting for extreme outlier observations, the incremental economic benefit estimate was $105,618, net benefit was $85,257, and the benefit–cost ratio was 5.2. These results quantify the potential economic and social advantages of the modified TC approach and highlight the policy implications of modified TC programs for homeless MICAs. This study is the first comprehensive economic evaluation of TC treatment for homeless MICAs; future research can draw from the economic analysis methods outlined here to apply to larger samples, longer follow-up periods, and other treatment settings.

This paper, the first in a series of reports from a field study on the efficacy of modified therapeutic community (TC) treatment for homeless mentally ill chemical abusers, presents sociodemographic profiles, psychiatric diagnosis, and psychological symptom data on 342 homeless mentally ill chemical abusing clients seeking treatment in mental health community residence settings. The findings reflect the multidimensional deficits, social dysfunctionality, and severity of psychopathology of the study sample. The paper discusses the implications of these findings for program design and program planning, with special reference to modified TC programs.