Counting What Matters: Considerations in Selecting a Common ACP Outcome Barry B. Cohen PhD Rainbow Research, Inc. July 18, 2013. Selecting a Common ACP Outcome. Completing an Advanc e Care Plan is a key Honoring Choices outcome.
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Counting What Matters: Considerations in Selecting a Common ACP Outcome
Barry B. Cohen PhDRainbow Research, Inc.
July 18, 2013
Completing an Advance Care Plan is a key Honoring Choices outcome.
TC Medical Society Survey Spring, 2012
Significant accomplishment For Honoring Choices partners.
With health care directives in the EMR:
Having these data is also a necessary first step in measuring results
What is our denominator?
A common denominator such as number of plan enrollees allows us to measure our results as a percentage or rate in ways that are valid and useful:
Measurement of these outcomes can contribute to continuous improvement.
If rates are low we may take a closer look at our processes:
Management and boards can determine:
Funders supporting Honoring Choices can determine:
Minnesota Community Measurement Health Care Home
“Percentage of patients age 65 or greater at the start of the measurement year who have evidence (documentation) of advance care planning in their medical record at their health care home clinic”
Having an ACP in place by age 65 and above is cost effective
Generally speaking young adults and middle aged adults have:
Mobility :Young adults frequently change employers and move frequently
- Likely to change plans before an ACP would be consulted vs. older adults who are less economically and geographically mobile
Propose we consider
In Minnesota (2010) Annual death rates first exceed 1,000/100,000 (1 in a 100) for:
Given the extent of racial disparities two outcomes would be empirically warranted.
Health plan accountability for enrolling younger American Indians and African Americans (> 55) would help ensure equitable access to this benefit with that of Whites, Latinos and Asian/Asian Pacific Islanders (> 65).
MCM’s cites a Harvard U. study finding “a correlation between end‐of‐life care preferences and race.”
“African Americans and Hispanics were both more likely to opt for intensive end‐of‐life care. African Americans were twice as likely as whites to say they would want life‐prolonging treatments.”
African Americans and Hispanics also less likely to have conversations with physicians about hospices care than Whites or Asian-Americans.
Two measures even if empirically justified and perhaps beneficial could be misperceived as invidious and could create/reinforce perceptions that health plans or physicians:
MCM observes that ACP as a standard of care might increase the proportion of African Americans willing to engage.
“Having a standard of care for physicians to offer patients advance care planning, as they would offer a screening for colorectal cancer, might help decrease disparities in care and increase patient confidence that their wishes will be adhered to.”
Honoring Choices has gone a step beyond in offering training in culturally appropriate ACP conversations with people of the same heritage. It need not be the physician.
Recommendation: Use age >60 as the standard regardless of race/ethnicity
Collecting ACP data by race/ethnicity for evaluation: