Agreement between older persons and their surrogate decision-makers regarding participation in advance care planning

OBJECTIVES: To examine agreement between older persons and their surrogates regarding participation in advance care planning (ACP). DESIGN: Observational cohort study. SETTING: Community. PARTICIPANTS: Persons aged 65 and older and the individual they identified as most likely to make treatment decisions on their behalf. MEASUREMENTS: Older persons were asked about participation in four activities: completion of living will, completion of healthcare proxy, communication regarding views about life‐sustaining treatment, and communication regarding views about quality versus quantity of life. Surrogates were asked whether they believed the older person had completed these activities. RESULTS: Of 216 pairs, 81% agreed about whether a living will had been completed (κ=0.61, 95% confidence interval (CI) 0.51–0.72). Only 68% of pairs agreed about whether a healthcare proxy had been completed (κ=0.39, 95% CI 0.29–0.50), 64% agreed about whether they had communicated regarding life‐sustaining treatment (κ=0.22, 95% CI 0.09–0.35), and 62% agreed about whether they had communicated regarding quality versus quantity of life (κ=0.23, 95% CI 0.11–0.35). CONCLUSION: Although agreement between older persons and their surrogates regarding living will completion was good, agreement about participation in other aspects of ACP was fair to poor. Additional study is necessary to determine who is providing the most accurate report of objective ACP components and whether agreement regarding participation in ACP is associated with greater shared understanding of patient preferences.     

Improvements in advance care planning in the Veterans Affairs System: results of a multifaceted intervention

BACKGROUND: Advance care planning (ACP) aims to guide health care in the event of decisional incapacity. Interventions to promote ACP have had limited effectiveness. We conducted an educational and motivational intervention in Department of Veterans Affairs outpatient clinics to increase ACP use and proxy and health care provider understanding of patients' preferences and values. METHODS: We recruited 23 providers and up to 14 of each of their patients; the patients were randomized to the control or intervention group. Eligibility criteria included a preexisting relationship with the provider, age 55 years or older, chronic health condition(s), and no recorded advance directive. The intervention group (n = 119) received an ACP workbook, motivational counseling by social workers, and cues to providers to discuss ACP. The control group (n = 129) received an advance directive booklet. RESULTS: The intervention patients reported more ACP discussions with their providers (64% vs 38%; P<.001). Living wills were filed in the medical record twice as often in the intervention group (48% vs 23%; P<.001). Provider-patient dyads in the intervention group had higher agreement scores than the control group for treatment preferences, values, and personal beliefs (58% vs 48%, 57% vs 46%, and 61% vs 47%, respectively; P<.01 for all comparisons). The agreement scores for the proxy-patient dyads did not differ between groups for treatment preferences and values, but were higher in the intervention than the control group for personal beliefs (67% vs 56%). CONCLUSION: This intervention demonstrates mixed results and highlights the ongoing challenges of helping health care providers and potential proxy decision makers represent patient preferences and values.     

Opiniones: End‐of‐Life Care Preferences and Planning of Older Latinos

OBJECTIVES: To measure end‐of‐life (EOL) care preferences and advance care planning (ACP) in older Latinos and to examine the relationship between culture‐based attitudes and extent of ACP. DESIGN: Cross‐sectional interview. SETTING: Twenty‐two senior centers in greater Los Angeles. PARTICIPANTS: One hundred forty‐seven Latinos aged 60 and older. MEASUREMENTS: EOL care preferences, extent of ACP, attitudes regarding patient autonomy, family‐centered decision‐making, trust in healthcare providers, and health and sociodemographic characteristics. RESULTS: If seriously ill, 84% of participants would prefer medical care focused on comfort rather than care focused on extending life, yet 47% had never discussed such preferences with their family or doctor, and 77% had no advance directive. Most participants favored family‐centered decision making (64%) and limited patient autonomy (63%). Greater acculturation, education, and desire for autonomy were associated with having an advance directive (P‐values <.03). Controlling for sociodemographic characteristics, greater acculturation (adjusted odds ratio (AOR)=1.6, 95% confidence interval (CI)=1.1–2.4) and preferring greater autonomy (AOR=1.6, 95% CI=1.1–2.3) were independently associated with having an advance directive. CONCLUSIONS: The majority of older Latinos studied preferred less‐aggressive, comfort‐focused EOL care, yet few had documented or communicated this preference. This discrepancy places older Latinos at risk of receiving high‐intensity care inconsistent with their preferences.     

Completing an Advance Directive in the Primary Care Setting: What Do We Need for Success?

OBJECTIVES: To systematically review studies designed to increase advance directive completion in the primary care setting and employ meta-analytic techniques to quantify their effects. DESIGN: Extensive bibliographic searches of English-language literature published from January 1991 through July 2005 were conducted. Investigators abstracted prespecified information (e.g., design, study duration, types of interventions employed) and advance directive completion rates for intervention and control arms in each investigation and calculated absolute rate differences (i.e., difference in completion rates between the two groups) for each study. Individual study and pooled-effect sizes were also calculated, along with 95% confidence intervals (CIs). SETTING: Literature review. RESULTS: Eighteen studies were retained in the final sample. Most studies employed multimodal interventions. The most common approach consisted of educational materials directed at patients (through mailing or at visit) coupled with a patient-healthcare provider interaction in a group or individual setting (n=7). Absolute differences in completion rates varied from a high of 44% (favors intervention) to a low of -2% (favors control). Effect sizes could be calculated for 15 of the 18 studies. The pooled effect size was 0.50 (95% CI=0.17-0.83), indicating a moderate overall effect in favor of the intervention. CONCLUSION: The majority of studies demonstrated statistically significant effects associated with the advance directive intervention. The most successful interventions incorporated direct patient-healthcare professional interactions over multiple visits. Passive education of patients using written materials (without direct counseling) was a relatively ineffective method for increasing advance directive completion rates in the primary care setting.     

Factors influencing the acceptance of changes in antiretroviral therapy among HIV-1-infected patients

Physicians routinely consider modifying antiretroviral therapy (ART) regimen for their patients with HIV. Little is known about the factors associated with patients' willingness to accept providers' recommended ART changes. This multicenter prospective observational study examined factors associated with willingness to accept ART changes recommended by their providers among HIV-infected adults from six urban outpatient HIV clinics. Patients were surveyed using the Patient Attitudes about Altering Antiretroviral Therapy Survey questionnaire (PAAARTS). Factors associated with willingness to accept ART changes were assessed using a multivariate generalized estimating equation (GEE) model to account for correlated responses. The Classification and Regression Trees (CART) analysis was also performed to determine subgroups of patients with higher acceptance of change. 216 of 289 patients (75%) definitely accepted recommended changes. Odds for acceptance were 3.2, 2.3, and 2.8 times higher for patients with higher attitudes and beliefs about ART (p < 0.01; 95% confidence interval [CI] = 1.59, 6.52), patients who rated their provider's care as excellent (p < 0.05; 95% CI = 1.07, 4.78), and non-Hispanic patients (p < 0.05; 95% CI 1.03, 7.57), respectively. CART analysis showed similar results and identified that when patients had less positive attitude about ART, acceptance rates were higher for non-Hispanic patients with higher assessments of their patient-provider communication. While most patients accepted providers' recommendation for ART changes, this willingness was influenced by both patients' attitudes and beliefs about ART and their assessment of either the effectiveness of patient-provider communication or their rating of providers' care. ART acceptance rates among Hispanic patients were lower.     

The effect of advance care planning on completion of advance directives and patient satisfaction in people with HIV/AIDS

The effects of advance care planning are poorly understood. The purpose of this study was to evaluate the effect of an advance care planning intervention on the completion of advance directives (ADs) and patient satisfaction. A volunteer sample of persons with HIV/AIDS received advance directive documents, watched an educational video and received individual counselling on completing an advance directive during three face-to-face interviews over approximately six months. The advance care planning intervention was associated with an increase in advance directive completion rates from 16.4% to 40.7% (p = 0.001), but 23.1% of advance directives reported as completed were legally invalid. There was a trend towards decreased overall patient satisfaction with health care (p = 0.07). Advance are planning increases the rate of AD completion but many 'completed' advance directives are legally invalid. Advance care planning did not improve patient satisfaction with health care.     

Are Racial Disparities in Alcohol Treatment Completion Associated With Racial Differences in Treatment Modality Entry? Comparison of Outpatient Treatment and Residential Treatment in Los Angeles County, 1998 to 2000

OBJECTIVE: To determine whether racial and ethnic disparities in publicly funded alcohol treatment completion are due to racial differences in attending outpatient and residential treatment. METHODS: Statistical analysis of alcohol treatment completion rates using alcohol treatment patients' discharge records from all publicly funded treatment facilities in Los Angeles County from 1998 to 2000 (n = 10,591). RESULTS: Among these patients, African American (OR = 0.52; 95% CI 0.47, 0.57) and Hispanic (OR = 0.89; 95% CI 0.81, 0.99) patients were significantly less likely to complete treatment as compared with White patients. We found that the odds of being in outpatient versus residential care were 1.42 (95% CI 1.29, 1.55) and 2.05 (95% CI 1.85, 2.26) for African American and Hispanic alcohol treatment patients, respectively, compared with White patients. Adjusting for addiction characteristics, employment, other patient-level factors that might influence treatment enrollment, and unobserved facility-level differences through a random effects regression model, these odds increased to 1.89 (95% CI 1.22, 2.94) for African American and to 2.12 (95% CI 1.40, 3.21) for Hispanics. We developed a conditional probability model to assess the contribution of racial differences in treatment modality to racial disparities in treatment completion. Estimates from this model indicate that were African American and Hispanic patients observed in outpatient care in this population to have the same probability of receiving residential care as White patients with otherwise similar characteristics, the White-African American difference in completion rates would be reduced from 13.64% (95% CI 11.58%, 15.71%) to 11.09% (95% CI 8.77%, 13.23%) and the White-Hispanic difference would disappear, changing from 2.63% (95% CI 0.29%, 4.95%) to -0.45% (-3.52%, 2.43%). CONCLUSION: It appears that reductions in racial disparities in treatment completion could be gained by increasing enrollment in residential alcohol treatment for African American and Hispanic alcohol abusers in Los Angeles County. Further research addressing why minority alcohol abusers are less likely to receive residential alcohol treatment should be conducted, as well as research that examines why African American alcohol treatment patients have lower completion rates as compared with White patients regardless of treatment modality.     

How Well Does the Surprise Question Predict 1-year Mortality for Patients Admitted with COPD?

BackgroundPatients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP.ObjectiveTo assess how well the SQ predicts mortality and prompts ACP for COPD patients.DesignRetrospective cohort study.SubjectsPatients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018.Main MeasuresEmergency department (ED) and inpatient clinicians answered, “Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?” The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document).Key ResultsThe 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39–4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64–4.36).ConclusionsThe 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06512-8.Key Words: prognostication, goals-of-care, advance care planning, surprise question, chronic obstructive pulmonary disease     

Motor vehicle crash fatalities: A comparison of Hispanic and non-Hispanic motorists in Colorado

STUDY OBJECTIVES: We compare the population-based death rates from traffic crashes in the Hispanic and non-Hispanic white populations in a single state, and compare fatally injured Hispanic and non-Hispanic drivers with respect to safety belt use, alcohol involvement, speeding, vehicle age, valid licensure, and urban-rural location. METHODS: Hispanic and non-Hispanic white motorists killed in traffic crashes in 1991-1995 were studied (n=2,272). Data from death certificates (age, sex, education, race, and ethnicity) and the Fatality Analysis Reporting System (FARS; driver, vehicle, and crash information) were merged. Average annual age-adjusted fatality rates were calculated; to compare Hispanic and non-Hispanic white motorists, rate ratios (RR) and 95% confidence intervals (CIs) were calculated. Odds ratios (ORs), adjusted for age, sex, and rural locale, were calculated to measure the association between Hispanic ethnicity and driver and crash characteristics. RESULTS: Eighty-five percent of FARS records were matched to death certificates. Compared with non-Hispanic white motorists, Hispanics had higher crash-related fatality rates overall (RR 1.75, 95% CI 1.60 to 1.92) and for drivers only (RR 1.62, 95% CI 1.41 to 1.85). After adjustment for age, sex, and rural locale, Hispanic drivers had higher rates of safety belt nonuse (OR 1.81, 95% CI 1.20 to 2.72), legal alcohol intoxication (OR 2.73, 95% CI 1.97 to 3.79), speeding (OR 1.36, 95% CI 0.99 to 1.88), and invalid licensure (OR 2.58, 95% CI 1.78 to 3.75). The average vehicle age for Hispanic drivers (10.1 years, 95% CI 9.3 to 11.0) was greater than for non-Hispanic white motorists (8.8 years, 95% CI 8.4 to 9.2). CONCLUSION: Compared with non-Hispanic whites, Hispanic drivers have higher rates of safety belt nonuse, speeding, invalid licensure and alcohol involvement, with correspondingly higher rates of death in traffic crashes. As traffic safety emerges as a public health priority in Hispanic communities, these data may help in developing appropriate and culturally sensitive interventions.     

Life‐Sustaining Treatments: What Do Physicians Want and Do They Express Their Wishes to Others?

OBJECTIVES: To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life-sustaining treatment they wish in the event of incapacity to make these decisions for themselves. DESIGN: Mailed survey to a cohort of physicians. SETTING: Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964. PARTICIPANTS: Physicians who completed the advance directive questionnaire (mean age 68). MEASUREMENTS: Questionnaires were sent out to known surviving physicians of the Precursors Study, an on-going study that began in 1946, asking physicians about their preferences for life-sustaining treatments. RESULTS: Of 999 physicians who were sent the survey, 765 (77%) responded. Forty-six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty-four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49-4.69) or family members (OR = 9.58, 95% CI = 5.33-17.23) were aware of their preferences for end-of-life care and were more likely to refuse treatments than those without advance directives. CONCLUSION: This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians.     

Advance Care Planning and Treatment Intensity Before Death Among Black,Hispanic, and White Patients Hospitalized with COVID-19

BackgroundBlack and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access.ObjectiveTo examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19.DesignRetrospective cohort analysis of manually abstracted electronic medical records.Patients7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020Main MeasuresAdvance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR).Key ResultsAdjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9–1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6–1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)).ConclusionsHospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.KEY WORDS: COVID-19, racial disparities, terminal care, mortality, intensive care unit, mechanical ventilation, do not resuscitate order, advance care planning, hospital medicine, medical decision-making     

Aging versus disease: the opinions of older black, Hispanic, and non-Hispanic white Americans about the causes and treatment of common medical conditions.

BACKGROUND: Little is known about how older people interpret disease and how those interpretations might relate to use of medical services. OBJECTIVE: To assess opinions of older subjects about the cause and treatment of common diseases and how they are related to health behaviors. DESIGN: In-home interview of a population-based sample (n = 601) of noninstitutionalized black, Hispanic, and non-Hispanic white American men and women aged 75 and older in Galveston County, Texas. RESULTS: Substantial proportions of the subjects considered heart disease, arthritis, or difficulty sleeping to be a normal part of aging. In multivariate analyses including age, gender, education, marital status, living arrangement, global self-rating of health, and comorbidity, older black subjects were less likely to view heart disease (OR = 0.41; 95% CI, 0.26-0.64), arthritis (OR = 0.48; 95% CI, 0.31-0.73), or sleep problems (OR = 0.50; 95% CI, 0.32-0.77) as a normal part of aging than were non-Hispanic whites. Blacks were more than three times as likely to attribute heart disease to overwork or stress than were non-Hispanic whites. In multivariate analyses, subjects who considered all three of the medical conditions to be a normal part of aging ("fatalistic") were less likely to have received preventive medical services in the previous year (OR = 0.13; 95% CI, 0.02-0.96), and subjects who felt that nothing could be done to treat any of the conditions ("nihilistic") were less likely to have a regular physician (OR = 0.24; 95% CI, 0.08-0.74). CONCLUSIONS: Substantial numbers of older subjects are fatalistic about the cause of disease and/or nihilistic about its treatment. These attitudes are associated with decreased utilization of health services. Attempts to improve the health of underserved groups should employ interventions that are sensitive to the health beliefs of the targeted group.     

Acculturation of attitudes toward end-of-life care: a cross-cultural survey of Japanese Americans and Japanese

OBJECTIVE: Cross-cultural ethical conflicts are common. However, little is known about how and to what extent acculturation changes attitudes toward end-of-life care and advance care planning. We compared attitudes toward end-of-life care among Japanese Americans and Japanese in Japan. DESIGN: Self-administered questionnaire in English and Japanese. SETTING AND PARTICIPANTS: Community-based samples of Japanese Americans in Los Angeles and Japanese in Nagoya, Japan: 539 English-speaking Japanese Americans (EJA), 340 Japanese-speaking Japanese Americans (JJA), and 304 Japanese living in Japan (JJ). MEASUREMENTS AND MAIN RESULTS: Few subjects (6% to 11%) had discussed end-of-life issues with physicians, while many (EJA, 40%; JJA, 55%; JJ, 54%) desired to do so. Most preferred group surrogate decision making (EJA, 75%; JJA, 57%; JJ, 69%). After adjustment for demographics and health status, desire for informing the patient of a terminal prognosis using words increased significantly with acculturation (EJA, odds ratio [OR] 8.85; 95% confidence interval, [95% CI] 5.4 to 14.3; JJA, OR 2.8; 95% CI 1.8 to 4.4; JJ, OR 1.0). EJA had more-positive attitudes toward forgoing care, advance care planning, and autonomous decision making. CONCLUSION: Preference for disclosure, willingness to forgo care, and views of advance care planning shift toward western values as Japanese Americans acculturate. However, the desire for group decision making is preserved. Recognition of the variability and acculturation gradient of end-of-life attitudes among Japanese Americans may facilitate decision making and minimize conflicts. Group decision making should be an option for Japanese Americans.     

Promoting signing of advance directives in faith communities

OBJECTIVE: To develop a participatory educational program implemented in faith communities that would increase discussion and signing of two types of advance directives-living will and durable power of attorney for health care decisions. DESIGN: Longitudinal study with four annual cycles of program implementation, evaluation, and revision incorporating a program that fostered the discussion, signing, and/or revision of advance directives. The program involved an educational workbook and ongoing support by parish nurses. SETTING: Seventeen faith communities in Wichita, Kansas. Faith communities included several predominantly white congregations, as well as several primarily African-American and Hispanic congregations. PARTICIPANTS: Seventeen faith communities, their pastors, and 25 parish nurses worked with 361 self-selected residents, living in community settings, to participate in the program as members of their faith communities. Congregations were recruited by the executive director of a local interfaith ministries organization and parish nurses. MAIN RESULTS: Two hundred forty-eight (69%) of the congregants who started the program completed it. Of the program completers, 83 (33%) had a directive prior to the program and 140 (56%) had a directive after completion. One hundred eighty-six of the completers discussed directives with family members. Overall, 89 (36%) of the 248 program completers revised an existing directive or signed one for the first time. Age was positively related to having signed/revised a directive prior to the program. Fear that advance directives would be used to deny medical care was negatively related to signing both prior to the program and after program completion, and contributed to participants' reluctance to sign directives. CONCLUSIONS: Educational programs implemented by parish nurses in faith communities can be effective in increasing rates of discussion, revision, and/or signing of advance directives.     

Occupational exposure,attitude to HIV-positive patients and uptake of HIV counselling and testing among health care workers in a tertiary hospital in Nigeria

Health care workers (HCWs) are at risk of occupational exposure to HIV. Their attitude to HIV-positive patients influences patients’ willingness and ability to access quality care. HIV counselling and testing (HCT) services are available to inform HCWs and patients about their status. There is little information about HCT uptake and attitude to HIV-positive patients among HCWs in tertiary health facilities in Nigeria. The aim of this study was to determine occupational exposure and attitude to HIV-positive patients and level of uptake of HCT services among HCWs in a tertiary hospital in Nigeria. A cross-sectional design was utilized. A total of 977 HCWs were surveyed using semi-structured, self-administered questionnaires. Nurses and doctors comprised 78.2% of the respondents. Their mean age was 35?±?8.4 years. Almost half, 47.0%, reported accidental exposure to blood and body fluids (BBFs) in the preceding year. The main predictor of accidental exposure to BBFs in the last year was working in a surgical department, OR?=?1.7, 95% CI (1.1–2.6). HCWs aged <40 years, OR?=?5.5, 95% CI (1.9–15.9), who had worked for >5 years, OR?=?3.6, 95% CI (1.4–9.3) and who work in nursing department, OR?=?6.8, 95% CI (1.7–27.1) were more likely to be exposed to BBFs. Almost half, 52.9%, had accessed HCT services. Predictors for HCT uptake were age <40 years OR?=?1.6, 95% CI (1.1–2.4), having worked for >5 years OR?=?1.5, 95% CI (1.03–2.2) and working in medical department OR?=?1.7, 95% CI (1.1–2.8). Respondents in nursing departments were more likely to require routine HIV test for all patients, OR?=?3.9, 95% CI (2.4–6.2). HCWs in the laboratory departments were more likely to believe that HIV patients should be on separate wards, OR?=?3.6, 95% CI (1.9–7.0). HCWs should be protected and encouraged to access HCT services in order to be effective role models in the prevention of HIV/AIDS.     

Advance Care Planning for Older Homeless‐Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study

Older homeless‐experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross‐sectional analysis of a cohort of 350 homeless‐experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision‐makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52–82), 75.2% were male, and 82.1% were black. Sixty‐one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7–20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9–5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0–4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5—0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4–17.5), being black (aOR=5.5, 95% CI=1.5–19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5–32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1–0.9) with lower odds. Although the majority of older homeless‐experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety‐net healthcare settings.     

Stages of change for the component behaviors of advance care planning

OBJECTIVES: To develop stages‐of‐change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP. DESIGN: Observational cohort study. SETTING: Community. PARTICIPANTS: Persons aged 65 and older recruited from physician offices and a senior center. MEASUREMENTS: Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life‐sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues. RESULTS: Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life‐sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life. CONCLUSION: Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP.     

Determinants of adherence to influenza vaccination among inner-city adults with persistent asthma.

AIMS: Despite guideline recommendation, influenza vaccination rates among asthmatic patients remain low. The objective of this study was to identify health beliefs associated with vaccination adherence in asthmatic patients. METHODS: We surveyed 167 adults with persistent asthma undergoing follow-up at a hospital-based clinic. Vaccination beliefs questions were based on the Health Belief Model. Patients who reported receiving influenza immunisation most or every year were considered adherent to vaccination. RESULTS: Overall, 71% of patients were adherent to influenza vaccination. In multivariate analyses, doctor or nurse recommendation (odds ratio [OR]: 14.71, 95% CI 5.40-40.05), the belief that the vaccine protects against influenza (OR: 7.21, 95% CI 2.25-23.10), and the belief that the vaccine could cause a cold (OR: 0.46, 95% CI 0.19-1.13) were independent predictors of adherence. CONCLUSIONS: Vaccination beliefs and physician recommendation were associated with influenza vaccination adherence among inner-city asthmatics. Future interventions should target these potentially modifiable factors.     

Colorectal cancer screening behavior and willingness: an outpatient survey in China

AIM:To identity the factors influencing colorectal cancer(CRC) screening behavior and willingness among Chinese outpatients.METHODS:An outpatient-based face-to-face survey was conducted from August 18 to September 7,2010 in Changhai Hospital.A total of 1200 consecutive patients aged ≥ 18 years were recruited for interview.The patient's knowledge about CRC and screening was pre-measured as a predictor variable,and other predictors included age,gender,educational level,monthly household income and health insu...