Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs.

BACKGROUND: Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options. OBJECTIVE: To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care. DESIGN: This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs. SETTING/SUBJECTS: Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases. MEASUREMENTS: The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare. RESULTS: We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793). CONCLUSIONS: ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.

Deliberate Practice with Standardized Patient Actors and the Development of Formative Feedback for Advance Care Planning Facilitators.

OBJECTIVE: Multimodal curricular assessment after adding standardized patient (SP) actor-based simulation to an advance care planning (ACP) facilitator training course and development of a formative feedback tool. BACKGROUND: ACP represents a highly valued service requiring more and better trained facilitators. METHODS: Participants were primarily nurses and social workers in a large multisite health system. The course included a precourse video demonstration of ACP, traditional lectures, and four 30-minute simulations with SPs. Knowledge was tested with a multiple choice question (MCQ) test. In addition to standard postcourse/postsimulation evaluations, learners were surveyed pre/post/30-90 days delayed for self-perceived confidence. A linear mixed-effects model was used to analyze changes over time. Trained faculty rated performance in simulations with an observational mini-clinical examination (mini-CEX)-type rating form with a checklist, global competency, and global communication rating. Inter-rater reliability (IRR) was calculated on randomly selected paired ratings. RESULTS: Sixty-seven individuals consented to participate. MCQ scores improved from 83% ± 10% to 92% ± 8% (p < 0.001). Paired learner surveys of self-confidence across six domains were available for 65 pre, 65 post, and 40 delayed with a mean positive change on a 0 to 10 point scale from pre-post (2.32 ± 1.65; p < 0.001) and predelayed (2.34 ± 1.96; p < 0.001) time frames. For the faculty observation ratings of simulation performance, the average raw agreement for critical actions was 82% and IRR was 0.71. CONCLUSIONS: Learner feedback and self-assessment suggest that actor-based simulation contributed to improved confidence in conducting ACP. The mini-CEX observation form is adequate for formative feedback, with further testing needed to make judgments of competence.

Draft genome and description of Orrella dioscoreae gen. nov. sp. nov., a new species of Alcaligenaceae isolated from leaf acumens of Dioscorea sansibarensis.

Dioscorea sansibarensis is a monocot species of inedible yam native of tropical Africa and Madagascar. Leaves of D. sansibarensis feature prominent acumen glands that are densely colonized by bacteria. We describe here the isolation and characterization of bacteria from leaf glands of D. sansibarensis specimens obtained from various botanical gardens. Phylogenetic and phenotypic characterizations indicate that the isolates belong to a novel genus and species of the Alcaligenaceae family for which we propose the name Orrella dioscoreae gen. nov. sp. nov., with type strain LMG 29303T [=CIP 111009T]. Strains isolated from different plants show limited phylogenetic and phenotypic diversity, indicating specific and tight association of the bacteria with the host plant. The analysis of the draft genome of strain LMG 29303T reveals features consistent with a recently evolved plant-associated lifestyle.

The genome analysis of Candidatus†Burkholderia crenata reveals that secondary metabolism may be a key function of the Ardisia crenata leaf nodule symbiosis.

A majority of Ardisia species harbour Burkholderia sp. bacteria within specialized leaf nodules. The bacteria are transmitted hereditarily and have not yet been cultured outside of their host. Because the plants cannot develop beyond the seedling stage without their symbionts, the symbiosis is considered obligatory. We sequenced for the first time the genome of Candidatus Burkholderia crenata (Ca. B. crenata), the leaf nodule symbiont of Ardisia crenata. The genome of Ca. B. crenata is the smallest Burkholderia genome to date. It contains a large amount of insertion sequences and pseudogenes and displays features consistent with reductive genome evolution. The genome does not encode functions commonly associated with plant symbioses such as nitrogen fixation and plant hormone metabolism. However, we identified unique genes with a predicted role in secondary metabolism in the genome of Ca. B. crenata. Specifically, we provide evidence that the bacterial symbionts are responsible for the synthesis of compound FR900359, a cyclic depsipeptide with biomedical properties previously isolated from leaves of A. crenata.

Can ventilation-feedback training augment exercise tolerance in patients with chronic obstructive pulmonary disease?

RATIONALE: Exercise-induced dynamic hyperinflation contributes to decreased exercise tolerance in chronic obstructive pulmonary disease (COPD). It is unknown whether respiratory retraining (ventilation-feedback [VF] training) can affect exercise-induced dynamic hyperinflation and increase exercise tolerance. OBJECTIVES: To determine whether patients with COPD would achieve longer exercise duration if randomized to a combination of exercise training plus VF training than either form of training on its own. METHODS: A total of 64 patients randomized to 1 of 3 groups: VF plus exercise (n = 22), exercise alone (n = 20), and VF alone (n = 22). MEASUREMENTS AND MAIN RESULTS: Exercise duration before and after 36 training sessions and exercise-induced dynamic hyperinflation and respiratory pattern before and after training were measured. In the 49 patients who completed training, duration of constant work-rate exercise was 40.0 (+/- 20.4) minutes (mean +/- SD) with VF plus exercise, 31.5 (+/- 17.3) minutes with exercise alone, and 16.1 (+/- 19.3) minutes with VF alone. Exercise duration was longer in VF plus exercise than in VF alone (P < 0.0001), but did not reach predetermined statistical significance when VF plus exercise was compared with exercise alone (P = 0.022) (because of multiple comparisons, P

Effect of ventilation-feedback training on endurance and perceived breathlessness during constant work-rate leg-cycle exercise in patients with COPD.

The purpose of this study was to evaluate the efficacy of a unique program of ventilation-feedback training combined with leg-cycle exercise to improve exertional endurance and decrease perceived dyspnea in patients with chronic obstructive pulmonary disease (COPD). Thirty-nine patients (67.5 +/- 8.1 yr of age) with moderate to severe COPD (42.6% of predicted forced expiratory volume in 1 s) were randomized to one of three 6-week experimental interventions: ventilation-feedback with exercise (V(+EX)), exercise only (EX(ONLY)), or ventilation-feedback only (VF(ONLY)). At baseline and at 6 weeks, patients completed a constant work-rate leg-cycle ergometer test at 85 percent of maximal power output. There were increases within the groups in exercise duration: 11.5 min (103%), 8.0 min (66%), and 0.4 min (4%) for the VF(+EX), EX(ONLY) and VF(ONLY) groups, respectively. The VF(ONLY) group experienced no significant within-group changes in selected gas exchange parameters. However, there were significant (p < 0.05) posttraining changes in minute ventilation, tidal volume, breathing frequency (f), and expiratory time (Te) in the VF(+EX) group, and in f and Te in the EX(ONLY) group. After completing the training, VF(+EX) and EX(ONLY) patients reported less breathlessness and perceived exertion (p < 0.05). The VF(ONLY) patients' ratings changed in the hypothesized direction but were not significant. Based on these preliminary data, VF(+EX) and EX(ONLY) were equally effective in improving leg-cycle exercise tolerance in patients with moderate to severe COPD.