A Letter to Your Care Providers: Implementation and Analysis of a Letter-based Advance Care Planning Initiative for Gynecologic Oncology Patients.

To determine the impact of a letter-based advance care planning (ACP) healthcare improvement (HI) initiative on rates of ACP conversations and documentation among gynecologic oncology (GO) inpatients. An HI initiative was implemented from January to December 2020 to improve ACP documentation among GO inpatients. Patients admitted to the GO service were given ACP packets with a letter-based ACP worksheet. GO inpatients who were interested in learning more about ACP were visited by medical students trained to lead ACP conversations. ACP documentation rates in the EMR (electronic medical record) pre- and post-intervention were evaluated. Descriptive statistics were calculated. Associations between sociodemographic characteristics and ACP documentation were analyzed using logistic regression. There were 172 patients admitted in 2019 (pre-implementation cohort). Of these, 45/172 patients (26%) had an advance directive (AD) documented in their electronic medical record (EMR). Following the implementation of the ACP HI in 2020, 55/168 patients (33%) had an AD documented in their EMR. This was a 7% absolute increase and 27% relative increase from pre-intervention AD documentation rates. Increasing age was associated with an increased likelihood of having an AD in the chart (p = 0.004). Married women were less likely to have an AD in their chart (p = 0.05). An HI utilizing a letter-based ACP packet given to GO inpatients improved AD documentation in the EMR. This HI offers a unique method for introducing ACP to patients. More work is needed to improve the occurrence and documentation of ACP conversations.

Qualitative Analysis of the Host-Perceived Impact of Unidirectional Global Surgery Training in Kijabe, Kenya: Benefits, Challenges, and a Desire for Bidirectional Exchange.

BACKGROUND: As globalization of surgical training increases, growing evidence demonstrates a positive impact of global surgery experiences on trainees from high-income countries (HIC). However, few studies have assessed the impact of these largely unidirectional experiences from the perspectives of host surgical personnel from low- and middle-income countries (LMIC). This study aimed to assess the impact of unidirectional visitor involvement from the perspectives of host surgical personnel in Kijabe, Kenya. METHODS: Voluntary semi-structured interviews were conducted with 43 host surgical personnel at a tertiary referral hospital in Kijabe, Kenya. Qualitative analysis was used to identify salient and recurring themes related to host experiences with visiting surgical personnel. Perceived benefits and challenges of HIC involvement and host interest in bidirectional exchange were assessed. RESULTS: Benefits of visitor involvement included positive learning experiences (95.3%), capacity building (83.7%), exposure to diverse practices and perspectives (74.4%), improved work ethic (51.2%), shared workload (44.2%), access to resources (41.9%), visitor contributions to patient care (41.9%), and mentorship opportunities (37.2%). Challenges included short stays (86.0%), visitor adaptation and integration (83.7%), cultural differences (67.4%), visitors with problematic behaviors (53.5%), learner saturation (34.9%), language barriers (32.6%), and perceived power imbalances between HIC and LMIC personnel (27.9%). Nearly half of host participants expressed concerns about the lack of balanced exchange between HIC and LMIC programs (48.8%). Almost all (96.9%) host trainees expressed interest in a bidirectional exchange program. CONCLUSION: As the field of global surgery continues to evolve, further assessment and representation of host perspectives is necessary to identify and address challenges and promote equitable, mutually beneficial partnerships between surgical programs in HIC and LMIC.

Stopping the revolving door: An exploratory analysis of health care super-utilization in gynecologic oncology.

The objective of this study was to determine the prevalence of and risk factors for health care super-utilization among gynecologic oncology patients at a single academic hospital. A retrospective cohort study of gynecologic oncology patients with an index unplanned encounter between January and December 2018 was performed. Super-utilizers were defined as patients with 3 or more unplanned hospital encounters during a 12-month period starting at the time of the index unplanned encounter. We identified 553 patients with gynecologic cancer. Of those, 37(7%) met inclusion criteria for super-utilizers accounting for 193/310(62%) of unplanned visits. The median number of unplanned visits was 4 (range 3-24). The most common cancers were uterine (N = 15 (41%)) and ovarian (N = 11 (30%)). Nineteen (51%) super-utilizers had advanced stage disease. Phases of oncologic care at index unplanned encounter included primary diagnosis (N = 24 (65%)), recurrence (N = 10 (27%)), and surveillance (N = 2 (5%)). Twelve super-utilizers (32%) had new diagnoses of cancer without prior therapy, 19(51%) had prior chemotherapy, 17(46%) had prior surgery, and 10(27%) had prior radiation therapy at the time of initial encounter. Fifteen super-utilizers (41%) were in the last year of life. The most common reasons for unplanned encounters were pain (66%) and gastrointestinal symptoms (61%). Multivariable analysis adjusting for key variables demonstrated that Medicaid insurance, ASA classification, and disease status are risk factors for health care super-utilization. The majority of health care utilization occurred during the first year of diagnosis. This exploratory analysis suggests an opportunity to decrease health care utilization, particularly during upfront treatment.