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Physician Orders for Life‐Sustaining Treatment Medical Intervention Orders and In‐Hospital Death Rates: Comparable Patterns in Two State Registries

2016; Wiley; Volume: 64; Issue: 8 Linguagem: Inglês

10.1111/jgs.14273

1532-5415

Alvin H. Moss, Dana Zive, Evan C. Falkenstine, Erik K. Fromme, Susan W. Tolle,

Grief, Bereavement, and Mental Health

To the Editor: In their systematic review of the Physician Orders for Life-Sustaining Treatment (POLST) literature, Hickman and colleagues observe limitations that merit further investigation.1 Among their concerns are the generalizability to other states of Oregon POLST research, the limited data about POLST use outside nursing home populations, and the need for epidemiological studies to better understand how POLST affects clinical outcomes. They note the potential of electronic registries linked to vital statistics to improve understanding of the association between POLST orders and healthcare usage. The goal of this study was to evaluate patterns observed in Oregon in another POLST program state, West Virginia, with different demographic characteristics and a different approach to electronic POLST registration. Specifically, the relationships between POLST medical intervention orders and in-hospital death were compared using electronic registry data linked to state death records. A cross-section of West Virginia e-Directive Registry2, 3 and Oregon POLST Registry4, 5 data from January 1, 2012, through December 31, 2013, was matched to in-state 2012 and 2013 death records. Only deaths from natural causes were included. Variables from death records included dates of birth and death, decedent county of residence, sex, age at death, and primary cause of death. Decedent counties were coded as rural or urban using the U.S. Department of Agriculture Economic Research Service Rural-Urban Continuum Codes. Variables from both registries included demographic characteristics and POLST orders from the decedent's final form. Death location was grouped into in-hospital, home, and out of hospital (clinic, physician's office, nursing and assisted living facilities, and inpatient hospice). Descriptive univariate statistics were used to characterize the sample and chi-square tests to determine significant between-group differences. Analyses were conducted using IBM SPSS statistics v.21 (IBM Corp., Armonk, NY). The Oregon Health Authority, Oregon Health & Science University, and West Virginia University institutional review boards reviewed this study and deemed it exempt. In 2012/13, the matched sample generated 25,670 Oregon and 1,330 West Virginia decedents with POLST forms in their state registries. Table 1 compares registrant demographic characteristics and POLST form orders. Registry decedents in West Virginia were younger than Oregon decedents (median age 79.7 vs 83.6), more likely to live in a rural county at the time of death (44.7% vs 15.5%), and more likely to have cancer as a primary cause of death (35.6% vs 28.4%) (all P < .001). Of decedents with POLST comfort measures orders, 10.8% in West Virginia and 6.8% in Oregon died in the hospital. Of decedents with full-treatment orders, 33.0% in West Virginia and 39.1% in Oregon died in the hospital (Table 1). Thus, individuals in both states with full-treatment orders were more than three times as likely to die in the hospital as those with comfort measure orders (both P < .001). This study confirms patterns previously observed in Oregon.5 Despite different demographic characteristics in Oregon and West Virginia, it demonstrates that in both states, the proportions of hospital deaths were strongly associated with POLST medical intervention orders, with individuals with orders for more treatments more likely to die in the hospital. There are limitations to this retrospective study. Individuals who choose to complete a POLST form may differ from the general population, and those whose forms are submitted to their state registry may not be representative of all individuals with POLST forms in these states. (In Oregon, form submission is mandated, unless an individual opts out, whereas West Virginia has an opt-in system.) Oregon and West Virginia have well-established POLST programs—it is unknown whether this study's results would be obtained in states with newer programs. Nonetheless, the sample captured individuals of all ages, from urban and rural regions, with varying causes of death, and from all care settings, not just nursing homes, throughout Oregon and West Virginia. This study contributes to the research on how POLST orders are associated with changes in clinical outcomes and healthcare usage. Using electronic registries linked to state death records, decedents in Oregon and West Virginia with registered POLST comfort measures orders were significantly less likely to die in the hospital than those with full-treatment orders. This study demonstrates that results from Oregon are replicable in another state with different demographic characteristics and different approaches to electronic POLST registration. This research was supported in part by a gift from Bill and Karen Early to the Oregon POLST Program. Dr. Moss's research at the West Virginia University Center for Health Ethics and Law was supported in part by the Mei-Ying Huang Research Fund, which was created by family and friends in her honor after her death. Conflict of Interest: Alvin H. Moss is a member of the National POLST Paradigm Task Force. Dana M. Zive is a member of the National POLST Paradigm Research Subcommittee, a research liaison for the Oregon POLST Task Force, a technology adviser to the National POLST Task Force, and director of the Oregon POLST Registry and has a current unrelated grant from the California Health Care Foundation. Erik K. Fromme is a member of the National POLST Paradigm Research Subcommittee and has a current unrelated grant from the Cambia Health Foundation. Susan W. Tolle is a member of the National POLST Paradigm Task Force and has current grants from the Archstone Foundation, California HealthCare Foundation, Retirement Research Foundation, Collins Foundation, Kinsman Foundation, and Storms Family Foundation. Evan C. Falkenstine is employed by the West Virginia Center for End-of-Life Care, which oversees the West Virginia e-Directive Registry. Author Contributions: Moss, Fromme, Tolle: study concept and design, interpretation of data, preparation of manuscript. Zive: study concept and design, acquisition of data, analysis and interpretation of data, preparation of manuscript. Falkenstine: study concept and design, acquisition of data, analysis and interpretation of data. Sponsor's Role: The Earlys had no role in any aspect of the research. The Huang family had no role in any aspect of the conduct of the research.