IU Indianapolis ScholarWorks :: Browsing by Author "Comer, Amber R."

Browsing by Author "Comer, Amber R."

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Assessment of Discordance Between Surrogate Care Goals and Medical Treatment Provided to Older Adults With Serious Illness
(JAMA Network, 2020-05) Comer, Amber R.; Hickman, Susan E.; Slaven, James E.; Monahan, Patrick O.; Sachs, Greg A.; Wocial, Lucia D.; Burke, Emily S.; Torke, Alexia M.; Health Sciences, School of Health and Human Sciences
Importance: An important aspect of high-quality care is ensuring that treatments are in alignment with patient or surrogate decision-maker goals. Treatment discordant with patient goals has been shown to increase medical costs and prolong end-of-life difficulties. Objectives: To evaluate discordance between surrogate decision-maker goals of care and medical orders and treatments provided to hospitalized, incapacitated older patients. Design, setting, and participants: This prospective cohort study included 363 patient-surrogate dyads. Patients were 65 years or older and faced at least 1 major medical decision in the medical and medical intensive care unit services in 3 tertiary care hospitals in an urban Midwestern area. Data were collected from April 27, 2012, through July 10, 2015, and analyzed from October 5, 2018, to December 5, 2019. Main outcomes and measures: Each surrogate's preferred goal of care was determined via interview during initial hospitalization and 6 to 8 weeks after discharge. Surrogates were asked to select the goal of care for the patient from 3 options: comfort-focused care, life-sustaining treatment, or an intermediate option. To assess discordance, the preferred goal of care as determined by the surrogate was compared with data from medical record review outlining the medical treatment received during the target hospitalization. Results: A total of 363 dyads consisting of patients (223 women [61.4%]; mean [SD] age, 81.8 [8.3] years) and their surrogates (257 women [70.8%]; mean [SD] age, 58.3 [11.2] years) were included in the analysis. One hundred sixty-nine patients (46.6%) received at least 1 medical treatment discordant from their surrogate's identified goals of care. The most common type of discordance involved full-code orders for patients with a goal of comfort (n = 41) or an intermediate option (n = 93). More frequent in-person contact between surrogate and patient (adjusted odds ratio [AOR], 0.43; 95% CI, 0.23-0.82), patient residence in an institution (AOR, 0.44; 95% CI, 0.23-0.82), and surrogate-rated quality of communication (AOR, 0.98; 95% CI, 0.96-0.99) were associated with lower discordance. Surrogate marital status (AOR for single vs married, 1.92; 95% CI, 1.01-3.66), number of family members involved in decisions (AOR for ≥2 vs 0-1, 1.84; 95% CI, 1.05-3.21), and religious affiliation (AOR for none vs any, 4.87; 95% CI, 1.12-21.09) were associated with higher discordance. Conclusions and relevance: This study found that discordance between surrogate goals of care and medical treatments for hospitalized, incapacitated patients was common. Communication quality is a modifiable factor associated with discordance that may be an avenue for future interventions.
Barriers to guideline-concordant antibiotic use among inpatient physicians: A case vignette qualitative study
(Wiley, 2016-03) Livorsi, D.; Comer, Amber R.; Matthias, Marianne S.; Perencevich, E.N.; Bair, M.J.; Department of Communication Studies, School of Liberal Arts
BACKGROUND: Greater adherence to antibiotic-prescribing guidelines may promote more judicious antibiotic use, which could benefit individual patients and society at large. OBJECTIVE: To assess physician knowledge and acceptance of antibiotic-prescribing guidelines through the use of case vignettes. DESIGN: We conducted semistructured interviews with 30 inpatient physicians. Participants were asked to respond to 3 hypothetical case vignettes: (1) a skin and soft tissue infection (SSTI), (2) suspected hospital-acquired pneumonia (HAP), and (3) asymptomatic bacteriuria (ASB). All participants received feedback according to guidelines from the Infectious Diseases Society of America (IDSA) and were asked to discuss their level of comfort with following these guidelines. SETTING: Two acute care teaching hospitals for adult patients. INTERVENTION: None. MEASUREMENTS: Data from transcribed interviews were analyzed using emergent thematic analysis. RESULTS: Participants were receptive to guidelines and believed they were useful. However, participants' responses to the case vignettes demonstrated that IDSA guideline recommendations were not routinely followed for SSTI, HAP, and ASB. We identified 3 barriers to guideline-concordant care: (1) physicians' lack of awareness of specific guideline recommendations; (2) tension between adhering to guidelines and the desire to individualize patient care; and (3) skepticism of certain guideline recommendations. CONCLUSIONS: Case vignettes may be useful tools to assess physician knowledge and acceptance of antibiotic-prescribing guidelines. Using case vignettes, we identified 3 barriers to following IDSA guidelines. Efforts to improve guideline-concordant antibiotic prescribing should focus on reducing such barriers at the local level.
Development and Validation of the Tele-Pulmonary Rehabilitation Acceptance Scale
(Daedalus, 2019) Almojaibel, Abdullah A.; Munk, Niki; Goodfellow, Lynda T.; Fisher, Thomas F.; Miller, Kristine K.; Comer, Amber R.; Bakas, Tamilyn; Justiss, Michael D.; Health Sciences, School of Health and Rehabilitation Sciences
BACKGROUND: Using telehealth in pulmonary rehabilitation (telerehabilitation) is a new field of health-care practice. To successfully implement a telerehabilitation program, measures of acceptance of this new type of program need to be assessed among potential users. The purpose of this study was to develop a scale to measure acceptance of using telerehabilitation by health-care practitioners and patients. METHODS: Three objectives were met (a) constructing a modified scale of the technology acceptance model, (b) judging the items for content validity, and (c) judging the scale for face validity. Nine experts agreed to participate and evaluate item relevance to theoretical definitions of domains. To establish face validity, 7 health-care practitioners and 5 patients were interviewed to provide feedback about the scale's clarity and ease of reading. RESULTS: The final items were divided into 2 scales that reflected the health-care practitioner and patient responses. Each scale included 3 subscales: perceived usefulness, perceived ease of use, and behavioral intention. CONCLUSIONS: The 2 scales, each with 3 subscales, exhibited evidence of content validity and face validity. The 17-item telerehabilitation acceptance scale for health-care practitioners and the 13-item telerehabilitation acceptance scale among patients warrant further psychometric testing as valuable measures for pulmonary rehabilitation programs.
Documentation of advance care planning forms in patients with amyotrophic lateral sclerosis
(Wiley, 2022-02) Takacs, Sara M.; Comer, Amber R.; Neurology, School of Medicine
Introduction/Aims Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder characterized by progressive weakness. Survival is typically only a few years from symptom onset. The often-predictable disease course creates opportunities to complete advance care planning (ACP) forms. The Physician Orders for Life-Sustaining Treatment (POLST) is a broadly used ACP paradigm to communicate end-of-life wishes but has not been well-studied in the ALS population. Methods In this retrospective chart review study, patients diagnosed with ALS seen between 2014 and 2018 at an academic ALS center were identified. Demographic information, clinical characteristics, and ACP data were collected. Results Of 513 patients identified, 30% had an ACP document. POLST forms were competed in 16.6% of patients with 73.8% of forms signed by a neurologist. Only 5.1% of patients saw a palliative care physician. Palliative care consultation was associated with having an POLST on file (P < .001). Patients with completed POLST forms were significantly more likely to have been seen in clinic more frequently (P < .001) and have a lower ALS Functional Rating Scale—Revised score on last visit (P = .005). Discussion Less than one third of patients with ALS completed an ACP document, and only a small percentage completed POLST forms. The data suggest a need for greater documentation of goals of care in the ALS population.
The effect of a state health care consent law on patient care in hospitals: A survey of physicians
(Sciedu Press, 2018-03-05) Comer, Amber R.; Gaffney, Margaret; Stone, Cynthia; Torke, Alexia; Physical Therapy, School of Health and Human Sciences
Objective: When a patient cannot make medical decisions for him or herself, and has not appointed a healthcare representative, default state healthcare consent laws determine who is able to make healthcare decisions for the patient. The narrow construction of some state laws leaves many patients in situations where the closest person to the patient does not qualify as a representative under the law, or where the patient has too many representatives and a consensus cannot be reached on the patient’s medical care. Methods: In order to determine how state healthcare consent laws affect patient care in hospitals, a survey of 412 Indiana physicians was conducted. Results: The data shows 53.8% of physicians experienced a delay in patient care because they were unable to identify a legally appropriate health care representative. Almost half (46.01%) of physicians experienced delay of patient care due to the inability to identify a ﬁnal decision maker when disputes arose between multiple legal representatives. Conclusions: The results of this study have important implications for hospital administrators as a delay in patient care can be costly and unnecessarily utilizes hospital resources. Additionally, the results of this study have important implications for the status of state surrogate decision making laws. Amending state laws to include more potential surrogates, has the potential to minimize delays in patient care and ensure that appropriate surrogates are making medical care decisions for patients without the undue burden of court intervention.
Electric Scooters (e-scooters): Assessing the Threat to Public Health and Safety in Setting Policies: Assessing e-scooter policies
(Society of Practitioners of Health Impact Assessment, 2020-11) Comer, Amber R.; Apathy, Nate; Waite, Carly; Bestmann, Zoe; Bradshaw, Jacob; Burchfield, Emily; Harmon, Brittany; Legg, Rebekah; Meyer, Star; O'Brien, Patrick; Sabec, Micha; Sayeed, Jami; Weaver, Alexis; D'Cruz, Lynn; Bartlett, Stephanie; Marchand, McKenzi; Zepeda, Isabel; Endri, Katelyn; Finnell, John T.; Grannis, Shaun; Silverman, Ross D.; Embi, Peter J.; Health Sciences, School of Health and Human Sciences
Objective: To determine self-reported incidences of health and safety hazards among persons who ride rentable electric scooters (e-scooters), knowledge of e-scooter laws, and attitudes and perceptions of the health and safety of e-scooter usage. Methods: A cross-sectional survey of n= 561 e-scooter riders and non-riders was conducted during June of 2019. Results: Almost half of respondents (44%) report that e-scooters pose a threat to the health and safety of riders. Riders and non-riders disagree regarding the hazards that e-scooters pose to pedestrians. Among riders, 15% report crashing or falling off an e-scooter. Only 2.5% of e-scooter riders self-report that they always wear a helmet while riding. Conclusions: E-scooter riders report substantial rates of harmful behavior and injuries. Knowledge of e-scooter laws is limited, and e-scooters introduce threats to the health and safety of riders, pedestrians on sidewalks, and automobile drivers. Enhanced public health interventions are needed to educate about potential health risks and laws associated with e-scooter use and to ensure health in all policies. Additionally, greater consideration should be given to public health, safety, and injury prevention when passing relevant state and local e-scooter laws.
The legal and ethical implications of the Indiana surrogate decision making impact on physicians and patient care in Indiana hospitals
(2015) Comer, Amber R.; Silverman, Ross David; Torke, Alexia Mary; Eberl, Jason; Gaffney, Margaret M.; Stone, Cynthia L.
Background: When a patient is incapacitated and unable to make health care decisions, a surrogate decision maker must be designated to make decisions about the patient’s care in his or her place. Studies show that fewer than 20% of patients in hospitals present with a designated health care representative form. Therefore, the overwhelming majority of surrogates in hospitals are identified via default state statutes. Little is known about the implications of state default surrogate decision making statutes on physicians and patient care in clinical practice. Methods: An evaluation of state surrogate decision making statutes was conducted in order to determine variability among state laws. Additionally, a statewide, quantitative, descriptive, cross-sectional survey of a random sample of 405 physicians working in Indiana hospitals was conducted to determine: 1) physicians’ knowledge of Indiana’s surrogate decision making law; 2) physicians’ approaches to hypothetical cases they might encounter in hospital practice; and 3) any delay in patient care physicians experience as a result of state surrogate decision making laws. Results: There is very little consistency among states regarding who may serve as a surrogate decision maker. In Indiana, less than half of the surveyed physicians (47.90%) were able to correctly identify legally allowable surrogates. When presented with clinica vignettes, nearly all physicians (84.90%) report that they would allow a grandchild to act as a surrogate decision maker, even though grandchildren are not legal surrogates under the law. Additionally, more than half of physicians (53.8%) experienced a delay in patient care due to the inability to identify a legal surrogate. Conclusions: The narrow construction of state laws can leave patients in situations where they either have no qualified surrogate under the law or where they have multiple surrogates. If there are multiple surrogates with competing interests a consensus may not be reached on the patient’s medical care. These situations result in a delay of patient care. The results of this study show that the Indiana Surrogate Decision Making law is flawed as it does not reflect the composition of Indiana families and leads to delays in patient care.
Massage perceptions and attitudes of undergraduate pre-professional health sciences students: a cross-sectional survey in one U.S. university
(BMC, 2020-07-08) Munk, Niki; Church, Abby; Nemati, Donya; Zabel, Samantha; Comer, Amber R.; Health Sciences, School of Health and Rehabilitation Sciences
Background Attitudes and beliefs about massage therapy have been explored among health professionals and health profession students, but not for undergraduate preprofessional health sciences students. Methods This cross-sectional survey sought to determine pre-professional health students’ attitudes and perceptions toward massage therapy and determine the extent demographic variables such as age, gender, race, along with lifetime massage experience are associated with neutral/negative perceptions. Results N = 129 undergraduate students completed the Attitudes Toward Massage scale and 7 supplemental items pertaining to sexuality and therapist gender preference along with questions regarding lifetime massage utilization. Prevalence of massage therapy utilization was 35.6% (lifetime) and 18.6% (last 12-months). Overall, positive attitudes towards massage therapy was observed with participants reporting massage experience expressing more positive massage attitudes (lifetime; p = 0.0081, the past 12 months; p = 0.0311). Participants with no massage experience were more likely to report neutral/negative attitudes toward massage (p = 0.04). Men were more likely to prefer their massage therapist to be of the opposite sex (38.9%) compared to women (2.1%) (p = < 0.0001). Men were less confident than women in their concern of becoming sexually aroused during massage (p = 0.0001) and in the belief that massage is sexually arousing (p = 0.048). Both genders expressed comfort with female and/or male massage therapists, but if given a choice, both prefer a female massage therapist. Conclusions Undergraduate pre-professional health sciences students have generally positive attitudes towards massage therapy however more research is needed regarding implicit gender bias and/or preferences. This work should inform future research designs examining the impact of attitudes and beliefs on patient referrals to massage therapy.
Medical decision making about long-term artificial nutrition after severe stroke: a case report
(PubMed, 2021-07) Comer, Amber R.; Williams, Linda S.; Bartlett, Stephanie L.; D'Cruz, Lynn E.; Torke, Alexia M.; Health Sciences, School of Health and Human Sciences
Choosing to use a percutaneous endoscopic gastrostomy (PEG tube) for long term artificial nutrition in the setting of inadequate oral intake after stroke is complex because the decision must be made in a relatively short amount of time and prognosis is often uncertain. This case study utilized interviews with attending and resident neurologists, and surrogate medical decision makers in order to examine how neurologists and surrogate medical decision makers approached the decision to either receive a PEG tube or pursue comfort measures after severe stroke in two patients. Although these two patients presented with similar clinical characteristics and faced similar medical decisions, different decisions regarding PEG tube placement were made. Major challenges included physicians who did not agree on prognosis and surrogates who did not agree on whether to place a PEG tube. These cases demonstrate the importance of the role of the surrogate medical decision maker and the necessity of physicians and surrogate medical decision makers approaching the complex decision of PEG tube placement after stroke together. Additionally, these cases highlight the differing views on what defines a good quality of life and show the vital importance of high-quality goals of care conversations about prognosis and quality of life when deciding whether to place a PEG tube after severe stroke.
Non-Traditional Surrogate Decision Makers for Hospitalized Older Adults
(Lippincott, Williams & Wilkins, 2018-04) Comer, Amber R.; Slaven, James E.; Montz, Annie; Burke, Emily; Inger, Lev; Torke, Alexia; Robert H. Mckinney School of Law
Background Without advanced preparation of legal documents, state law determines who may serve as a surrogate decision maker for patients in hospitals. Objectives To examine the relationship characteristics associated with traditional versus non-traditional healthcare surrogates who are making medical decisions for patients in hospitals. Research Design Secondary analysis of a baseline cross-sectional survey of a larger prospective observational study. Subjects 364 patient/ surrogate dyads consisting of patients age 65 years and older admitted to the medical or medical ICU services who lacked decision making capacity based on a physician assessment and also had a surrogate available. Results This study of surrogate decision makers for hospitalized older adults found that the relationships of non-traditional surrogates such as, nieces, nephews, and friends serving in the surrogate role is nearly identical to those of traditional, first degree relatives serving as a surrogate. Over two-thirds (71.2%) of non-traditional surrogates saw the patient in person at least weekly compared to 80.8% of legal surrogates (p-value .9023). Almost all traditional and non-traditional surrogates discussed the patient’s medical preferences with the patient (96.9% of legal surrogates and 89.2% of non-traditional surrogates; p=0.0510). Conclusion This study shows that both traditional and non-traditional surrogates, who are a patient’s primary care giver have similar relationships with patients. The findings of this study suggest that requiring family members such as grandchildren to take the extra step of formal appointment through a legal channel may not be necessary to protect patients. Therefore, broader state laws expanding the list of surrogates authorized by state statute to include more non-traditional surrogates may be necessary.

Browsing by Author "Comer, Amber R."

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