This paper describes the Advanced Dementia End-of-Life Planning and Prognosis (ADEPP) quality improvement project, designed to address the significant underutilization of hospice services among dementia patients in Lee County, Florida. Drawing on Census and state epidemiologic data, the paper identifies an estimated 2,500 county residents with end-stage dementia who are not enrolled in hospice care, despite having less than one year to live. The study focuses on provider-associated barriers—including reluctance to discuss end-of-life care, unwillingness to discontinue aggressive treatment, and prognostic uncertainty—as primary obstacles to hospice utilization. The project distributes the ADEPP Tool to dementia care providers and evaluates changes in provider attitudes and practices toward end-of-life planning. The manuscript targets the American Journal of Hospice & Palliative Medicine and follows a standard research paper structure including methods, results, discussion, and limitations.
Hospice is significantly underutilized by patients suffering from end-stage dementia, and dementia patients residing in Lee County, Florida are no exception. Based on analysis of Census Bureau data from 2012 and 2014, combined with state health statistics from the Bureau of Planning & Evaluation (2013) and statistics published by the Alzheimer's Association (2014), an estimated 2,500 Lee County residents suffer from dementia, have less than a year to live, and are not enrolled in hospice. The average length of stay for Lee County hospice patients is just 10 days, much lower than the national average of 106 days for dementia patients. This substantial gap in hospice utilization represents both a clinical opportunity and a quality concern.
Provider-associated barriers are among the most commonly cited reasons for hospice underutilization. These barriers often include provider unwillingness to end aggressive treatments, difficulty providing an accurate prognosis, and reluctance to discuss end-of-life care concerns with the dying patient and informal caregivers. Accordingly, provider barriers are the focus of a Doctor of Nursing Practice (DNP) quality improvement project, which will distribute an Advanced Dementia End-of-Life Planning and Prognosis (ADEPP) Tool to Lee County providers caring for dementia patients. The goal is to improve end-of-life planning practices and prognostic accuracy. The design of the tool is based on best-practice recommendations by dementia care experts, as well as related research findings.
The outcome measures for this intervention include provider evaluations of the tool and any changes in provider attitudes towards end-of-life care. The proposed manuscript will present the findings of this intervention for the purpose of contributing to generalizable knowledge in the field of palliative care and hospice medicine.
The journal selected for manuscript submission is the American Journal of Hospice & Palliative Medicine (AJHPM). The "Journal Author Name Estimator" (JANE) website was used to locate an appropriate journal—one that had been actively publishing articles on the same topic. The initial search was based on the proposed manuscript title, but articles retrieved by the JANE search engine were not close matches to the proposed quality improvement project. Rather than relying solely on the title, a series of keywords and phrases were entered into the search engine, which returned the American Journal of Hospice & Palliative Care (the same journal as AJHPM) as a leading result.
Among the articles retrieved by JANE was one authored by Snyder and colleagues (2013), which was cited repeatedly in the quality improvement project proposal because the survey instrument they developed was adapted for the current project. The other articles retrieved by JANE and published by AJHPM were similarly relevant. By contrast, articles retrieved from the next-most-relevant journal, The Journal of Palliative Medicine, were not as directly applicable to the project objectives.
Although the Article Influence scores were considerably lower for AJHPM than for The Journal of Palliative Medicine, suggesting AJHPM publications may have less broad citation impact, the instructions provided with the rubric for this assignment recommended that first-time authors place less weight on Article Influence scores when selecting a journal. To further evaluate the influence of the selected journal, a search for articles citing the Snyder et al. (2013) article was conducted using Google Scholar, which retrieved 10 citations. This citation count is remarkable given the recent publication date, indicating that the Snyder et al. (2013) publication is influential within this specific field of research, despite the lower Article Influence score for the journal. For these reasons, AJHPM is the chosen journal for submission.
The manuscript will begin with an abstract outlining the clinical question, methods, results, and discussion. The clinical question addressed by this quality improvement project is whether clinician exposure to evidence- and knowledge-based recommendations in dementia care will improve clinician attitudes towards palliative and hospice services, thereby increasing hospice referral rates for this patient population. An Advanced Dementia End-of-Life Planning and Prognosis (ADEPP) tool, based on these recommendations, will be sent to providers caring for dementia patients. Survey and interview data evaluating before and after attitudes towards planning end-of-life care, providing prognoses, and referring patients for hospice care will be collected. Providers are expected to report experiencing greater comfort with discussing end-of-life planning and hospice care with patients and family caregivers. These findings are anticipated to be consistent with the evidence that provider education improves patient outcomes.
The Background section will describe common symptoms of patients with end-stage dementia, the difficulties faced by informal caregivers, and what hospice services can provide. It will present empirical evidence supporting hospice use and documenting that provider barriers are among the most common obstacles to timely referrals. The Background will also discuss the value of provider education for improving hospice utilization and present statistics showing low hospice utilization rates for Lee County residents as justification for the quality improvement project. The section will conclude by stating clear objectives: to improve the quality of care provided to end-stage dementia patients and informal caregivers through improved end-of-life planning and timely referrals to hospice services.
"Participant selection, tool development, implementation, and analysis"
The Results section will describe the participant population demographically, presented graphically using tables. Quantitative data generated by survey items will be presented in both tabular and graphical formats. Qualitative findings from questionnaires and interviews will be discussed in the text and are likely to include direct quotes from participants, highlighting key themes related to provider attitudes and comfort with end-of-life discussions.
The Discussion section will present major findings in reference to the stated objectives of the quality improvement project. It will examine the significance and implications of the findings in relation to prior scientific studies and recommendations by dementia care experts. Where appropriate, recommendations for wider implementation of the ADEPP tool will be provided, supporting the translation of this local quality improvement effort into a more generalizable intervention.
"Project limitations, conclusions, and implications for practice"
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