Auriemma Catherine L, Song Anne, Walsh Lake, Han Jason, Yapalater Sophia, Bain Alexander, Haines Lindsay, Scott Stefania, Whitman Casey, Parks Taylor Stephanie, Weissman Gary E, Gonzales Matthew J, Weerasinghe Roshanthi, Wendt Staci J, Courtright Katherine R
Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia.
Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia.
JAMA Netw Open. 2025 Jul 1;8(7):e2518967. doi: 10.1001/jamanetworkopen.2025.18967.
Goal-concordant care (GCC) is recognized as the highest quality of care and most important outcome measure for serious illness research, yet practical methods for measuring it are lacking.
To measure GCC using clinical notes in patients' medical records.
DESIGN, SETTING, AND PARTICIPANTS: This longitudinal cohort study involved a retrospective medical record review in 3 urban hospitals in a single health system. Participants included adults with a hospital encounter of 3 or more days between April 1 and July 31, 2019, and 50% or higher predicted 6-month mortality risk. Data abstraction occurred from July 2021 through June 2022.
Acute care hospitalization and a 50% or higher predicted 6-month mortality risk.
Pairs of clinicians independently reviewed clinical notes from admission through 6 months or death to classify the care received during each epoch between patients' documented goals of care (GOC) discussions, into 1 of 4 categories: (1) comfort focused, (2) maintain or improve function, (3) life extension, or (4) unclear. The GOC discussions had been previously classified using the same 4 categories. The primary study outcome was GCC, defined as the alignment of classification of care received and GOC. Secondary outcomes included goal-discordant care, if GOC and care-received classifications were misaligned, and uncertain concordance, if either care received or GOC was classified as unclear or GOC were not documented. Interrater reliability for classification of care received was assessed using Cohen κ statistics.
Among 109 patients (53 female [49%]), the median (IQR) age was 70 (63-79) years. The most common serious illnesses were cardiac disease (76 patients [70%]), metastatic cancer (50 patients [45%]), and chronic kidney disease (42 patients [39%]). Interrater reliability for care-received classification was almost perfect (95% interrater agreement, Cohen κ = 0.92; 95% CI, 0.86-0.99). A total of 398 epochs of care were identified, 198 (50%) of which were classified as goal concordant. Of the remaining 200 epochs, 74 (19%) were classified as goal discordant and 126 (32%) of uncertain concordance. During at least 1 epoch of care over the 6-month follow-up, 85 patients (78%) received care of uncertain concordance and 43 (39%) received goal-discordant care.
In this cohort study of seriously ill adults, GCC was measured using clinical notes alone. These findings can inform automated text-based classification methods to improve the efficiency and scalability of this method and facilitate pragmatic and reliable measurement of GCC in serious illness research and quality improvement efforts.
目标一致的护理（GCC）被认为是重症研究中最高质量的护理和最重要的结果指标，但缺乏衡量它的实用方法。
使用患者病历中的临床记录来衡量GCC。
设计、设置和参与者：这项纵向队列研究涉及对单一医疗系统中3家城市医院的病历进行回顾性研究。参与者包括在2019年4月1日至7月31日期间住院3天或更长时间且预测6个月死亡风险为50%或更高的成年人。数据提取于2021年7月至2022年6月进行。
急性护理住院以及预测6个月死亡风险为50%或更高。
临床医生对从入院到6个月或死亡期间的临床记录进行独立审查，以便将患者记录的护理目标（GOC）讨论期间每个阶段所接受的护理分类为以下4类之一：（1）以舒适为重点；（2）维持或改善功能；（3）延长生命；（4）不明确。GOC讨论之前已使用相同的4类进行分类。主要研究结局是GCC，定义为所接受护理的分类与GOC的一致性。次要结局包括目标不一致的护理（如果GOC与所接受护理的分类不一致），以及不确定的一致性（如果所接受护理或GOC被分类为不明确或未记录GOC）。使用Cohen κ统计量评估所接受护理分类的评分者间信度。
在109名患者（53名女性[49%]）中，年龄中位数（IQR）为70（63 - 79）岁。最常见的重症疾病是心脏病（76例患者[70%]）、转移性癌症（50例患者[45%]）和慢性肾病（42例患者[39%]）。所接受护理分类的评分者间信度几乎完美（评分者间一致性为95%，Cohen κ = 0.92；95% CI，0.86 - 0.99）。共确定了398个护理阶段，其中198个（50%）被分类为目标一致。在其余200个阶段中，74个（19%）被分类为目标不一致，126个（32%）为不确定的一致性。在6个月的随访期间，至少有1个护理阶段，85名患者（78%）接受了一致性不确定的护理，43名患者（39%）接受了目标不一致的护理。
在这项针对重症成年人的队列研究中，仅使用临床记录来衡量GCC。这些发现可为基于文本的自动分类方法提供参考，以提高该方法的效率和可扩展性，并促进在重症研究和质量改进工作中对GCC进行实用且可靠的测量。
