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Pollack LR, Downey L, Nomitch JT, Lee RY, Engelberg RA, Weiss NS, Kross EK, Khandelwal N. Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure. Ann Am Thorac Soc 2024; 21:907-915. [PMID: 38323911 PMCID: PMC11160134 DOI: 10.1513/annalsats.202308-694oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 02/05/2024] [Indexed: 02/08/2024] Open
Abstract
Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.
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Affiliation(s)
- Lauren R. Pollack
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Jamie T. Nomitch
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Robert Y. Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Ruth A. Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | | | - Erin K. Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; and
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
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Bose Brill S, Riley SR, Prater L, Schnell PM, Schuster ALR, Smith SA, Foreman B, Xu WY, Gustin J, Li Y, Zhao C, Barrett T, Hyer JM. Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure. J Gen Intern Med 2024:10.1007/s11606-024-08604-1. [PMID: 38769259 DOI: 10.1007/s11606-024-08604-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 01/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice. OBJECTIVE Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life. DESIGN This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020. PARTICIPANTS A total of 48,466 deceased patients diagnosed with heart failure on Medicare. MAIN MEASURES Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services. KEY RESULTS In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter. CONCLUSIONS Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.
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Affiliation(s)
- Seuli Bose Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH, 43215, USA.
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Sean R Riley
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH, 43215, USA
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Laura Prater
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Patrick M Schnell
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Biostatistics, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Anne L R Schuster
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sakima A Smith
- Division of Cardiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Beth Foreman
- Division of Cardiology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Wendy Yi Xu
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Jillian Gustin
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Yiting Li
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Chen Zhao
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Todd Barrett
- Ohio State University Ross Heart Hospital, Columbus, OH, USA
| | - J Madison Hyer
- Center for Health Outcomes in Medicine Scholarship and Service, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Johnson CL, Colley A, Pierce L, Lin JA, Bongiovanni T, Roman S, Sudore RL, Wick E. Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement. J Trauma Acute Care Surg 2023; 94:863-869. [PMID: 37218039 PMCID: PMC10206277 DOI: 10.1097/ta.0000000000003909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients. METHODS We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP. RESULTS Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09-12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55-6.88; p < 0.001). CONCLUSION Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients' care preferences to the surgical and other inpatient medical teams. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Christopher L Johnson
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Alexis Colley
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Logan Pierce
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Joseph A Lin
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Tasce Bongiovanni
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Sanziana Roman
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Hong N, Root A, Handel B. The Role of Information and Nudges on Advance Directives and End-of-Life Planning: Evidence From a Randomized Trial. Med Care Res Rev 2023; 80:283-292. [PMID: 36935565 DOI: 10.1177/10775587231157800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Despite the substantial personal and economic implications of end-of-life decisions, many individuals fail to document their wishes, which often leads to patient dissatisfaction and unnecessary medical spending. We conducted a randomized trial of 1,200 patients aged 55 years and older to facilitate advance directive (AD) completion and better understand why patients fail to engage in high-value planning. We found that including a physical AD form with paper letters as a nudge to decrease hassle costs increased AD completion by 9.0 percentage points (95% confidence interval [CI] = [4.2, 13.9] percentage points). The intervention was especially effective for individuals aged 70 years and older, as AD completion increased by 17.5 percentage points (95% CI = [5.7, 9.4] percentage points). When compared with the impact of costless electronic reminders, each additional AD completion from the letter interventions costs as little as US$37. Our findings suggest that simple, inexpensive interventions with paper communication as behavioral nudges can be effective, especially in older populations.
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Affiliation(s)
- Nianyi Hong
- Congressional Budget Office, Washington, DC, USA
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Rosa WE, Izumi S, Sullivan DR, Lakin J, Rosenberg AR, Creutzfeldt CJ, Lafond D, Tjia J, Cotter V, Wallace C, Sloan DE, Cruz-Oliver DM, DeSanto-Madeya S, Bernacki R, Leblanc TW, Epstein AS. Advance Care Planning in Serious Illness: A Narrative Review. J Pain Symptom Manage 2023; 65:e63-e78. [PMID: 36028176 PMCID: PMC9884468 DOI: 10.1016/j.jpainsymman.2022.08.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility. OBJECTIVE To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness. METHODS We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care. RESULTS Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations. CONCLUSIONS We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Shigeko Izumi
- School of Nursing (S.I.), Oregon Health and Science University, Portland, Oregon
| | - Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine (D.R.S.), School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joshua Lakin
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Abby R Rosenberg
- Division of Hematology-Oncology, Department of Pediatrics (A.R.R.), University of Washington School of Medicine, Seattle, Washington; Palliative Care and Resilience Lab (A.R.R.), Seattle Children's Research Institute, Seattle, Washington
| | | | - Debbie Lafond
- Pediatric and Neonatal Needs Advanced (PANDA) Education Consultants (D.L.)
| | - Jennifer Tjia
- Chan Medical School, University of Massachusetts (J.T.), Worcester, Massachusetts
| | - Valerie Cotter
- School of Nursing, Johns Hopkins University (V.C.), Baltimore, Maryland; School of Medicine, Johns Hopkins University (V.C.), Baltimore, Maryland
| | - Cara Wallace
- College for Public Health and Social Justice (C.W.), Saint Louis University, St. Louis, Missouri
| | - Danetta E Sloan
- Department of Health (D.E.S.), Behavior and Society, Johns Hopkins University, Baltimore, Maryland
| | - Dulce Maria Cruz-Oliver
- Geriatric Medicine and Gerontology (D.M.C.O.), Beacham Center for Geriatric Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Thomas W Leblanc
- Department of Medicine (T.W.L.), Duke University School of Medicine, Durham, North Carolina
| | - Andrew S Epstein
- Department of Medicine (A.S.E.), Memorial Sloan Kettering Cancer Center, New York, New York
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O'Rourke MA, Myers JS, Meyskens FL. Replace the advance directive with a patient activation approach to serious illness communication. J Am Geriatr Soc 2022; 71:1345-1349. [PMID: 36524594 DOI: 10.1111/jgs.18194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Mark Allen O'Rourke
- Integrative Oncology University of South Carolina School of Medicine Greenville Greenville South Carolina USA
| | - Jamie S. Myers
- KU Medical Center University of Kansas School of Nursing Kansas City Kansas USA
| | - Frank L. Meyskens
- Chau Family Comprehensive Cancer Center, School of Medicine College of Health Sciences, University of California Irvine Irvine California USA
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