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Baird CE, Wulff-Burchfield E, Egan PC, Hugar LA, Vyas A, Trikalinos NA, Liu MA, Bélanger E, Olszewski AJ, Bantis LE, Panagiotou OA. Predictors of high-intensity care at the end of life among older adults with solid tumors: A population-based study. J Geriatr Oncol 2024; 15:101774. [PMID: 38676975 PMCID: PMC11162260 DOI: 10.1016/j.jgo.2024.101774] [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: 11/01/2023] [Revised: 03/05/2024] [Accepted: 04/12/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION High-intensity end-of-life (EoL) care can be burdensome for patients, caregivers, and health systems and does not confer any meaningful clinical benefit. Yet, there are significant knowledge gaps regarding the predictors of high-intensity EoL care. In this study, we identify risk factors associated with high-intensity EoL care among older adults with the four most common malignancies, including breast, prostate, lung, and colorectal cancer. MATERIALS AND METHODS Using SEER-Medicare data, we conducted a retrospective analysis of Medicare beneficiaries aged 65 and older who died of breast, prostate, lung, or colorectal cancer between 2011 and 2015. We used multivariable logistic regression to identify clinical, demographic, socioeconomic, and geographic predictors of high-intensity EoL care, which we defined as death in an acute care hospital, receipt of any oral or parenteral chemotherapy within 14 days of death, one or more admissions to the intensive care unit within 30 days of death, two or more emergency department visits within 30 days of death, or two or more inpatient admissions within 30 days of death. RESULTS Among 59,355 decedents, factors associated with increased likelihood of receiving high-intensity EoL care were increased comorbidity burden (odds ratio [OR]:1.29; 95% confidence interval [CI]:1.28-1.30), female sex (OR:1.05; 95% CI:1.01-1.09), Black race (OR:1.14; 95% CI:1.07-1.23), Other race/ethnicity (OR:1.20; 95% CI:1.10-1.30), stage III disease (OR:1.11; 95% CI:1.05-1.18), living in a county with >1,000,000 people (OR:1.23; 95% CI:1.16-1.31), living in a census tract with 10%-<20% poverty (OR:1.09; 95% CI:1.03-1.16) or 20%-100% poverty (OR:1.12; 95% CI:1.04-1.19), and having state-subsidized Medicare premiums (OR:1.18; 95% CI:1.12-1.24). The risk of high-intensity EoL care was lower among patients who were older (OR:0.98; 95% CI:0.98-0.99), lived in the Midwest (OR:0.69; 95% CI:0.65-0.75), South (OR:0.70; 95% CI:0.65-0.74), or West (OR:0.81; 95% CI:0.77-0.86), lived in mostly rural areas (OR:0.92; 95% CI:0.86-1.00), and had poor performance status (OR:0.26; 95% CI:0.25-0.28). Results were largely consistent across cancer types. DISCUSSION The risk factors identified in our study can inform the development of new interventions for patients with cancer who are likely to receive high-intensity EoL care. Health systems should consider incorporating these risk factors into decision-support tools to assist clinicians in identifying which patients should be referred to hospice and palliative care.
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Affiliation(s)
- Courtney E Baird
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Elizabeth Wulff-Burchfield
- Medical Oncology Division and Palliative Medicine Division, Department of Internal Medicine, University of Kansas School of Medicine, University of Kansas Cancer Center, The University of Kansas Health System, Kansas City, KS, USA
| | - Pamela C Egan
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lee A Hugar
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Ami Vyas
- University of Rhode Island, College of Pharmacy, Department of Pharmacy Practice, Kingston, RI, USA
| | - Nikolaos A Trikalinos
- Division of Oncology, Department of Medicine, Washington University Medical School Campus, St. Louis, MO, USA; Siteman Cancer Center, St. Louis, MO, USA
| | - Michael A Liu
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Emmanuelle Bélanger
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Adam J Olszewski
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Leonidas E Bantis
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Orestis A Panagiotou
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
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Malhotra C, Balasubramanian I. Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time. J Alzheimers Dis 2023:JAD221161. [PMID: 37125548 DOI: 10.3233/jad-221161] [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: 05/02/2023]
Abstract
BACKGROUND Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time. OBJECTIVE Assess caregivers' EOL care goal for PWSDs and change in these goals over time. METHODS Using a prospective cohort of 215 caregivers of PWSDs, we assessed the proportion of caregivers whose EOL care goal for PWSDs changed between two consecutive time points. Mixed effects multinomial regression models assessed factors associated with caregivers' EOL care goals for PWSD (maximal, moderate, minimal life extension); and change in EOL care goal from previous time point. RESULTS At baseline, 20% of the caregivers had a goal of maximal life extension for their PWSD, and 59% changed their EOL care goal at least once over a period of 16 months. Caregivers of PWSDs with lower quality of life (RR: 1.15, CI: 1.06, 1.24), who expected shorter life expectancy for PWSDs (RR: 10.34, CI: 2.14, 49.99) and who had an advance care planning discussion (RR: 3.52, CI: 1.11, 11.18) were more likely to have a goal of minimal life extension for PWSD. Caregivers with higher anticipatory grief (RR: 0.96, CI: 0.93,1) were more likely to have a goal of maximal life extension. Change in PWSDs' quality of life and change in caregivers' anticipatory grief were associated with change in caregivers' EOL care goals. CONCLUSION Caregivers' EOL care goals for PWSDs change over time with change in PWSD and caregiver related factors. Findings have implications regarding how health care providers can engage with caregivers.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Duberstein PR, Hoerger M, Norton SA, Mohile S, Dahlberg B, Hyatt EG, Epstein RM, Wittink MN. The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States. Soc Sci Med 2023; 317:115546. [PMID: 36509614 DOI: 10.1016/j.socscimed.2022.115546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/21/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.
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Affiliation(s)
- Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, 683 Hoes Lane West, Piscataway, NJ, 08854, United States.
| | - Michael Hoerger
- Department of Psychology, Psychiatry, and Medicine, Tulane University, 131 S. Robertson Building, 131 S Robertson St, New Orleans, LA, 70112, United States; Tulane Cancer Center, Tulane University, 1415 Tulane Ave, New Orleans, LA, 70112, United States.
| | - Sally A Norton
- School of Nursing, University of Rochester, 255 Crittenden Blvd, Rochester, NY, 14642, United States; Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
| | - Supriya Mohile
- Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 90 Crittenden Blvd, Rochester, NY, 14642, United States.
| | - Britt Dahlberg
- Center for Humanism, Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States.
| | - Erica Goldblatt Hyatt
- Rutgers School of Social Work, 536 George St, New Brunswick, NJ, 08901, United States.
| | - Ronald M Epstein
- Department of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, 90 Crittenden Blvd, Rochester, NY, 14642, United States; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
| | - Marsha N Wittink
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, 14642, United States.
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Tark A, Estrada LV, Stone PW, Baernholdt M, Buck HG. Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies. Palliat Med 2023; 37:10-25. [PMID: 36081200 PMCID: PMC10790406 DOI: 10.1177/02692163221122268] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Frameworks are the conceptual underpinnings of the study. Both conceptual and theoretical frameworks are often used in palliative and end-of-life care studies to help with study design, guide, and conduct investigations. While an increasing number of investigators have included frameworks in their study, to date, there has not been a comprehensive review of frameworks that were utilized in palliative and end-of-life care research studies. AIM To summarize conceptual and theoretical frameworks used in palliative and end-of-life care research studies. And to synthesize which of eight domains from the National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care (fourth edition) each framework belongs to. DESIGN Systematic review. DATA SOURCES Four electronic databases (EMBASE, the Cumulative Index to Nursing and Allied Health, PsychINFO, and PubMed) were searched from July 2010 to September 2021. RESULTS A total 2231 citations were retrieved, of which 44 articles met eligibility. Across primary studies, 33,801 study participants were captured. Twenty-six investigators (59.1%) proposed previously unpublished frameworks. In 10 studies, investigators modified existing frameworks, mainly to overcome inherent limitations. In eight studies, investigators utilized existing frameworks referenced in previously published studies. There were eight orientations identified among 44 frameworks we reviewed (e.g. system, patient, patient-doctor). CONCLUSIONS We examined palliative and end-of-life research studies to identify and characterize conceptual or theoretical frameworks proposed or utilized. Of 44 frameworks we reviewed, 21 studies (47.7%) were aligned with a Clinical Practice Guideline's single domain, while the rest two or more of eight guidelines in quality palliative care domains.
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Elbaum A, Kinsey L, Mariano J. Decision-Making Across Cultures. Cancer Treat Res 2023; 187:85-104. [PMID: 37851221 DOI: 10.1007/978-3-031-29923-0_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
This chapter surveys the range of different orientations toward decision-making, common clinical scenarios, and considerations to bear in mind when caring for culturally diverse patients at the end of life. While this chapter draws on the cultural competency literature, its primary goal is to articulate an approach to end-of-life care that is rooted in cultural humility and structural competency. Medical providers, as representatives of the social institution of medicine, have their own cultural values that often come into conflict with patients' cultural values, especially when patients and providers have different unspoken visions of the "good death," or when patients wish to receive interventions that their providers deem futile. In the final section of the chapter, we seek to move away from this confrontational paradigm by analyzing two case studies of decision-making across cultures in order to empower providers to engage in value-based shared decision-making and thereby achieve goal-concordant care.
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Affiliation(s)
- Alan Elbaum
- University of California San Francisco, San Francisco, USA.
| | | | - Jeffrey Mariano
- Department of Geriatrics, Palliative Medicine and Continuing Care, Kaiser Permanente Bernard J. Tyson School of Medicine, Southern California Permanente Medical Group, Kaiser Permanente West Los Angeles, Pasadena, USA
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6
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Zhu Y, Enguidanos S. Advance directives completion and hospital out-of-pocket expenditures. J Hosp Med 2022; 17:437-444. [PMID: 35527477 PMCID: PMC9325451 DOI: 10.1002/jhm.12839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/12/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Health care costs remain high at the end of life. It is not known if there is a relationship between advance directive (AD) completion and hospital out-of-pocket costs. This analysis investigated whether AD completion was associated with lower hospital out-of-pocket costs at end of life. METHODS We used Health and Retirement Study participants who died between 2000 and 2014 (N = 9228) to examine the association between AD completion status and hospital out-of-pocket spending in the last 2 years of life through the use of a two-part model controlling for socioeconomic status, death-related characteristics and health insurance coverage. RESULTS About 44% of decedents had completed ADs. Having an AD was significantly associated with $673 lower hospital out-of-pocket costs, with a higher magnitude of savings among younger decedents. Decedents who completed ADs 3 months or less before death had higher out-of-pocket costs ($1854 on average) than those who completed ADs more than 3 months before death ($1176 on average). CONCLUSIONS AD completion was significantly associated with lower hospital out-of-pocket costs, with greater out-of-pocket savings among younger decedents. Early AD completers experienced lower costs than decedents who completed ADs closer to death.
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Affiliation(s)
- Yujun Zhu
- Leonard Davis School of GerontologyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Susan Enguidanos
- Leonard Davis School of GerontologyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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7
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Nothelle S, Kelley AS, Zhang T, Roth DL, Wolff JL, Boyd C. Fragmentation of care in the last year of life: Does dementia status matter? J Am Geriatr Soc 2022; 70:2320-2329. [PMID: 35488709 PMCID: PMC9378534 DOI: 10.1111/jgs.17827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/20/2022] [Accepted: 03/25/2022] [Indexed: 12/01/2022]
Abstract
Background Care at the end of life is commonly fragmented; however, little is known about commonly used measures of fragmentation of care in the last year of life (LYOL). We sought to understand differences in fragmentation of care by dementia status among seriously ill older adults in the LYOL. Methods We analyzed data from adults ≥65 years in the National Health and Aging Trends Study who died and had linked 2011–2017 Medicare fee‐for‐service claims for ≥12 months before death. We categorized older adults as having serious illness due to dementia (hereafter dementia), non‐dementia serious illness or no serious illness. For outpatient fragmentation, we calculated the Bice–Boxerman continuity of care index (COC), which measures care concentration, and the known provider of care index (KPC), which measures the proportion of clinicians who were previously seen. For acute care fragmentation, we divided the number of hospitals and emergency departments visited by the total number of visits. We built separate multivariable quantile regression models for each measure of fragmentation. Results Of 1793 older adults, 42% had dementia, 53% non‐dementia serious illness and 5% neither. Older adults with dementia had fewer hospitalizations than older adults with non‐dementia serious illness but more than older adults without serious illness (mean 1.9 vs 2.3 vs 1, p = 0.002). In adjusted models, compared to older adults with non‐dementia serious illness, those with dementia had significantly less fragmented care across all quantiles of COC (range 0.016–0.110) but a lower predicted 90th percentile of KPC, meaning more older adults with dementia had extremely fragmented care on the KPC measure. There was no significant difference in acute care fragmentation. Conclusions In the LYOL, older adults with dementia have fewer healthcare encounters and less fragmentation of care by the COC index than older adults with non‐dementia serious illness.
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Affiliation(s)
- Stephanie Nothelle
- Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Talan Zhang
- Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - David L Roth
- Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cynthia Boyd
- Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland, USA
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8
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Amroud MS, Raeissi P, Hashemi SM, Reisi N, Ahmadi SA. A comparative study of the status of supportive-palliative care provision in Iran and selected countries: Strengths and weaknesses. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2021; 10:370. [PMID: 34912906 PMCID: PMC8641730 DOI: 10.4103/jehp.jehp_1413_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/02/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Terminally, illnesses such as cancer, AIDS, dementia, and advanced heart disease will require special supportive and palliative care, although a few numbers of these patients are provided with these services. The aim of the present study was to perform a comparative study of supportive-palliative care provision in selected countries. MATERIALS AND METHODS This research was a descriptive comparative study that its research population was the frameworks of palliative and supportive care provision in Egypt, Turkey, America, Australia, Canada, the Netherlands, and China. These frameworks were compared across six dimensions of service receivers, financing, providers, service provider centers, type of services provided, and training. Data collection tool has included the checklist and information sources, documents, evidence, articles, books, and journals collected through the Internet and organizations related to the health information of selected countries and by the library search. Data were investigated and analyzed using the data collection tool and checklists. FINDINGS The findings showed that the developed countries having decentralized trusteeship structure had a more favorable status in palliative and supportive care provision. The type of services provided was a combination of mental, psychological, social, spiritual, financial, and physical and communication services. Provider centers included hospital, the elderly, and cancer and charity centers. CONCLUSION Regarding the investigation and recognition of the status of supportive-palliative care provision, it was observed that the provision of these services was a concern of the selected countries, but they did not have a defined model or pattern to provide these services. Therefore, it is suggested that each country takes a step to redesign and define frameworks and structures in the evolution of supportive-palliative cares in accordance with the particular conditions, indigenous culture, religion, and other effective cases of that country and pays special attention to the role and position of supportive-palliative cares.
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Affiliation(s)
- Mohammad Salimi Amroud
- Department of Health Services Management, School of Health Management and Medical Information Science, Iran University of Medical Sciences, Tehran, Iran
| | - Pouran Raeissi
- Department of Health Services Management, School of Health Management and Medical Information Science, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed-Masoud Hashemi
- Department of Anesthesiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nahid Reisi
- Department of Pediatric Hematology and Oncology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed-Ahmad Ahmadi
- Department of Health Services Management, School of Health Management and Medical Information Science, Iran University of Medical Sciences, Tehran, Iran
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Ovaitt AK, McCammon S. Ethical Considerations in Caring for Patients with Advanced Malignancy. Surg Oncol Clin N Am 2021; 30:581-589. [PMID: 34053670 DOI: 10.1016/j.soc.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patients with advanced malignancy have decisions to make about next steps that are multifactorial and highly ramified. At each step, they, their loved ones, and their health care providers will attempt to make right decisions and avoid wrong ones. Beyond bare ethical principles, these patients face tensions between what they hope for, what is possible, and what those around them expect and advise. This article uses a case-based approach to explore the balance between prognostication and directive counsel; affective forecasting and decisional regret; hope and the therapeutic misconception; and issues of patient ownership and abandonment at the end of life.
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Affiliation(s)
- Alyssa K Ovaitt
- Department of Otolaryngology-Head and Neck Surgery, The University of Alabama at Birmingham, Faculty Office Tower 1155, 1720 2nd Avenue South, Birmingham, AL 35294-3412, USA
| | - Susan McCammon
- Department of Otolaryngology-Head and Neck Surgery, The University of Alabama at Birmingham, Faculty Office Tower 1155, 1720 2nd Avenue South, Birmingham, AL 35294-3412, USA; Department of Internal Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Community-Based Palliative Care, UAB Center for Palliative and Supportive Care, The University of Alabama at Birmingham, Faculty Office Tower 1155, 1720 2nd Avenue South, Birmingham, AL 35294-3412, USA.
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10
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Grandjean C, Ullmann P, Marston M, Maitre MC, Perez MH, Ramelet AS. Sources of Stress, Family Functioning, and Needs of Families With a Chronic Critically Ill Child: A Qualitative Study. Front Pediatr 2021; 9:740598. [PMID: 34805041 PMCID: PMC8600118 DOI: 10.3389/fped.2021.740598] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022] Open
Abstract
PICU hospitalization is particularly stressful for families. When it is prolonged and the prognostic is uncertain, it can significantly and negatively affect the whole family. To date, little is known on how families with a chronic critically ill (CCI) child are affected. This national study explored the specific PICU-related sources of stress, family functioning and needs of families of CCI patients during a PICU hospitalization. This descriptive qualitative study was conducted in the eight pediatric intensive care units in Switzerland. Thirty-one families with a child meeting the CCI criteria participated in semi-structured interviews. Interviews, including mothers only (n = 12), fathers only (n = 8), or mother and father dyads (n = 11), were conducted in German, French, or English by two trained researchers/clinical nurses specialists. Interviews were recorded, transcribed verbatim, and analyzed using deductive and inductive content analyses. Five overarching themes emerged: (1) high emotional intensity, (2) PICU-related sources of stress, (3) evolving family needs, (4) multi-faceted family functioning, and (5) implemented coping strategies. Our study highlighted the importance of caring for families with CCI children. Parents reported high negative emotional responses that affect their family functioning. Families experience was highly dependent on how HCPs were able to meet the parental needs, provide emotional support, reinforce parental empowerment, and allow high quality of care coordination.
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Affiliation(s)
- Chantal Grandjean
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Pascale Ullmann
- School of Healthcare, University of Applied Sciences and Arts, Fribourg, Switzerland
| | - Mark Marston
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland.,University Children's Hospital Basel, Basel, Switzerland
| | - Marie-Christine Maitre
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
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Murali KP, Merriman JD, Yu G, Vorderstrasse A, Kelley A, Brody AA. An Adapted Conceptual Model Integrating Palliative Care in Serious Illness and Multiple Chronic Conditions. Am J Hosp Palliat Care 2020; 37:1086-1095. [PMID: 32508110 PMCID: PMC7483852 DOI: 10.1177/1049909120928353] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Seriously ill adults with multiple chronic conditions (MCC) who receive palliative care may benefit from improved symptom burden, health care utilization and cost, caregiver stress, and quality of life. To guide research involving serious illness and MCC, palliative care can be integrated into a conceptual model to develop future research studies to improve care strategies and outcomes in this population. METHODS The adapted conceptual model was developed based on a thorough review of the literature, in which current evidence and conceptual models related to serious illness, MCC, and palliative care were appraised. Factors contributing to patients' needs, services received, and service-related variables were identified. Relevant patient outcomes and evidence gaps are also highlighted. RESULTS Fifty-eight articles were synthesized to inform the development of an adapted conceptual model including serious illness, MCC, and palliative care. Concepts were organized into 4 main conceptual groups, including Factors Affecting Needs (sociodemographic and social determinants of health), Factors Affecting Services Received (health system; research, evidence base, dissemination, and health policy; community resources), Service-Related Variables (patient visits, service mix, quality of care, patient information, experience), and Outcomes (symptom burden, quality of life, function, advance care planning, goal-concordant care, utilization, cost, death, site of death, satisfaction). DISCUSSION The adapted conceptual model integrates palliative care with serious illness and multiple chronic conditions. The model is intended to guide the development of research studies involving seriously ill adults with MCC and aid researchers in addressing relevant evidence gaps.
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Affiliation(s)
| | | | - Gary Yu
- 5894NYU Rory Meyers College of Nursing, New York, NY, USA
| | - Allison Vorderstrasse
- Florence S. Downs PhD Program in Nursing Research and Theory, 5894NYU Rory Meyers College of Nursing, New York, NY, USA
| | - Amy Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 5925Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, 5894NYU Rory Meyers College of Nursing, New York, NY, USA
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12
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Batten JN, Blythe JA, Wieten S, Cotler MP, Kayser JB, Porter-Williamson K, Harman S, Dzeng E, Magnus D. Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study. BMJ Qual Saf 2020; 30:668-677. [PMID: 33082165 DOI: 10.1136/bmjqs-2020-011222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/01/2020] [Accepted: 08/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied. DESIGN AND METHODS Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences. RESULTS The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories. CONCLUSIONS There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.
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Affiliation(s)
- Jason N Batten
- Department of Medicine, Stanford University, Stanford, California, USA .,Department of Anesthesia, Stanford University, Stanford, California, USA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Jacob A Blythe
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Sarah Wieten
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Miriam Piven Cotler
- Department of Health Sciences, California State University Northridge, Northridge, California, USA
| | - Joshua B Kayser
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Karin Porter-Williamson
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Stephanie Harman
- Department of Medicine, Stanford University, Stanford, California, USA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
| | - Elizabeth Dzeng
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA
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13
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Abstract
Critical care clinicians strive to reverse the disease process and are frequently faced with difficult end-of-life (EoL) situations, which include transitions from curative to palliative care, avoidance of disproportionate care, withholding or withdrawing therapy, responding to advance treatment directives, as well as requests for assistance in dying. This article presents a summary of the most common issues encountered by intensivists caring for patients around the end of their life. Topics explored are the practices around limitations of life-sustaining treatment, with specific mention to the thorny subject of assisted dying and euthanasia, as well as the difficulties encountered regarding the adoption of advance care directives in clinical practice and the importance of integrating palliative care in the everyday practice of critical-care physicians. The aim of this article is to enhance understanding around the complexity of EoL decisions, highlight the intricate cultural, religious, and social dimensions around death and dying, and identify areas of potential improvement for individual practice.
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Affiliation(s)
- Victoria Metaxa
- Critical Care Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
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14
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Ornstein KA, Roth DL, Huang J, Levitan EB, Rhodes JD, Fabius CD, Safford MM, Sheehan OC. Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort. JAMA Netw Open 2020; 3:e2014639. [PMID: 32833020 PMCID: PMC7445597 DOI: 10.1001/jamanetworkopen.2020.14639] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain. OBJECTIVE To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death. DESIGN, SETTING, AND PARTICIPANTS This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records. RESULTS The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents. CONCLUSIONS AND RELEVANCE Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.
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Affiliation(s)
- Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David L. Roth
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jin Huang
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - J. David Rhodes
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - Chanee D. Fabius
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Monika M. Safford
- Division of General Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Orla C. Sheehan
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
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15
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May P, Normand C, Del Fabbro E, Fine RL, Morrison RS, Ottewill I, Robinson C, Cassel JB. Economic Analysis of Hospital Palliative Care: Investigating Heterogeneity by Noncancer Diagnoses. MDM Policy Pract 2019; 4:2381468319866451. [PMID: 31535032 PMCID: PMC6737878 DOI: 10.1177/2381468319866451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 06/18/2019] [Indexed: 01/03/2023] Open
Abstract
Background. Single-disease-focused treatment and hospital-centric care are poorly suited to meet complex needs in an era of multimorbidity. Understanding variation in palliative care’s association with treatment choices is essential to optimizing interdisciplinary decision making in care of complex patients. Aim. To estimate the association between palliative care and hospital costs by primary diagnosis and multimorbidity for adults with one of six life-limiting conditions: heart failure, chronic obstructive pulmonary disease (COPD), liver failure, kidney failure, neurodegenerative conditions including dementia, and HIV/AIDS. Methods. Data from four studies (2002–2015) were pooled to provide an analytic dataset of 73,304 participants with mean costs $10,483, of whom 5,348 (7%) received palliative care. We estimated average effect of palliative care on direct hospital costs among the treated, using propensity scores to control for observed confounding. Results. Palliative care was associated with a statistically significant reduction in total direct costs for heart failure (estimated treatment effect: −$2666; 95% confidence interval [CI]: −$3440 to −$1892), neurodegenerative conditions (−$3523; −$4394 to −$2651), COPD (−$1613; −$2217 to −$1009), kidney failure (−$3589; −$5132 to −$2045), and liver failure (−$7574; −$9232 to −$5916). The association for liver failure patients was statistically significantly larger than for any other disease group. Cost-saving associations were also statistically larger for patients with multimorbidity than single disease for two of the six groups: neurodegenerative and liver failure. Conclusions. Heterogeneity in treatment effect estimates was observable in assessing association between palliative care and hospital costs for adults with serious life-limiting illnesses other than cancer. The results illustrate the importance of careful definition of palliative care populations in research and practice, and raise further questions about the role of interdisciplinary decision making in treatment of complex medical illness.
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Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Egidio Del Fabbro
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | | | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai, New York
| | - Isabel Ottewill
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | | | - J Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
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16
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Duberstein PR, Kravitz RL, Fenton JJ, Xing G, Tancredi DJ, Hoerger M, Mohile SG, Norton SA, Prigerson HG, Epstein RM. Physician and Patient Characteristics Associated With More Intensive End-of-Life Care. J Pain Symptom Manage 2019; 58:208-215.e1. [PMID: 31004774 PMCID: PMC6679778 DOI: 10.1016/j.jpainsymman.2019.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties. OBJECTIVE To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL. METHODS We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life. RESULTS Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification. CONCLUSION Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.
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Affiliation(s)
- Paul R Duberstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, Piscataway, New Jersey, USA.
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Sacramento, California, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California, USA
| | - Joshua J Fenton
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California, USA; Department of Family and Community Medicine, University of California, Davis, Sacramento, California, USA
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; Department of Pediatrics, University of California, Davis, Sacramento, California, USA
| | - Michael Hoerger
- Tulane Cancer Center, Tulane University, New Orleans, Louisiana, USA; Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sally A Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester, Rochester, New York, USA
| | - Holly G Prigerson
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA; Cornell Center for Research on End-of-Life Care, New York, New York, USA
| | - Ronald M Epstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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17
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Metaxa V, Anagnostou D, Vlachos S, Arulkumaran N, van Dusseldorp I, Bensemmane S, Aslakson R, Davidson JE, Gerritsen R, Hartog C, Curtis R. Palliative care interventions in intensive care unit patients - a systematic review protocol. Syst Rev 2019; 8:148. [PMID: 31228954 PMCID: PMC6588840 DOI: 10.1186/s13643-019-1064-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 06/05/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Even though data suggest that palliative care (PC) improves patient quality of life, caregiver burden, cost, and intensive care unit (ICU) length of stay, integration of PC in the ICU is far from being universally accepted. Poor understanding of what PC provides is one of the barriers to the widespread implementation of their services in ICU. Evidence suggests that the availability of specialist PC is lacking in most European countries and provided differently depending on geographical location. The aim of this systematic review is to compare the numbers and types of PC interventions and gauge their impact on stakeholder outcomes and ICU resource utilisation. METHODS We will undertake a systematic review of the published peer-reviewed journal articles; our search will be carried out MEDLINE, Embase, Cochrane, CINAHL, and PsycINFO. The search strategy will include variations in the term 'palliative care' and 'intensive care'. All studies with patient populations undergoing palliative care interventions will be selected. Only full-text articles will be considered, and conference abstracts excluded. There will be no date restrictions on the year of publications or on language. The primary aim of the present study is to compare the numbers and types of PC interventions in ICU and their impact on stakeholder (patient, family, clinician, other) outcomes. Reporting of findings will follow the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. DISCUSSION This review will provide insight into the implementation of palliative care in ICU, elucidate differences between countries and health systems, reveal most effective models, and contribute to identifying research priorities to improve outcomes. SYSTEMATIC REVIEW REGISTRATION International Prospective Register of Systematic reviews PROSPERO ( CRD42018094315 ).
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Affiliation(s)
- Victoria Metaxa
- King’s College Hospital, London, SE5 9RS UK
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Despina Anagnostou
- Human Health Sciences, School of Medicine, Kyoto University, Kyoto, Japan
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Savvas Vlachos
- King’s College Hospital, London, SE5 9RS UK
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Nishkantha Arulkumaran
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
- Systematic Reviews Group, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Ingeborg van Dusseldorp
- Medical Information Specialist, Medical Centre Leeuwarden, MCL Academy, Leeuwarden, Netherlands
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Sherihane Bensemmane
- European Society of Intensive Care Medicine, Rue Belliard 19, 1040 Bruxelles, Belgium
- Systematic Reviews Group, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Rebecca Aslakson
- Department of Medicine, Division of Primary Care and Population Health, Palliative Care Section, Stanford University, Stanford, CA 94305 USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA 94305 USA
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Judy E. Davidson
- Department of Nursing, University of California San Diego Health, San Diego, USA
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Rik Gerritsen
- Centrum voor Intensive care, Medisch Centrum Leeuwarden, PO Box 888, 8901BR Leeuwarden, Netherlands
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Christiane Hartog
- Department for Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
| | - Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104 USA
- Ethics Section, European Society of Intensive Care Medicine (ESICM), Brussels, Belgium
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18
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May P, Garrido MM, Del Fabbro E, Noreika D, Normand C, Skoro N, Cassel JB. Evaluating Hospital Readmissions for Persons With Serious and Complex Illness: A Competing Risks Approach. Med Care Res Rev 2019; 77:574-583. [PMID: 30658539 DOI: 10.1177/1077558718823919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Hospital readmission rate is a ubiquitous measure of efficiency and quality. Individuals with life-limiting illnesses account heavily for admissions but evaluation is complicated by high-mortality rates. We report a retrospective cohort study examining the association between palliative care (PC) and readmissions while controlling for postdischarge mortality with a competing risks approach. Eligible participants were adult inpatients admitted to an academic, safety-net medical center (2009-2015) with at least one diagnosis of cancer, heart failure, chronic obstructive pulmonary disease, liver failure, kidney failure, AIDS/HIV, and selected neurodegenerative conditions. PC was associated with reduced 30-, 60-, and 90-day readmissions (subhazard ratios = 0.57, 0.53, and 0.52, respectively [all p < .001]). Hospital PC is associated with a reduction in readmissions, and this is not explained by higher mortality among PC patients. Performance measures only counting those alive at a given end point may underestimate systematically the effects of treatments with a high-mortality rate.
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Affiliation(s)
- Peter May
- Trinity College Dublin, Dublin, Ireland
| | - Melissa M Garrido
- James J. Peters VA Medical Center, Bronx, NY, USA.,Icahn School of Medicine at Mount Sinai, NY, USA
| | | | | | - Charles Normand
- Trinity College Dublin, Dublin, Ireland.,King's College London, England, UK
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19
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Ornstein KA, Garrido MM, Siu AL, Bollens‐Lund E, Langa KM, Kelley AS. Impact of In-Hospital Death on Spending for Bereaved Spouses. Health Serv Res 2018; 53 Suppl 1:2696-2717. [PMID: 29488621 PMCID: PMC6056590 DOI: 10.1111/1475-6773.12841] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine how patients' location of death relates to health care utilization and spending for surviving spouses. DATA SOURCES/STUDY SETTING Health and Retirement Study (HRS) 2000-2012 linked to the Dartmouth Atlas and Medicare claims data. STUDY DESIGN This was an observational study. We matched bereaved spouses whose spouses died in a hospital to those whose spouses died outside the hospital using propensity scores based on decedent and spouse demographic and clinical characteristics, care preferences, and regional practice patterns. DATA COLLECTION/EXTRACTION METHODS We identified 1,348 HRS decedents with surviving spouses. We linked HRS data from each dyad with Medicare claims and regional characteristics. PRINCIPAL FINDINGS In multivariable models, bereaved spouses of decedents who died in the hospital had $3,106 higher Medicare spending 12 months postdeath (p = .04) compared to those whose spouses died outside a hospital. Those surviving spouses were also significantly more likely to have an ED visit (OR = 1.5; p < .01) and hospital admission (OR = 1.4; p = .02) in the year after their spouse's in-hospital death. Increased Medicare spending for surviving spouses persisted through the 24-month period postdeath ($5,310; p = .02). CONCLUSIONS Bereaved spouses of decedents who died in the hospital had significantly greater Medicare spending and health care utilization themselves after their spouses' death.
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Affiliation(s)
- Katherine A. Ornstein
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Melissa M. Garrido
- James J. Peters Veterans Affairs Medical CenterBronxNY
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Albert L. Siu
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Evan Bollens‐Lund
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Kenneth M. Langa
- Department of Internal MedicineVeterans Affairs Center for Clinical Management ResearchInstitute for Social ResearchInstitute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | - Amy S. Kelley
- Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
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20
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Wang SY, Hsu SH, Huang S, Doan KC, Gross CP, Ma X. Regional Practice Patterns and Racial/Ethnic Differences in Intensity of End-of-Life Care. Health Serv Res 2018; 53:4291-4309. [PMID: 29951996 DOI: 10.1111/1475-6773.12998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine whether regional practice patterns impact racial/ethnic differences in intensity of end-of-life care for cancer decedents. DATA SOURCES The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. STUDY DESIGN We classified hospital referral regions (HRRs) based on mean 6-month end-of-life care expenditures, which represented regional practice patterns. Using hierarchical generalized linear models, we examined racial/ethnic differences in the intensity of end-of-life care across levels of HRR expenditures. PRINCIPAL FINDINGS There was greater variation in intensity of end-of-life care among Hispanics, Asians, and whites in high-expenditure HRRs than in low-expenditure HRRs. CONCLUSIONS Local practice patterns may influence racial/ethnic differences in end-of-life care.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
| | - Sylvia H Hsu
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Schulich School of Business, York University, Toronto, ON, Canada
| | - Siwan Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT.,Beijing PricewaterhouseCoopers Management Consulting (Shanghai) Limited, Beijing, China
| | - Kathy C Doan
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Xiaomei Ma
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
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21
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Hung YN, Wen FH, Liu TW, Chen JS, Tang ST. Hospice Exposure Is Associated With Lower Health Care Expenditures in Taiwanese Cancer Decedents' Last Year of Life: A Population-Based Retrospective Cohort Study. J Pain Symptom Manage 2018; 55:755-765.e5. [PMID: 29080802 DOI: 10.1016/j.jpainsymman.2017.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 01/04/2023]
Abstract
CONTEXT Evidence for the association of hospice exposure with lower health care expenditures at end of life (EOL) remains inconclusive and neglects EOL care being concentrated in patients' last few months. OBJECTIVE The association between hospice exposure and health care expenditures in cancer patients' last one, three, six, and 12 months was evaluated. METHODS In this population-based, retrospective cohort study, Taiwanese cancer decedents in 2001-2010 (N = 195,228) were matched 1:1, with proportions of matched hospice users reaching 87.8%, by a hospice-utilization propensity score. For each matched pair, exposure to hospice (time from hospice enrollment to death) was matched to equivalent periods for hospice nonusers before death. Hospice-care associations with health care expenditures were evaluated by hospice use/exposure interactions with multilevel linear regression modeling using generalized estimating equations. RESULTS The unadjusted main effect showed lower total mean health care expenditures for hospice users than for hospice nonusers only in the last one and three months (rate ratio [95% CI]: 0.86 [0.81, 0.90] and 0.93 [0.89, 0.96], respectively). However, after accounting for exposure time, hospice care was significantly associated with lower health care expenditures at exposures of ≤30, ≤60, and ≤180 days for health care expenditures measured in the last one and three months, six months, and 12 months, respectively. Savings for patients with lengthy hospice stays were neutralized or even disappeared. CONCLUSION Hospice care was associated with lower health care expenditures when it could actively intervene in EOL care. Hospice philosophy should be applied not only shortly before death but also throughout the dying trajectory to achieve maximum cost savings.
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Affiliation(s)
- Yen-Ni Hung
- School of Gerontology Health Management and Master's Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan R.O.C
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan R.O.C
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan R.O.C
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan R.O.C
| | - Siew Tzuh Tang
- Department of Nursing, Graduate School of Nursing, Tao-Yuan, Chang Gung University, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan R.O.C; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan R.O.C.
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Abstract
AIM To examine the intensity of care at the end of life among older adults in Korea and to identify the individual and institutional factors associated with care intensity. METHODS This secondary data analysis included a sample of 6278 decedents aged 65 years or older who were identified from the 2009 to 2010 Korean National Health Insurance Service-National Sample Cohort Claims data. We examined the medical care received by the cohort in the last 30 days of their lives. RESULTS Overall, 36.5% of the sample received at least 1 intensive care procedure in the last 30 days of their lives; 26.3% of patients experienced intensive care unit admission, with an average stay of 7.45 days, 19.5% received mechanical ventilation, 12.3% received cardiopulmonary resuscitation, and 15.5% had a feeding tube placement. A statistical analysis using a multiple logistic regression model with random effects showed that younger age, higher household income, primary diagnoses of diseases (ischemic heart disease, infectious disease, chronic lung disease, or chronic heart disease), and characteristics of care setting (large hospitals and facilities located in metropolitan areas) were significantly associated with the likelihood of receiving high-intensity care at the end of life. CONCLUSION A substantial number of older adults in Korea experienced high-intensity end-of-life care. Both individual and institutional factors were associated with the likelihood of receiving high-intensity care. Gaining an understanding of the intensity of care at the end of life and the impact of the determinants would advance efforts to improve quality of care at the end of life for older adults in Korea.
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Affiliation(s)
- Su Hyun Kim
- 1 College of Nursing, Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea
| | - Sangwook Kang
- 2 Department of Applied Statistics, Yonsei University, Seoul, South Korea
| | - Mi-Kyung Song
- 3 Center for Nursing Excellence in Palliative Care, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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Kelley AS, Bollens-Lund E, Covinsky KE, Skinner JS, Morrison RS. Prospective Identification of Patients at Risk for Unwarranted Variation in Treatment. J Palliat Med 2017; 21:44-54. [PMID: 28772096 DOI: 10.1089/jpm.2017.0063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Understanding factors associated with treatment intensity may help ensure higher value healthcare. OBJECTIVE To investigate factors associated with Medicare costs among prospectively identified, seriously ill older adults and examine if baseline prognosis influences the impact of these factors. DESIGN/SUBJECTS Prospective observation of Health and Retirement Study cohort with linked Medicare claims. MEASUREMENTS We identified people with incident serious illness (a serious medical condition, for example, metastatic cancer or functional impairment); calculated subjects' one-year mortality risk; and then followed them for one year. We examined relationships between individual and regional characteristics and total Medicare costs, and then stratified analyses by one-year mortality risk: low, moderate, and high. RESULTS From 2002 to 2012, 5208 subjects had incident serious illness: mean age 78 years, 60% women, 76% non-Hispanic white, and 39% hospitalized in the past year. During one-year follow-up, 12% died. Total Medicare costs averaged $20,607. In multivariable analyses, indicators of poor health (e.g., cancer, advanced heart and lung disease, multimorbidity, functional impairment, and others) were significantly associated with higher costs (p < 0.05). However, among those with high mortality risk, health-related variables were not significant. Instead, African American race (rate ratio [RR] 1.56) and moderate-to-high spending regions (RR 1.31 and 1.54, respectively) were significantly associated with higher costs. For this high-risk population, residence in high-spending regions was associated with $31,476 greater costs among African Americans, and $11,162 among other racial groups, holding health constant. CONCLUSIONS Among seriously ill older adults, indicators of poor health are associated with higher costs. Yet, among those with poorest prognoses, nonmedical characteristics-race and regional practice patterns-have greater influence on treatment. This suggests there may be novel opportunities to improve care quality and value by assuring patient-centered, goal-directed care.
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Affiliation(s)
- Amy S Kelley
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center , Bronx, New York
| | - Evan Bollens-Lund
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Kenneth E Covinsky
- 3 Division of Geriatrics, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Jonathan S Skinner
- 4 Department of Economics, Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice , Dartmouth Geisel School of Medicine, Lebanon , New Hampshire
| | - R Sean Morrison
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center , Bronx, New York
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Copeland TP, Franc BL. High-cost cancer imaging: Opportunities for utilization management. J Cancer Policy 2017. [DOI: 10.1016/j.jcpo.2016.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data. Med Care 2017; 55:155-163. [PMID: 27579912 PMCID: PMC5266421 DOI: 10.1097/mlr.0000000000000634] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Health care spending increases sharply at the end of life. Little is known about variation of cost of end of life care between regions and the drivers of such variation. We studied small-area patterns of cost of care in the last year of life in Switzerland. Methods: We used mandatory health insurance claims data of individuals who died between 2008 and 2010 to derive cost of care. We used multilevel regression models to estimate differences in costs across 564 regions of place of residence, nested within 71 hospital service areas. We examined to what extent variation was explained by characteristics of individuals and regions, including measures of health care supply. Results: The study population consisted of 113,277 individuals. The mean cost of care during last year of life was 32.5k (thousand) Swiss Francs per person (SD=33.2k). Cost differed substantially between regions after adjustment for patient age, sex, and cause of death. Variance was reduced by 52%–95% when we added individual and regional characteristics, with a strong effect of language region. Measures of supply of care did not show associations with costs. Remaining between and within hospital service area variations were most pronounced for older females and least for younger individuals. Conclusions: In Switzerland, small-area analysis revealed variation of cost of care during the last year of life according to linguistic regions and unexplained regional differences for older women. Cultural factors contribute to the delivery and utilization of health care during the last months of life and should be considered by policy makers.
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Hung YN, Liu TW, Wen FH, Chou WC, Tang ST. Escalating Health Care Expenditures in Cancer Decedents' Last Year of Life: A Decade of Evidence from a Retrospective Population-Based Cohort Study in Taiwan. Oncologist 2017; 22:460-469. [PMID: 28232596 DOI: 10.1634/theoncologist.2016-0283] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/02/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND No population-based longitudinal studies on end-of-life (EOL) expenditures were found for cancer decedents. METHODS This population-based, retrospective cohort study examined health care expenditures from 2001 to 2010 among 339,546 Taiwanese cancer decedents' last year of life. Individual patient-level data were linked from administrative datasets. Health care expenditures were converted from Taiwan dollars to U.S. dollars by health-specific purchasing power parity conversions to account for different health-purchasing powers. Associations of patient, physician, hospital, and regional factors with EOL care expenditures were evaluated by multilevel linear regression model by generalized estimating equation method. RESULTS Mean annual EOL care expenditures for Taiwanese cancer decedents increased from 2000 to 2010 from U.S. $49,591 to U.S. $68,773, respectively, with one third of spending occurring in the patients' last month. Increased EOL care expenditures were associated with male gender, younger age, being married, diagnosed with hematological malignancies and cancers other than lung, gastric, and hepatic-pancreatic cancers, and dying within 7-24 months of diagnosis. Patients spent less at EOL when they had higher comorbidities and metastatic disease, died within 6 months of diagnosis, were under care of oncologists, gastroenterologists, and intensivists, and received care at a teaching hospital with more terminally ill cancer patients. Higher EOL care expenditures were associated with greater EOL care intensity at the primary hospital and regional levels. CONCLUSION Taiwanese cancer decedents consumed considerable National Health Insurance disbursements at EOL, totaling more than was consumed in six developed non-U.S. countries surveyed in 2010. To slow increasing cost and improve EOL cancer care quality, interventions to ensure appropriate EOL care provision should target hospitals and clinicians less experienced in providing EOL care and those who tend to provide aggressive EOL care to high-risk patients. The Oncologist 2017;22:460-469Implications for Practice: Cancer-care costs are highest during the end-of-life (EOL) period for cancer decedents. This population-based study longitudinally examined EOL expenditures for cancer decedents. Mean annual EOL-care expenditures for Taiwanese cancer decedents increased from U.S. $49,591 to U.S. $68,773 from the year 2000 to 2010, with one third of spending in patients' last month and more than for six developed non-U.S. countries surveyed in 2010. To slow the increasing cost of EOL-cancer care, interventions should target hospitals/clinicians less experienced in providing EOL care, who tend to provide aggressive EOL care to high-risk patients, to avoid the physical suffering, emotional burden, and financial costs of aggressive EOL care.
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Affiliation(s)
- Yen-Ni Hung
- School of Gerontology Health Management and Master Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan, Republic of China
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, Republic of China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
- Graduate School of Nursing, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung City, Taiwan, Republic of China
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Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis. Palliat Support Care 2017; 15:741-752. [PMID: 28196551 DOI: 10.1017/s1478951516001164] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Hospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality. METHOD A systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I 2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence. RESULTS Of the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI 95%] = -2.22-2.61 days; p = 0.87; I 2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI 95% = 0.52-0.84; p < 0.01; I 2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively. SIGNIFICANCE OF RESULTS Hospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.
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Ornstein KA, Aldridge MD, Garrido MM, Gorges R, Bollens-Lund E, Siu AL, Langa KM, Kelley AS. The Use of Life-Sustaining Procedures in the Last Month of Life Is Associated With More Depressive Symptoms in Surviving Spouses. J Pain Symptom Manage 2017; 53:178-187.e1. [PMID: 27864126 PMCID: PMC5253251 DOI: 10.1016/j.jpainsymman.2016.08.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/11/2016] [Accepted: 08/26/2016] [Indexed: 11/15/2022]
Abstract
CONTEXT Family caregivers of individuals with serious illness who undergo intensive life-sustaining medical procedures at the end of life may be at risk of negative consequences including depression. OBJECTIVES The objective of this study was to determine the association between patients' use of life-sustaining procedures at the end of life and depressive symptoms in their surviving spouses. METHODS We used data from the Health and Retirement Study, a longitudinal survey of U.S. residents, linked to Medicare claims data. We included married Medicare beneficiaries aged 65 years and older who died between 2000 and 2011 (n = 1258) and their surviving spouses. The use of life-sustaining procedures (i.e., intubation/mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral/parenteral nutrition, and cardiopulmonary resuscitation) in the last month of life was measured via claims data. Using propensity score matching, we compared change in depressive symptoms of surviving spouses. RESULTS Eighteen percent of decedents underwent one or more life-sustaining procedures in the last month of life. Those whose spouses underwent life-sustaining procedures had a 0.32-point increase in depressive symptoms after death (scale range = 0-8) and a greater likelihood of clinically significant depression (odds ratio = 1.51) compared with a matched sample of spouses of those who did not have procedures (P < 0.05). CONCLUSION Surviving spouses of those who undergo intensive life-sustaining procedures at the end of life experience a greater magnitude of increase in depressive symptoms than those whose spouses do not undergo such procedures. Further study of the circumstances and decision making surrounding these procedures is needed to understand their relationship with survivors' negative mental health consequences and how best to provide appropriate support.
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Affiliation(s)
- Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Melissa M Garrido
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Rebecca Gorges
- Harris School of Public Policy, University of Chicago, Chicago, Illinois
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Albert L Siu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Kenneth M Langa
- Department of Internal Medicine, Veterans Affairs Center for Clinical Management Research, Institute for Social Research, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
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Luta X, Panczak R, Maessen M, Egger M, Goodman DC, Zwahlen M, Stuck AE, Clough - Gorr K. Dying among older adults in Switzerland: who dies in hospital, who dies in a nursing home? BMC Palliat Care 2016; 15:83. [PMID: 27662830 PMCID: PMC5035491 DOI: 10.1186/s12904-016-0156-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 09/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Institutional deaths (hospitals and nursing homes) are an important issue because they are often at odds with patient preference and associated with high healthcare costs. The aim of this study was to examine deaths in institutions and the role of individual, regional, and healthcare supply characteristics in explaining variation across Swiss Hospital Service Areas (HSAs). METHODS Retrospective study of individuals ≥66 years old who died in a Swiss institution (hospital or nursing homes) in 2010. Using a two-level logistic regression analysis we examined the amount of variation across HSAs adjusting for individual, regional and healthcare supply measures. The outcome was place of death, defined as death in hospital or nursing homes. RESULTS In 2010, 41,275 individuals ≥66 years old died in a Swiss institution; 54 % in nursing homes and 46 % in hospitals. The probability of dying in hospital decreased with increasing age. The OR was 0.07 (95 % CI: 0.05-0.07) for age 91+ years compared to those 66-70 years. Living in peri-urban areas (OR = 1.06 95 % CI: 1.00-1.11) and French speaking region (OR = 1.43 95 % CI: 1.22-1.65) was associated with higher probability of hospital death. Females had lower probability of death in hospital (OR = 0.54 95 % CI: 0.51-0.56). The density of ambulatory care physicians (OR = 0.81 95 % CI: 0.67-0.97) and nursing homes beds (OR = 0.67 95 % CI: 0.56-0.79) was negatively associated with hospital death. The proportion of dying in hospital varied from 38 % in HSAs with lowest proportion of hospital deaths to 60 % in HSAs with highest proportion of hospital deaths (1.6-fold variation). CONCLUSIONS We found evidence for variation across regions in Switzerland in dying in hospital versus nursing homes, indicating possible overuse and underuse of end of life (EOL) services.
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Affiliation(s)
- Xhyljeta Luta
- Institute of Social and Preventive Medicine, University of Bern, Finkeubelweg 11, CH-3012 Bern, Switzerland
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Finkeubelweg 11, CH-3012 Bern, Switzerland
| | - Maud Maessen
- Institute of Social and Preventive Medicine, University of Bern, Finkeubelweg 11, CH-3012 Bern, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Finkeubelweg 11, CH-3012 Bern, Switzerland
| | - David C. Goodman
- Institute of Social and Preventive Medicine, University of Bern, Finkeubelweg 11, CH-3012 Bern, Switzerland
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire USA
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Finkeubelweg 11, CH-3012 Bern, Switzerland
| | - Andreas E. Stuck
- Institute of Social and Preventive Medicine, University of Bern, Finkeubelweg 11, CH-3012 Bern, Switzerland
- University Department of Geriatrics, Inselspital Bern, Bern, Switzerland
| | - Kerri Clough - Gorr
- Institute of Social and Preventive Medicine, University of Bern, Finkeubelweg 11, CH-3012 Bern, Switzerland
- Section of Geriatrics, Boston University Medical Center, Boston, MA USA
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Byhoff E, Harris JA, Langa KM, Iwashyna TJ. Racial and Ethnic Differences in End-of-Life Medicare Expenditures. J Am Geriatr Soc 2016; 64:1789-97. [PMID: 27588580 DOI: 10.1111/jgs.14263] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life. DESIGN Retrospective cohort study. SETTING Health and Retirement Study (HRS). PARTICIPANTS Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105). MEASUREMENTS Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected. RESULTS The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models. CONCLUSION Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.
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Affiliation(s)
- Elena Byhoff
- Department of Medicine, University of Michigan, Ann Arbor, Michigan. .,Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan. .,Veterans Affairs Center for Clinical Management and Research, Ann Arbor, Michigan.
| | - John A Harris
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Kenneth M Langa
- Department of Medicine, University of Michigan, Ann Arbor, Michigan.,Veterans Affairs Center for Clinical Management and Research, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.,Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Theodore J Iwashyna
- Department of Medicine, University of Michigan, Ann Arbor, Michigan.,Veterans Affairs Center for Clinical Management and Research, Ann Arbor, Michigan.,Institute for Social Research, University of Michigan, Ann Arbor, Michigan.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Hung YN, Cheng SHC, Liu TW, Chang WC, Chen JS, Tang ST. Trend in and Correlates of Undergoing Radiotherapy in Taiwanese Cancer Patients' Last Month of Life. J Pain Symptom Manage 2016; 52:395-403. [PMID: 27265817 DOI: 10.1016/j.jpainsymman.2016.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/17/2016] [Accepted: 03/16/2016] [Indexed: 11/19/2022]
Abstract
CONTEXT A significant proportion of cancer patients at end of life (EOL) undergo radiotherapy, but this evidence is not from nationwide population-based studies. OBJECTIVES The aims of this population-based study were to investigate the trend in undergoing radiotherapy among Taiwanese cancer patients' last month of life (EOL radiotherapy) in 2001-2010 and to identify factors associated with EOL radiotherapy. METHODS This was a population-based retrospective cohort study analyzing data from Taiwan's national death registry, cancer registry, and National Health Insurance claims for EOL radiotherapy using multilevel generalized linear mixed modeling. Participants were Taiwanese cancer patients (N = 339,546) who died in 2001-2010. RESULTS Overall, 8.59% (7.97%-9.85%) of patients underwent EOL radiotherapy with a decreasing trend over time. Correlates of EOL radiotherapy included male gender, younger age, residing in less urbanized areas, diagnosis of lung cancer, metastatic disease, death within two years of diagnosis, and without comorbidities. Cancer patients were more likely to undergo EOL radiotherapy if they received primary care from medical oncologists and pediatricians, in a nonprofit, teaching hospital with a larger case volume of terminally ill cancer patients, and greater EOL care intensity. CONCLUSION Approximately one-tenth of Taiwanese cancer patients underwent EOL radiotherapy with a decreasing trend over time. Undergoing EOL radiotherapy was associated with demographics, disease characteristics, physician specialty, and primary hospital's characteristics and EOL care practice patterns. Clinical and financial interventions should target hospitals/physicians that tend to aggressively treat at-risk cancer patients at EOL to carefully evaluate the appropriateness and effectiveness of using EOL radiotherapy.
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Affiliation(s)
- Yen-Ni Hung
- School of Gerontology Health Management and Master Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Republic of China
| | - Skye Hung-Chun Cheng
- Department of Radiation Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Republic of China
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Republic of China
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, Republic of China
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, Republic of China
| | - Siew Tzuh Tang
- Chang Gung University Graduate School of Nursing and Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Taiwan, Republic of China.
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Characteristics and Correlates of Increasing Use of Surgery in Taiwanese Cancer Patients’ Last Month of Life, 2001–2010. Ann Surg 2016; 264:283-90. [DOI: 10.1097/sla.0000000000001373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Chronic Critical Illness in Infants and Children: A Speculative Synthesis on Adapting ICU Care to Meet the Needs of Long-Stay Patients. Pediatr Crit Care Med 2016; 17:743-52. [PMID: 27295581 DOI: 10.1097/pcc.0000000000000792] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES In this review, we examine features of ICU systems and ICU clinician training that can undermine continuity of communication and longitudinal guidance for decision making for chronically critically ill infants and children. Drawing upon a conceptual model of the dynamic interactions between patients, families, clinicians, and ICU systems, we propose strategies to promote longitudinal decision making and improve communication for infants and children with prolonged ICU stays. DATA SOURCES We searched MEDLINE and PubMed from inception to September 2015 for English-language articles relevant to chronic critical illness, particularly of pediatric patients. We also reviewed bibliographies of relevant studies to broaden our search. STUDY SELECTION Two authors (physicians with experience in pediatric neonatology, critical care, and palliative care) made the final selections. DATA EXTRACTION We critically reviewed the existing data and models of care to identify strategies for improving ICU care of chronically critically ill children. DATA SYNTHESIS Utilizing the available data and personal experience, we addressed concerns related to family perspectives, ICU processes, and issues with ICU training that shape longitudinal decision making. CONCLUSIONS As the number of chronically critically ill infants and children increases, specific communication and decision-making models targeted at this population could improve the feedback between acute, daily ICU decisions and the patient's overall goals of care. Adaptations to ICU systems of care and ICU clinician training will be essential components of this progress.
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Horton JR, Morrison RS, Capezuti E, Hill J, Lee EJ, Kelley AS. Impact of Inpatient Palliative Care on Treatment Intensity for Patients with Serious Illness. J Palliat Med 2016; 19:936-42. [PMID: 27248056 DOI: 10.1089/jpm.2015.0240] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Palliative care is associated with decreased treatment intensity and improved quality for individual patients at the end of life, but little is known about how hospital-wide outcomes are affected by the diffusion of palliative care principles. OBJECTIVE We examined the relationship between presence of palliative care programs and hospitals' average treatment intensity, as indicated by mean intensive care unit (ICU) length of stay (LOS) and days under Medicare hospice coverage, in the last six months of life among Medicare beneficiaries aged 67 and over with serious chronic illness. METHODS We linked hospital-level data from the American Hospital Association Annual Survey, National Palliative Care Registry, and Dartmouth Atlas of Health Care to examine hospital-level treatment intensity for chronically ill Medicare beneficiaries who died in 2010. We used propensity score-adjusted linear regression to estimate the relationship between palliative care programs and hospitals' mean ICU LOS and hospice length of enrollment. RESULTS Among 974 hospitals meeting inclusion criteria, we compared 295 hospitals with palliative care programs to 679 hospitals without. Hospitals with palliative care programs were higher volume, more likely to be teaching hospitals, and have oncology services and less likely to be located in rural areas. In propensity score weighted analyses, the mean ICU LOS in hospitals with palliative care was shorter by 0.23 days (standard error [SE] = 0.26), but this was not statistically significant (p = 0.76). In addition, the mean length of hospice enrollment among beneficiaries served by hospitals with palliative care was longer by 0.22 days (SE = 0.61), but also was not statistically significant (p = 0.76). CONCLUSIONS Hospital-based palliative care programs alone may not be sufficient to impact ICU LOS or hospice length of enrollment for all chronically ill older adults admitted to hospitals. Future work should measure hospital-wide palliative care outcomes and effects of core palliative knowledge and skills provided by nonpalliative care specialists.
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Affiliation(s)
- Jay R Horton
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - R Sean Morrison
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Elizabeth Capezuti
- 2 City University of New York , Hunter College School of Nursing, New York, New York
| | | | - Eric J Lee
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Amy S Kelley
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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Hung YN, Liu TW, Lin DT, Chen YC, Chen JS, Tang ST. Receipt of Life-Sustaining Treatments for Taiwanese Pediatric Patients Who Died of Cancer in 2001 to 2010: A Retrospective Cohort Study. Medicine (Baltimore) 2016; 95:e3461. [PMID: 27100448 PMCID: PMC4845852 DOI: 10.1097/md.0000000000003461] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aggressive life-sustaining treatments have the potential to be continued beyond benefit, but have seldom been systematically/nationally explored in pediatric cancer patients. Furthermore, factors predisposing children dying of cancer to receive life-sustaining treatments at end of life (EOL) have never been investigated in a population-based study. This population-based study explored determinants of receiving life-sustaining treatments in pediatric cancer patients' last month of life. For this retrospective cohort study, we used administrative data on 1603 Taiwanese pediatric cancer patients who died in 2001 to 2010. Individual patient-level data were linked with encrypted identification numbers from the National Register of Deaths Database, Cancer Registration System database, National Health Insurance claims datasets, and Database of Medical Care Institutions Status. Life-sustaining treatments included intensive care unit (ICU) care, cardiopulmonary resuscitation (CPR), and mechanical ventilation. Associations of patient, physician, hospital, and regional factors with receiving ICU care, CPR, and mechanical ventilation in the last month of life were evaluated by multilevel generalized linear mixed models. In their last month of life, 22.89%, 46.48%, and 61.45% of pediatric cancer patients received CPR, mechanical ventilation, and ICU care, respectively, with no significant decreasing trends from 2001 to 2010. Patients were more likely to receive all three identified life-sustaining treatments at EOL if they were diagnosed with a hematologic malignancy or a localized disease, died within 1 year of diagnosis, and received care from a pediatrician. Receipt of ICU care or mechanical ventilation increased with increasing EOL-care intensity of patients' primary hospital, whereas use of mechanical ventilation decreased with increasing quartile of hospice beds in the patients' primary hospital region. Taiwanese pediatric cancer patients received aggressive life-sustaining treatments in the month before death. Healthcare policies and interventions should aim to help pediatricians treating at-risk pediatric cancer patients and hospitals with a tendency to provide aggressive EOL treatments to avoid the expense of life-sustaining treatments when chance of recovery is remote and to devote resources to care that produces the greatest benefits for children, parents, and society.
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Affiliation(s)
- Yen-Ni Hung
- From the School of Gerontology Health Management and Master's Program in Long-Term Care, College of Nursing, Taipei Medical University (Y-NH); National Institute of Cancer Research, National Health Research Institutes (T-WL); Department of Pediatrics, National Taiwan University (D-TL); Department of Nursing, College of Medicine and Nursing, Hung Kuang University (Y-CC); Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine (J-SC); and School of Nursing, Chang Gung University and Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung (STT), Tao-Yuan, Taiwan, R.O.C
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Ornstein KA, Aldridge MD, Mair CA, Gorges R, Siu AL, Kelley AS. Spousal Characteristics and Older Adults' Hospice Use: Understanding Disparities in End-of-Life Care. J Palliat Med 2016; 19:509-15. [PMID: 26991831 DOI: 10.1089/jpm.2015.0399] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hospice use has been shown to benefit quality of life for patients with terminal illness and their families, with further evidence of cost savings for Medicare and other payers. While disparities in hospice use by patient diagnosis, race, and region are well documented and attention to the role of family members in end-of-life decision-making is increasing, the influence of spousal characteristics on the decision to use hospice is unknown. OBJECTIVES To determine the association between spousal characteristics and hospice use. DESIGN We used data from the Health and Retirement Study (HRS), a prospective cohort study, linked to the Dartmouth Atlas of Health Care and Medicare claims. SETTING National study of 1567 decedents who were married or partnered at the time of death (2000-2011). MEASURES Hospice use at least 1 day in the last year of life as measured via Medicare claims data. Spousal factors (e.g., education and health status) measured via survey. RESULTS In multivariate models controlling for patient factors and regional variation, spouses with lower educational attainment than their deceased spouse had decreased likelihood of hospice use (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40-0.82). Health of the spouse was not significantly associated with likelihood of decedent hospice use in adjusted models. IMPLICATIONS Although the health of the surviving spouse was not associated with hospice use, their educational level was a predictor of hospice use. Spousal and family characteristics, including educational attainment, should be examined further in relation to disparities in hospice use. Efforts to increase access to high-quality end-of-life care for individuals with serious illness must also address the needs and concerns of caregivers and family.
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Affiliation(s)
- Katherine A Ornstein
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Melissa D Aldridge
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Christine A Mair
- 4 Department of Sociology and Anthropology, University of Maryland , Baltimore, Maryland
| | - Rebecca Gorges
- 5 Harris School of Public Policy, University of Chicago , Chicago, Illinois
| | - Albert L Siu
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,3 James J. Peters Veterans Affairs Medical Center , Bronx, New York
| | - Amy S Kelley
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,3 James J. Peters Veterans Affairs Medical Center , Bronx, New York
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Pataky R, Cheung W, de Oliveira C, Bremner K, Chan K, Hoch J, Krahn M, Peacock S. Population-based trends in systemic therapy use and cost for cancer patients in the last year of life. Curr Oncol 2016; 23:S32-41. [PMID: 26985144 PMCID: PMC4780587 DOI: 10.3747/co.23.2946] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The use of systemic therapy near the end of life can expose cancer patients to severe toxicity for minimal survival gain and comes with a high cost. Early palliative care is recommended, but there is evidence that aggressive care remains common. To better understand those patterns, the present study set out to describe trends in systemic therapy use and cost for cancer patients in the last year of life. METHODS Using the BC Cancer Registry, a retrospective population-based cohort of cancer decedents (2002-2007) was identified and linked to systemic therapy records. The outcomes of interest were any systemic therapy use and total systemic therapy costs during the last year of life. Multiple logistic regression (systemic therapy use) and generalized linear regression (costs) were conducted, adjusting for age, sex, and survival. Subgroup analyses were performed for patients with primary colorectal, lung, prostate, or breast cancer. RESULTS From 2002 to 2007, use of systemic therapy in the last 12-4 months of life increased by 21% (95% ci: 10% to 33%); no significant change in use in the last 3 months of life was observed. Costs for both periods increased over time, by 48% (95% ci: 36% to 63%) and by 33% (95% ci: 19% to 49%) respectively. The trends varied across cancer sites, with the greatest increases being observed for lung and colorectal cancer patients. CONCLUSIONS The use and costs of systemic therapy have generally been increasing, putting pressure on health care providers and payers, but the quality-of-life implications for patients must be better understood.
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Affiliation(s)
- R.E. Pataky
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
- BC Cancer Agency, Vancouver, BC
| | | | - C. de Oliveira
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
- Centre for Addiction and Mental Health, Toronto, ON
| | - K.E. Bremner
- Toronto General Research Institute and The Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON
| | - K.K.W. Chan
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
- Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON
| | - J.S. Hoch
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
| | - M.D. Krahn
- Toronto General Research Institute and The Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON
- Faculty of Pharmacy, University of Toronto, University Health Network, Toronto, ON
| | - S.J. Peacock
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
- BC Cancer Agency, Vancouver, BC
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC
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Liu TW, Hung YN, Soong TC, Tang ST. Increasing Receipt of High-Tech/High-Cost Imaging and Its Determinants in the Last Month of Taiwanese Patients With Metastatic Cancer, 2001-2010: A Retrospective Cohort Study. Medicine (Baltimore) 2015; 94:e1354. [PMID: 26266390 PMCID: PMC4616695 DOI: 10.1097/md.0000000000001354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/04/2015] [Accepted: 07/07/2015] [Indexed: 11/26/2022] Open
Abstract
One strategy for controlling the skyrocketing costs of cancer care may be to target high-tech/high-cost imaging at the end of life (EOL). This population-based study investigated receipt of high-tech/high-cost imaging and its determinants for Taiwanese patients with metastatic cancer in their last month of life.Individual patient-level data were linked with encrypted identification numbers from computerized administrative data in Taiwan, that is, the National Register of Deaths Database, Cancer Registration System database, and National Health Insurance claims datasets, Database of Medical Care Institutions Status, and national census statistics (population/household income). We identified receipt of computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and radionuclide bone scans (BSs) for 236,911 Taiwanese cancer decedents with metastatic disease, 2001 to 2010. Associations of patient, physician, hospital, and regional factors with receiving CT, MRI, and bone scan in the last month of life were evaluated by multilevel generalized linear-mixed models.Over one-third (average [range]: 36.11% [33.07%-37.31%]) of patients with metastatic cancer received at least 1 high-tech/high-cost imaging modality in their last month (usage rates for CT, MRI, PET, and BS were 31.05%, 5.81%, 0.25%, and 8.15%, respectively). In 2001 to 2010, trends of receipt increased for CT (27.96-32.22%), MRI (4.34-6.70%), and PET (0.00-0.62%), but decreased for BS (9.47-6.57%). Facilitative determinants with consistent trends for at least 2 high-tech/high-cost imaging modalities were male gender, younger age, married, rural residence, lung cancer diagnosis, dying within 1 to 2 years of diagnosis, not under medical oncology care, and receiving care at a teaching hospital with a larger volume of terminally ill cancer patients and greater EOL care intensity. Undergoing high-tech/high-cost imaging at EOL generally was not associated with regional characteristics, healthcare resources, and EOL care intensity.To more effectively use high-tech/high-cost imaging at EOL, clinical and financial interventions should target nonmedical oncologists/hematologists affiliated with teaching hospitals that tend to aggressively treat high volumes of terminally ill cancer patients, thereby avoiding unnecessary EOL care spending and transforming healthcare systems into affordable high-quality cancer care delivery systems.
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Affiliation(s)
- Tsang-Wu Liu
- From the National Institute of Cancer Research, National Health Research Institutes, Miaoli County (T-WL); School of Gerontology Health Management and Master's Program in Long-Term Care, College of Nursing, Taipei Medical University (Y-NH); Department of Radiology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei (TCS); and Chang Gung University, School of Nursing, Kwei-Shan, Tao-Yuan, Taiwan, R.O.C. (STT)
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Tang ST, Liu TW, Liu LN, Chiu CF, Hsieh RK, Tsai CM. Physician-patient end-of-life care discussions: correlates and associations with end-of-life care preferences of cancer patients-a cross-sectional survey study. Palliat Med 2014; 28:1222-30. [PMID: 24965755 DOI: 10.1177/0269216314540974] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Honoring patients' treatment preferences is a key component of high-quality end-of-life care. Connecting clinical practices to patients' preferences requires effective communication. However, few cancer patients reported discussing end-of-life-care preferences with their physicians. AIM To identify correlates of physician-patient end-of-life-care discussions and to investigate associations of physician-patient end-of-life-care discussions with patient end-of-life-care preferences. DESIGN A cross-sectional survey from April 2011 through November 2012. SETTING/PARTICIPANTS A convenience sample of 2467 cancer patients (89.3% participation rate) whose disease was diagnosed as terminal and unresponsive to current curative cancer treatment was recruited from 23 teaching hospitals throughout Taiwan. RESULTS Only 7.8% of respondents reported discussing end-of-life-care preferences with their physicians. Physicians were more likely to discuss end-of-life-care preferences with cancer patients who accurately understood their prognosis but less likely to do so if patients were married or received care in a hospital with an inpatient hospice unit. Furthermore, physician-patient end-of-life-care discussions were significantly, positively associated with the likelihood of preferring comfort-oriented care and hospice care, but negatively associated with preferences for receiving cardiopulmonary resuscitation when life is in danger and aggressive life-sustaining treatments at end of life, including intensive care unit admission, cardiac massage, intubation, and mechanical ventilation support. CONCLUSION Physician-patient end-of-life-care discussions are correlated with accurate prognostic awareness, marital status, and institutional characteristics and negatively associated with terminally ill cancer patients' preferences for aggressive end-of-life care. Interventions should be developed to facilitate timely end-of-life-care discussions between at-risk patients and their physicians, thus honoring patients' end-of-life-care preferences and possibly avoiding futile life-sustaining treatments.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Chang Gung University, Tao-Yuan, Taiwan
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan
| | - Li Ni Liu
- Department of Nursing, Fu Jen Catholic University, Taipei, Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center, China Medical University Hospital, Taichung, Taiwan
| | - Ruey-Kuen Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chun-Ming Tsai
- Chest Department, Taipei Veterans General Hospital, Taipei, Taiwan
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Pitfalls in Communication That Lead to Nonbeneficial Emergency Surgery in Elderly Patients With Serious Illness. Ann Surg 2014; 260:949-57. [DOI: 10.1097/sla.0000000000000721] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tschirhart EC, Du Q, Kelley AS. Factors influencing the use of intensive procedures at the end of life. J Am Geriatr Soc 2014; 62:2088-94. [PMID: 25376084 DOI: 10.1111/jgs.13104] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To examine individual and regional factors associated with the use of intensive medical procedures in the last 6 months of life. DESIGN Retrospective cohort study. SETTING The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of older adults. PARTICIPANTS HRS decedents aged 66 and older (N = 3,069). MEASUREMENTS Multivariable logistic regression was used to evaluate associations between individual and regional factors and receipt of five intensive procedures: intubation and mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral and parenteral nutrition, or cardiopulmonary resuscitation in the last 6 months of life. RESULTS Approximately 18% of subjects (n = 546) underwent at least one intensive procedure in the last 6 months of life. Characteristics significantly associated with lower odds of an intensive procedure included aged 85-94 (vs 65-74, adjusted odds ratio (AOR) = 0.67, 95% confidence interval (CI) = 0.51-0.90), Alzheimer's disease (AOR = 0.71, 95% CI = 0.54-0.94), cancer (AOR = 0.60, 95% CI = 0.43-0.85), nursing home residence (AOR = 0.70, 95% CI = 0.50-0.97), and having an advance directive (AOR = 0.71, 95% CI = 0.57-0.89). In contrast, living in a region with higher hospital care intensity (AOR = 2.16, 95% CI = 1.48-3.13) and black race (AOR = 2.02, 95% CI = 1.52-2.69) each doubled one's odds of undergoing an intensive procedure. CONCLUSION Individual characteristics and regional practice patterns are important determinants of intensive procedure use in the last 6 months of life. The effect of nonclinical factors highlights the need to better align treatments with individual preferences.
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Affiliation(s)
- Evan C Tschirhart
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Tucker-Seeley RD, Abel GA, Uno H, Prigerson H. Financial hardship and the intensity of medical care received near death. Psychooncology 2014; 24:572-8. [PMID: 25052138 DOI: 10.1002/pon.3624] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/26/2014] [Accepted: 06/30/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although end-of-life (EOL) care can present a substantial financial burden for the household, the influence of this burden on the intensity of care received at the EOL remains unknown. The goal of this study was to determine the association between financial hardship and intensive care in the last week of life. METHODS The Coping with Cancer (CwC) Study is a longitudinal, multisite cohort study of terminally ill cancer patients and their informal caregivers, September 2002-February 2008. Patients (N = 281) were followed from baseline to death, a median of 4.4 months after baseline assessment. Intensive care was defined as the use of resuscitation and/or ventilation in the patient's last week of life. Financial hardship was measured at study baseline as a positive response to whether the household had to use all or most of their savings because of the family member's illness. RESULTS Twenty-nine percent reported financial hardship, and 9% received intensive EOL care. Patients reporting financial hardship had a 3.22 (95% CI: 1.38, 7.53) higher likelihood of receiving intensive EOL care compared with patients not reporting financial hardship. After adjusting for sociodemographic characteristics and patient preferences, patients reporting financial hardship had a 3.05 (95% CI: 1.22, 7.62) higher likelihood of receiving intensive EOL care. CONCLUSION The depletion of a family's financial resources is a significant predictor of intensive EOL care, over and above the influence of sociodemographic characteristics and patient preferences.
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Kelley AS, Langa KM, Smith AK, Cagle J, Ornstein K, Silveira MJ, Nicholas L, Covinsky KE, Ritchie CS. Leveraging the health and retirement study to advance palliative care research. J Palliat Med 2014; 17:506-11. [PMID: 24694096 DOI: 10.1089/jpm.2013.0648] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The critical need to expand and develop the palliative care evidence base was recently highlighted by the Journal of Palliative Medicine's series of articles describing the Research Priorities in Geriatric Palliative Care. The Health and Retirement Study (HRS) is uniquely positioned to address many priority areas of palliative care research. This nationally representative, ongoing, longitudinal study collects detailed survey data every 2 years, including demographics, health and functional characteristics, information on family and caregivers, and personal finances, and also conducts a proxy interview after each subject's death. The HRS can also be linked with Medicare claims data and many other data sources, e.g., U.S. Census, Dartmouth Atlas of Health Care. SETTING While the HRS offers innumerable research opportunities, these data are complex and limitations do exist. Therefore, we assembled an interdisciplinary group of investigators using the HRS for palliative care research to identify the key palliative care research gaps that may be amenable to study within the HRS and the strengths and weaknesses of the HRS for each of these topic areas. CONCLUSION In this article we present the work of this group as a potential roadmap for investigators contemplating the use of HRS data for palliative care research.
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Affiliation(s)
- Amy S Kelley
- 1 Brookdale Depratment of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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Tang ST, Liu TW, Chow JM, Chiu CF, Hsieh RK, Chen CH, Liu LN, Feng WL. Associations between accurate prognostic understanding and end-of-life care preferences and its correlates among Taiwanese terminally ill cancer patients surveyed in 2011-2012. Psychooncology 2014; 23:780-7. [DOI: 10.1002/pon.3482] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 12/15/2013] [Accepted: 12/17/2013] [Indexed: 01/03/2023]
Affiliation(s)
- Siew Tzuh Tang
- School of Nursing; Chang Gung University; Tao-Yuan Taiwan
| | - Tsang-Wu Liu
- National Health Research Institutes; National Institute of Cancer Research; Taipei Taiwan
| | - Jyh-Ming Chow
- Section of Hematology and Medical Oncology; Wan-Fang Hospital; Taipei Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center; China Medical University Hospital; Taichung Taiwan
| | - Ruey-Kuen Hsieh
- Division of Hematology and Oncology, Department of Internal Medicine; Mackay Memorial Hospital; Taipei Taiwan
| | - Chen H. Chen
- School of Nursing; Kang-Ning Junior College of Medical Care and Management; Taipei Taiwan
| | - Li Ni Liu
- Department of Nursing; Fu Jen Catholic University; Taipei Taiwan
| | - Wei-Lien Feng
- National Health Research Institutes; National Institute of Cancer Research; Taipei Taiwan
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Kelley AS, Deb P, Du Q, Aldridge Carlson MD, Morrison RS. Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff (Millwood) 2014; 32:552-61. [PMID: 23459735 DOI: 10.1377/hlthaff.2012.0851] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53-105 days before death. Using data from the Health and Retirement Study, 2002-08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53-105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1-7, 8-14, and 15-30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.
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Affiliation(s)
- Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, USA.
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Abstract
The U.S. health care system is struggling to improve the quality of health care while containing costs. The rapidly expanding population of older adults with serious illness presents both the greatest challenge and potentially the greatest opportunity to achieving this goal. In order to capitalize on this opportunity, we must first examine the epidemiology of the care of older adults with serious illness, that is, a full description of the characteristics and quality of care from the time of diagnosis through the full course of illness, including measurement of all factors that may influence or impact that care. Several methodological challenges exist in this area of study, including but not limited to, defining the onset of serious illness, avoiding bias in sample selection, and measuring the full breadth of personal, social, local, regional and provider factors that may influence care. Yet, this work is possible through a combination of targeted primary research and efficient leveraging of ongoing studies and existing data sources. Through these studies, we may identify those factors and services associated with high value health care, and learn to develop and refine policies and health care delivery models that yield the greatest improvements in care for seriously ill older patients and their families.
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Affiliation(s)
- Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York 10029-6574, USA.
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Bükki J, Scherbel J, Stiel S, Klein C, Meidenbauer N, Ostgathe C. Palliative care needs, symptoms, and treatment intensity along the disease trajectory in medical oncology outpatients: a retrospective chart review. Support Care Cancer 2013; 21:1743-50. [PMID: 23344656 DOI: 10.1007/s00520-013-1721-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 01/09/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early integration of palliative care into cancer disease management is beneficial for patients with advanced tumors. However, little is known about the association of palliative care interventions with symptom burden and treatment aggressiveness at the end of life (EoL). METHODS To assess determinants of symptom burden and treatment intensity at the EoL, a retrospective chart review was conducted in university cancer clinic outpatients who died between July 2009 and June 2011. The objective was the correlation of place of death, palliative care utilization, prior EoL discussion, and social background (determinant variables) with symptom burden and treatment intensity (outcome variables). RESULTS Ninety-six patients (61 men and 35 women) died; the mean age at death was 62.4 years (range 24-83). Mean duration of treatment was 17.9 months (range 1-129). Data on the last 14 days (3) of life were available for 62 (44) patients. Forty-seven patients received aggressive EoL care which was strongly associated with hospital death (p = 0.000, χ2 test). The 15 patients having used palliative care services or dying in a palliative care unit (PCU) had fewer symptoms (p = 0.006, t test) and interventions (p = 0.000, t test) at the EoL. Having addressed EoL issues was correlated with fewer procedures during the last 3 days (p = 0.035, t test). CONCLUSIONS Most cancer patients receive aggressive EoL care interfering with quality of life. Despite limitations by small sample size and missing data, the results suggest that palliative care utilization is associated with reduced symptom burden and intensity of treatment at the EoL. Timely discussion of EoL issues may reduce the number of unnecessary interventions and facilitate referral to the PCU.
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Affiliation(s)
- Johannes Bükki
- Departement of Palliative Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
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Alter DA, Ko DT, Tu JV, Stukel TA, Lee DS, Laupacis A, Chong A, Austin PC. The average lifespan of patients discharged from hospital with heart failure. J Gen Intern Med 2012; 27:1171-9. [PMID: 22549300 PMCID: PMC3515002 DOI: 10.1007/s11606-012-2072-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 03/01/2012] [Accepted: 03/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND There are no life-tables quantifying the average life-spans of post-hospitalized heart failure populations across various strata of risk. OBJECTIVE To quantify the life-expectancies (i.e., average life-spans) of heart failure patients at the time of hospital discharge according to age, gender, predictive 30-day mortality heart failure risk index, and comorbidity burden. DESIGN Population-based retrospective cohort study. SETTING Ontario, Canada. PATIENTS 7,865 heart failure patients discharged from Ontario hospitals between 1999 and 2000. MEASUREMENTS Data were obtained from the Enhanced Feedback for Effective Cardiac Treatment EFFECT provincial quality improvement initiative. All patients were linked to administrative data, and tracked longitudinally until March 31, 2010. Detailed clinical variables were obtained from medical chart abstraction, and death data were obtained from vital statistics. Average life-spans were calculated using Cox Proportion Hazards models in conjunction with the Declining Exponential Approximation of Life Expectancy (D.E.A.L.E) method to extrapolate life-expectancy, adjusting for age, gender, predicted 30-day mortality, left ventricular function and comorbidity, and was reported according to key prognostic risk-strata. RESULTS The average life-span of the cohort was 5.5 years (STD +/- 10.0) ranging from 19.5 years for low-risk women of less than 50 years old to 2.9 years for high-risk octogenarian males. Average life-spans were lower by 0.13 years among patients with impaired as compared with preserved left ventricular function, and by approximately one year among patients with three or more as compared with no concomitant comorbidities. In total, 17.4 % and 27 % of patients had died within 6 months and 1 year respectively, despite having predicted life-spans exceeding one-year. LIMITATIONS Data regarding changes in patient clinical status over time were unavailable. CONCLUSIONS The development of risk-adjusted life-tables for heart failure populations is feasible and mirrored those with advanced malignant diseases. Average life span varied widely across clinical risk strata, and may be less accurate among those at or near their end of life.
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Affiliation(s)
- David A Alter
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Kelley AS, Ettner SL, Morrison RS, Du Q, Sarkisian CA. Disability and decline in physical function associated with hospital use at end of life. J Gen Intern Med 2012; 27:794-800. [PMID: 22382455 PMCID: PMC3378753 DOI: 10.1007/s11606-012-2013-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 12/28/2011] [Accepted: 01/30/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hospital use near the end of life is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions. OBJECTIVE To concurrently examine regional and patient factors, including disability and functional decline, associated with end-of-life hospital use. DESIGN/PARTICIPANTS We sampled decedents aged 65 and older (n = 2,493) from the Health and Retirement Study (2000-2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last 6 months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI). KEY RESULTS Median hospital days was 7 (range = 0-183). 53% of respondents had functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47-9.05, depending on category). Dementia was associated with fewer days (-3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27). CONCLUSIONS Functional decline is significantly associated with end-of-life hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.
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Affiliation(s)
- Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Kelley AS, Ettner SL, Wenger NS, Sarkisian CA. Determinants of death in the hospital among older adults. J Am Geriatr Soc 2011; 59:2321-5. [PMID: 22092014 DOI: 10.1111/j.1532-5415.2011.03718.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate patient-level determinants of in-hospital death, adjusting for patient and regional characteristics. DESIGN Using multivariable regression, the relationship between in-hospital death and participants' social, functional, and health characteristics was investigated, controlling for regional Hospital Care Intensity Index (HCI) from the Dartmouth Atlas of Health Care. SETTING The Health and Retirement Study, a longitudinal nationally representative cohort of older adults. PARTICIPANTS People aged 67 and older who died between 2,000 and 2,006 (N = 3,539) were sampled. MEASUREMENTS In-hospital death. RESULTS Thirty-nine percent (n = 1,380) of participants died in the hospital (range 34% in Midwest to 45% in Northeast). Nursing home residence, functional dependence, and cancer or dementia diagnosis, among other characteristics, were associated with lower adjusted odds of in-hospital death. Being black or Hispanic, living alone, and having more medical comorbidities were associated with greater adjusted odds, as was higher HCI. Sex, education, net worth, and completion of an advance directive did not correlate with in-hospital death. CONCLUSION Black race, Hispanic ethnicity, and other functional and social characteristics are correlates of in-hospital death, even after controlling for the role of HCI. Further work must be done to determine whether preferences, provider characteristics and practice patterns, or differential access to medical and community services drive this difference.
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Affiliation(s)
- Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York, USA.
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