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Levoy K, Ashare RL, Ganta N, O'Connor N, Meghani SH. Caregiver Engagement in Serious Illness Communication in a Long-Term Acute Care Hospital Setting. Am J Hosp Palliat Care 2024; 41:1109-1119. [PMID: 38100624 DOI: 10.1177/10499091231219799] [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: 12/17/2023] Open
Abstract
CONTEXT Prolonged management of critical illnesses in long-term acute care hospitals (LTACH) makes serious illness communication (SIC), a clinical imperative. SIC in LTACH is challenging as clinicians often lack training and patients are typically unable to participate-making caregivers central. OBJECTIVES This qualitative descriptive study characterized caregiver engagement in SIC encounters, while considering influencing factors, following the implementation of Ariadne Labs' SIC training at a LTACH in the Northeastern United States. METHODS Clinicians' documented SIC notes (2019-2020) were analyzed using directed content analysis. Codes were grouped into four categories generated from two factors that influence SIC-evidence of prognostic understanding (yes/no) and documented preferences (yes/no)-and caregiver engagement themes identified within each category. RESULTS Across 125 patient cases, 251 SIC notes were analyzed. In the presence of prognostic understanding and documented preferences, caregivers acted as upholders of patients' wishes (29%). With prognostic understanding but undocumented preferences, caregivers were postponers of healthcare decision-making (34%). When lacking prognostic understanding but having documented preferences, caregivers tended to be searchers, intent on identifying continued treatment options (13%). With poor prognostic understanding and undocumented preferences, caregivers were strugglers, having difficulty with the clinicians or family unit over healthcare decision-making (21%). CONCLUSION The findings suggest that two factors-prognostic understanding and documented preferences-are critical factors clinicians can leverage in tailoring SIC to meet caregivers' SIC needs in the LTACH setting. Such strategies shift attention away from SIC content alone toward factors that influence caregivers' ability to meaningfully engage in SIC to advance healthcare decision-making.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Rebecca L Ashare
- Department of Psychology, State University of New York at Buffalo, Buffalo, NY, USA
| | - Niharika Ganta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nina O'Connor
- Temple Center for Population Health, Temple Health, Philadelphia, PA, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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2
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Edwards ST, O'Neill A, Niederhausen M, Salvi A, Laliberte A, Saha S, Hynes DM, Pizer S, Kinosian B. Trajectories of care and outcomes of Veterans receiving home-based primary care. J Am Geriatr Soc 2024; 72:80-90. [PMID: 37772617 DOI: 10.1111/jgs.18607] [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] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described. METHODS We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps. RESULTS We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care. CONCLUSIONS HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.
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Affiliation(s)
- Samuel T Edwards
- Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon, USA
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Allison O'Neill
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health and Science University - Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Apoorva Salvi
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Avery Laliberte
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Somnath Saha
- Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
- Health Management and Policy Program, School of Public Health and Nutrition, College of Health, Oregon State University, Corvallis, Oregon, USA
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Steven Pizer
- Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- Partnered Evidence-Based Policy Resource Center, Department of Veterans Affairs, Boston, Massachusetts, USA
| | - Bruce Kinosian
- Division of Geriatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Geriatrics and Extended Care Data Analysis Center, Cpl Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Deyhim N, Saini A, Beck A, Everett NS, Agbara EI. A hospital within a hospital: An innovative pharmacy model to improve the continuum of care. Am J Health Syst Pharm 2023; 80:1364-1370. [PMID: 37280157 DOI: 10.1093/ajhp/zxad131] [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] [Received: 06/05/2023] [Indexed: 06/08/2023] Open
Abstract
PURPOSE To describe the implementation of a contracted pharmacy service model for a co-located long-term acute care hospital (LTAC). SUMMARY Historically, most LTACs have been free-standing healthcare facilities, but there is an increased trend towards the co-located LTAC ("hospital within a hospital") model. Co-located LTACs represent a solution for the management of patient throughput within a health system, with optimized bed capacity at the host hospital, increased revenue under a prospective payment system, and reduced readmission rates. A co-located LTAC will likely share resources with the host hospital, including ancillary departments such as pharmacy services, through a contractual model. Operationalization of pharmacy services in a co-located LTAC presents unique challenges in the integration of pharmacy services. Pharmacy leaders at Houston Methodist collaborated with executive leadership and other healthcare disciplines to expand services from a free-standing LTAC to a co-located LTAC at the academic medical center location. The contracted pharmacy service operationalization processes in the co-located LTAC comprised licensure and regulations, accreditation, information technology enhancements, a staffing model, operations/distribution services, clinical services, and a defined quality reporting structure. Admissions from the host hospital to the LTAC consisted of patients requiring long-term antibiotic administrations, pre- and post-organ transplant care, complex wound care, oncologic-related treatment, and neurological rehabilitation for strengthening and continued care. CONCLUSION The framework described here offers guidance to health-system pharmacy departments to support establishment of a co-located LTAC. The case study outlines challenges, considerations, and processes for implementation of a successful contracted pharmacy service model.
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Affiliation(s)
- Niaz Deyhim
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, TX, and Department of Pharmacy Services, Houston Methodist Continuing Care Hospital - Texas Medical Center, Houston, TX, USA
| | - Anita Saini
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, TX, and Department of Pharmacy Services, Houston Methodist Continuing Care Hospital - Texas Medical Center, Houston, TX, USA
| | - Amanda Beck
- Department of Pharmacy Services, Houston Methodist Hospital, Houston, TX, USA
| | | | - Echefula I Agbara
- Department of Pharmacy Services, Houston Methodist West Hospital, Houston, TX
- Department of Pharmacy Services, Houston Methodist Continuing Care Hospital, Katy, TX, USA
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Abunasser JJ, Perez O, Wang X, Wang Y, Khouli H, Duggal A. One-Year Outcomes of Patients Requiring Tracheostomy Placement Due to Severe Acute Respiratory Syndrome Coronavirus 2 Infection. Crit Care Explor 2023; 5:e0951. [PMID: 37546232 PMCID: PMC10400056 DOI: 10.1097/cce.0000000000000951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes (COVID-19) have resulted in an increase in critical illness and in the prevalence of acute respiratory failure with the need for tracheostomy. The characteristics and long-term outcomes of this patient cohort are not well identified. RESEARCH QUESTION What are the characteristics of patients who develop the need for tracheostomy due to SARS-CoV-2 with acute respiratory distress syndrome (ARDS)? What is their 90-day and 1-year survival and are there any identifiable risk factors for mortality and ventilator dependency? STUDY DESIGN AND METHODS Retrospective, follow-up cohort study of adult patients with COVID-19 infection and ARDS who required tracheostomy placement in a large healthcare system. RESULTS One hundred sixty-four consecutive patients with SARS-CoV-2 admitted to ICUs for ARDS who required tracheostomy placement between March 2020 and March 2021 were identified. One hundred nine (66.5%) were male. Average age was 63.5 years. The most common comorbidities were obesity, hypertension, diabetes mellitus, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and asthma. The most common complications during hospitalization were delirium, secondary infections, acute kidney injury, pneumothorax, and venous thromboembolism. Ninety-day and 1-year mortality were 29.9% and 44.5%, respectively. Ninety-six patients (58.5%) were liberated from the ventilator, and 84 (51.2%) had the tracheostomy tube decannulated. Asthma, COPD, atrial fibrillation, and renal replacement therapy requirement in the ICU correlated with increased risk of ventilator dependency. Among survivors at 1 year, 71 patients (43.3%) were residing at home and 20 patients (12.2%) remained in a skilled nursing facility. INTERPRETATION COVID-19 has resulted in a significant burden of acute critical illness and acute respiratory failure with the need for tracheostomy. A significant percentage of patients with SARS-CoV-2 requiring tracheostomy were alive and at home 1 year after tracheostomy placement. Long-term care support, including tracheostomy, beyond 90 days appears to be beneficial in this patient population and warrants further investigation.
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Affiliation(s)
- Jafar J Abunasser
- Respiratory Institute, Department of Critical Care, Cleveland Clinic, Cleveland, OH
| | - Oscar Perez
- Respiratory Institute, Department of Critical Care, Cleveland Clinic, Cleveland, OH
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Yifan Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Hassan Khouli
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Abhijit Duggal
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
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Holod AF, Choi J, Tate J. Optimizing Recovery Following Critical Illness: A Systematic Review of Home-Based Interventions. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2022. [DOI: 10.1177/10848223221127440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Around 5 million Americans are treated in an intensive care unit (ICU) annually. Upon discharge, it is not uncommon for ICU survivors to experience psychological, physical, or cognitive symptoms related to their ICU stay. Home-based interventions have been touted as a potential treatment modality for post-ICU sequelae. However, limited evidence exists regarding the effectiveness of home-based interventions for patients in the post-ICU recovery period. As such, the purpose of this review was to aggregate and summarize the findings of studies focused on post-ICU rehabilitation, following critical illness, delivered in the home setting. A literature search was performed in MEDLINE, CINAHL, EMBASE, APA PsycINFO, and Google Scholar. Studies were included if they: used a RCT or quasi-experimental study design; included participants aged ≥18 years discharged home from an ICU; examined the effectiveness of a home-based, post-ICU intervention; were published in English after the year 2010; and were peer-reviewed. Nine studies met inclusion criteria. Sample sizes ranged from 21 to 386, with most participants receiving mechanical ventilation. Target outcomes included: physical function, psychological well-being, cognitive function, quality of life, and healthcare utilization. Interventions included face-to-face, web-based, telephone, or self-directed activities. Findings of included studies were mixed or inconclusive. Limitations of this review include: inclusion of only adult ICU survivors, exclusion of Post-Intensive Care Syndrome as a search term, and search restricted to pre-pandemic studies. Findings suggest a need for more rigorous research to develop and test home-based interventions.
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Affiliation(s)
- Alicia F. Holod
- The Ohio State University College of Nursing, Columbus, OH, USA
| | - JiYeon Choi
- Yonsei University College of Nursing, Seoul, South Korea
| | - Judith Tate
- The Ohio State University College of Nursing, Columbus, OH, USA
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Morgan P. The Role of the Long-Term Acute Care Hospital Following Critical Illness-Has the Coronavirus Disease 2019 Pandemic Demonstrated Their Usefulness or Emphasized Their Downside? Crit Care Med 2022; 50:341-343. [PMID: 34259669 PMCID: PMC8796831 DOI: 10.1097/ccm.0000000000005206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Paul Morgan
- Critical Care Directorate, University Hospital of Wales, Cardiff, Wales, United Kingdom
- Cardiff and Vale University Local Health Board, Heath Park, Cardiff, Wales, United Kingdom
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Auriemma CL, Taylor SP, Harhay MO, Courtright KR, Halpern SD. Hospital-free Days: A Pragmatic and Patient-centered Outcome for Trials Among Critically and Seriously Ill Patients. Am J Respir Crit Care Med 2021; 204:902-909. [PMID: 34319848 DOI: 10.1164/rccm.202104-1063pp] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hospital-free days (HFDs), alternatively known as "days alive and outside the hospital," is increasingly used as a primary or secondary outcome in randomized trials among critically and seriously ill patients. This novel outcome measure addresses an existing gap in the availability of patient-centered, reliably obtained outcome measures among patients with acute respiratory failure, advanced lung diseases, lung transplantation, and other serious and critical illnesses. Traditional outcomes such as mortality, organ-failure-free days, and longitudinal patient-reported measures have distinct drawbacks that limit their suitability as endpoints in trials of patients with serious illness, particularly those trials with pragmatic designs. By contrast, HFDs provides a summary measure of important health events and is easily calculated from administrative or electronic health record data, thereby balancing the goals of patient-centeredness and pragmatic measurement. However, before HFDs can be widely adopted as an endpoint in trials of patients with respiratory and critical illnesses, several questions must be addressed regarding the optimal definition, measurement, and analysis of HFDs. In this perspective, we outline important considerations relevant to the use of HFDs as a trial endpoint and suggest directions for further development of the measure.
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Affiliation(s)
- Catherine L Auriemma
- University of Pennsylvania, 6572, Medicine, Philadelphia, Pennsylvania, United States;
| | | | - Michael O Harhay
- University of Pennsylvania, Biostatistics, Epidemiology and Informatics, Philadelphia, Pennsylvania, United States
| | - Katherine R Courtright
- University of Pennsylvania Perelman School of Medicine, 14640, Medicine, Philadelphia, Pennsylvania, United States
| | - Scott D Halpern
- University of Pennsylvania Perelman School of Medicine, 14640, Philadelphia, Pennsylvania, United States
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Sumarsono N, Sudore RL, Smith AK, Pantilat SZ, Anderson WG, Makam AN. Availability of Palliative Care in Long-Term Acute Care Hospitals. J Am Med Dir Assoc 2021; 22:2207-2211. [PMID: 33965406 PMCID: PMC10186213 DOI: 10.1016/j.jamda.2021.04.007] [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: 11/30/2020] [Revised: 03/30/2021] [Accepted: 04/03/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the availability of palliative care programs in long-term acute care hospitals (LTACHs) DESIGN: Cross-sectional analysis using the 2016 American Hospital Association (AHA) Annual Survey. SETTING AND PARTICIPANTS LTACHs in the United States. METHOD We used descriptive analyses to compare the prevalence of palliative care programs in LTACHs across the United States in 2016. For LTACHs without a program, we also examined palliative care physician capacity in regions where those LTACHs resided to evaluate if expertise existed in those regions. RESULTS One-third (36.5%) of 405 LTACHs (50.6% response rate) self-reported having a palliative care program. Among LTACHs without palliative care, 42.4% were in regions with the highest palliative care physician capacity nationwide. CONCLUSIONS AND IMPLICATIONS LTACHs care for patients with serious and prolonged illnesses, many of whom would benefit from palliative care. Despite this, our study finds that specialty palliative care is limited in LTACHs. The limited palliative care availability in LTACHs is mismatched with the needs of this seriously ill population. Greater focus on increasing palliative care in LTACHs is essential and may be feasible as 40% of LTACHs without a palliative care program were located in regions with the highest palliative care physician capacity.
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Affiliation(s)
- Nathan Sumarsono
- University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Rebecca L Sudore
- Division of Geriatrics, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Alexander K Smith
- Division of Geriatrics, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, University of California, San Francisco, CA, USA
| | - Wendy G Anderson
- Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA; Supportive and Palliative Care Program, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Anil N Makam
- Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, CA, USA.
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9
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Makam AN, Nguyen OK, Miller ME, Shah SJ, Kapinos KA, Halm EA. Comparative effectiveness of long-term acute care hospital versus skilled nursing facility transfer. BMC Health Serv Res 2020; 20:1032. [PMID: 33176767 PMCID: PMC7656509 DOI: 10.1186/s12913-020-05847-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background Long-term acute care hospital (LTACH) use varies considerably across the U.S., which may reflect uncertainty about the effectiveness of LTACHs vs. skilled nursing facilities (SNF), the principal post-acute care alternative. Given that LTACHs provide more intensive care and thus receive over triple the reimbursement of SNFs for comparable diagnoses, we sought to compare outcomes and spending between LTACH versus SNF transfer. Methods Using Medicare claims linked to electronic health record (EHR) data from six Texas Hospitals between 2009 and 2010, we conducted a retrospective cohort study of patients hospitalized on a medicine service in a high-LTACH use region and discharged to either an LTACH or SNF and followed for one year. The primary outcomes included mortality, 60-day recovery without inpatient care, days at home, and healthcare spending Results Of 3503 patients, 18% were transferred to an LTACH. Patients transferred to LTACHs were younger (median 71 vs. 82 years), less likely to be female (50.5 vs 66.6%) and white (69.0 vs. 84.1%), but were sicker (24.3 vs. 14.2% for prolonged intensive care unit stay; median diagnosis resource intensity weight of 2.03 vs. 1.38). In unadjusted analyses, patients transferred to an LTACH vs. SNF were less likely to survive (59.1 vs. 65.0%) or recover (62.5 vs 66.0%), and spent fewer days at home (186 vs. 200). Adjusting for demographic and clinical confounders available in Medicare claims and EHR data, LTACH transfer was not significantly associated with differences in mortality (HR, 1.12, 95% CI, 0.94–1.33), recovery (SHR, 1.07, 0.93–1.23), and days spent at home (IRR, 0.96, 0.83–1.10), but was associated with greater Medicare spending ($16,689 for one year, 95% CI, $12,216–$21,162). Conclusion LTACH transfer for Medicare beneficiaries is associated with similar clinical outcomes but with higher healthcare spending compared to SNF transfer. LTACH use should be reserved for patients who require complex inpatient care and cannot be cared for in SNFs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05847-6.
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Affiliation(s)
- Anil N Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA. .,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA. .,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, San Francisco, USA.
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, San Francisco, USA.,Division of Hospital Medicine, University Hospital of UCSF, San Francisco, USA
| | - Michael E Miller
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sachin J Shah
- Division of Hospital Medicine, University of California San Francisco, San Francisco, USA
| | - Kandice A Kapinos
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.,RAND Corporation, Arlington, VA, USA
| | - Ethan A Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA
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Tapper CX, Curseen K. Rehabilitation Concerns in the Geriatric Critically Ill and Injured - Part 1. Crit Care Clin 2020; 37:117-134. [PMID: 33190765 DOI: 10.1016/j.ccc.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Elderly patients who are critically ill have unique challenges that must be considered when attempting to prognosticate survival and determine expectations for physical rehabilitation and meaningful recovery. Furthermore, frail elderly patients present unique rehabilitation and clinical challenges when suffering from critical illness. There are multiple symptoms and syndromes that affect morbidity and mortality of elderly patients who require intensive care unit management including delirium, dementia, pain, and constipation. Rehabilitation goals should be based on patient values, clinical course, and functional status. Patients and families need accurate prognostic information to choose the appropriate level of care needed after critical illness.
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Affiliation(s)
- Corey X Tapper
- Division of General Internal Medicine, Section of Palliative Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 8021, Baltimore, MD 21287, USA.
| | - Kimberly Curseen
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Supportive and Palliative Care Outpatient Services, Emory Healthcare, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA
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11
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Anderson TS, Marcantonio ER, McCarthy EP, Herzig SJ. National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia. J Am Geriatr Soc 2020; 68:2240-2248. [PMID: 32700399 DOI: 10.1111/jgs.16636] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND/OBJECTIVES Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking. DESIGN Retrospective cohort study using the National Inpatient Sample from 2012 to 2016. SETTING U.S. acute care hospitals. PARTICIPANTS A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia. MEASUREMENTS Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs. RESULTS The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community. CONCLUSION The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.
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Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ellen P McCarthy
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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12
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Nakagawa S, Abrukin L, Blinderman CD. Time-Critical Goals of Care in the Emergency Department During COVID-19: A Three-Stage Protocol. J Am Geriatr Soc 2020; 68:1913-1915. [PMID: 32557585 PMCID: PMC7323252 DOI: 10.1111/jgs.16686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Shunichi Nakagawa
- Department of Medicine, Adult Palliative Care Services, Columbia University Irving Medical Center, New York, New York, USA
| | - Liliya Abrukin
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Craig D Blinderman
- Department of Medicine, Adult Palliative Care Services, Columbia University Irving Medical Center, New York, New York, USA
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Makam AN, Nguyen OK, Halm EA. Reply to Comment on: The Clinical Course After Long-Term Acute Care Hospital Admission Among Older Medicare Beneficiaries. J Am Geriatr Soc 2020; 68:667-668. [PMID: 31903543 DOI: 10.1111/jgs.16317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/12/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Anil N Makam
- Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Oanh Kieu Nguyen
- Division of Hospital Medicine, Chan Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California
| | - Ethan A Halm
- Department of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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Dawson A, Grigonis A. Comment on: The Clinical Course after Long-term Acute Care Hospital Admission among Older Medicare Beneficiaries. J Am Geriatr Soc 2020; 68:666-667. [PMID: 31903544 DOI: 10.1111/jgs.16320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Amanda Dawson
- Select Medical, Research Unit, Inpatient Hospital Division, Mechanicsburg, Pennsylvania
| | - Antony Grigonis
- Select Medical, Quality and Healthcare Analytics Department, Inpatient Hospital Division, Mechanicsburg, Pennsylvania
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Zuckerbraun SM, Deutsch A, Eicheldinger C, Frasier AM, Loft JD, Clift JB. Risk Adjustment, Mode Adjustment, and Nonresponse Bias Analysis on Quality Measures From a Long-Term Care Hospital Experience of Care Survey. Arch Phys Med Rehabil 2020; 101:841-851. [PMID: 31904343 DOI: 10.1016/j.apmr.2019.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/14/2019] [Accepted: 11/17/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To develop a patient risk adjustment model for experience of care (EOC) quality measures for long-term care hospitals (LTCHs) that includes mode of survey administration. To assess presence of nonresponse bias in the adjusted facility-level scores. DESIGN We tested 3 modes of collecting the EOC data: mail-only, mixed (ie, mail with telephone follow-up), and in-facility. This study used sequential modeling and impact analysis, specified a risk and mode adjustment model, and evaluated presence of nonresponse after adjustment. SETTING LTCHs. PARTICIPANTS Patients (N=1364) and 69 LTCHs. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Risk and mode adjusted responses to 28 survey questions and 6 facility-level scores derived from survey responses. RESULTS Mode of data collection and patient risk variables (age, sex, overall health, overall mental health, marital status, education, race, and whether a proxy responded) were included in the model. Clinical variables were not significant. The in-facility mode was associated with significantly higher performance scores than the other modes. When the recommended risk and mode adjustment model was applied, nonresponse bias was not observed in any mode. CONCLUSIONS LTCH EOC data should be adjusted for patient risk variables including mode of data collection.
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Affiliation(s)
- Sara M Zuckerbraun
- Social, Statistical and Environmental Sciences, Survey Research Division, RTI International, Research Triangle Park, North Carolina.
| | - Anne Deutsch
- Social, Statistical and Environmental Sciences, E-Health, Quality and Analytics Division, RTI International, Research Triangle Park, North Carolina
| | - Celia Eicheldinger
- Social, Statistical and Environmental Sciences, Division for Statistical and Data Sciences, RTI International, Research Triangle Park, North Carolina
| | - Alicia M Frasier
- Social, Statistical and Environmental Sciences, Survey Research Division, RTI International, Research Triangle Park, North Carolina
| | - John D Loft
- Social, Statistical and Environmental Sciences, Survey Research Division, RTI International, Research Triangle Park, North Carolina
| | - Joseph B Clift
- Centers for Medicare & Medicaid Services, Baltimore, Maryland
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