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Li W, Li L, Ornstein KA, Morrison RS, Liu B. Spatiotemporal Patterns of Hospitalizations Among Older Adults With Co-Presence of Cancer and Dementia in US Counties: 2013-2018. J Appl Gerontol 2024; 43:601-611. [PMID: 37963605 DOI: 10.1177/07334648231213747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
We assessed the spatiotemporal patterns of hospitalization with comorbid cancer and dementia. Using the 2013-2018 inpatient claims data for Medicare fee-for-service (FFS) beneficiaries, we calculated hospitalization rates by dividing the total admissions from individuals with the co-presence of a major cancer (breast, prostate, lung, and colorectal) and dementia diagnoses with the total counts of FFS beneficiaries aged 65 or older. We identified 22 hotspots with high hospitalization rates that showed heterogeneous spatial and temporal utilization patterns. The odds of a county being a hotspot increased significantly with the county-level percentage of dual Medicare-Medicaid beneficiaries (aOR 1.05; 95% CI: 1.04-1.07) and the prevalence of cancer (aOR 1.73; 95% CI: 1.59-1.89), while decreased significantly with increasing degree of rurality (aOR .82; 95% CI: .79-.85) and decreased yearly over time (aOR .72; 95% CI: .68-.75). The identified hotspots and factors at the county-level may help understand healthcare utilization patterns and assess resource allocation for this unique patient group.
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Affiliation(s)
- Weixin Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Lihua Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Ornstein
- Center for Equity in Aging, Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
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Hua M, Guo L, Ing C, Lackraj D, Wang S, Morrison RS. Specialist Palliative Care Use and End-of-Life Care in Patients With Metastatic Cancer. J Pain Symptom Manage 2024; 67:357-365.e15. [PMID: 38278187 PMCID: PMC11032225 DOI: 10.1016/j.jpainsymman.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024]
Abstract
CONTEXT For patients with advanced cancer, high intensity treatment at the end of life is measured as a reflection of the quality of care. Use of specialist palliative care has been promoted to improve care quality, but whether its use is associated with decreased treatment intensity on a population-level is unknown. OBJECTIVES To determine whether receipt of specialist palliative care use is associated with differences in end-of-life quality metrics in patients with metastatic cancer. METHODS Retrospective propensity-matched cohort of patients age ≥ 65 who died with metastatic cancer in U.S. hospitals with palliative care programs that participated in the National Palliative Care Registry in 2018-2019. Cox proportional hazards regression was used to assess the impact of specialist palliative care on use of chemotherapy in the last 14 days of life, use of intensive care unit (ICU) in the last 30 days of life, use of hospice, and hospice enrollment ≥ three days. RESULTS After 1:2 matching, our cohort consisted of 15,878 exposed and 31,756 unexposed patients. Receipt of specialist palliative care was associated with a decrease in use of chemotherapy (adjusted hazard ratio (aHR) 0.59 [0.50-0.70]) and ICU at the end of life (aHR 0.86 [0.80-0.92]), and an increase in hospice use (aHR 1.92 [1.85-1.99]) and hospice enrollment for ≥three days (aHR 2.00 [1.93-2.07]). CONCLUSION On a population-level, use of specialist palliative care was associated with improved metrics for quality end-of-life care for patients dying with metastatic cancer, underscoring the importance of its integration into cancer care.
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Affiliation(s)
- May Hua
- Department of Anesthesiology (M.H., C.I.), College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.
| | - Ling Guo
- Department of Anesthesiology (L.G.), College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Caleb Ing
- Department of Anesthesiology (M.H., C.I.), College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Deven Lackraj
- Department of Anesthesiology (D.L.), Columbia University College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Shuang Wang
- Department of Biostatistics (S.W.), Mailman School of Public Health, Columbia University, New York, New York, USA
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai and James J Peters VA (R.S.M.), Bronx, New York, USA
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Reckrey JM, McKendrick K, Morrison RS, Osakwe ZT, Ornstein KA, Aldridge M. Variation in Hospice Aide Care by Residential Setting. J Palliat Med 2024. [PMID: 38647702 DOI: 10.1089/jpm.2023.0585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Background: Hospice care frequently includes hands-on care from hospice aides, but the need for hospice aide care may vary in residential settings (e.g., assisted livings and nursing homes). Objectives: The objective of this study is to compare hospice aide use and factors associated with use across residential settings. Design: This longitudinal cohort study used data from Medicare beneficiaries in the United States enrolled in the Medicare Current Beneficiary Survey (MCBS) who died between 2010 and 2019 and had hospice claims and available residential setting data in MCBS (n = 1,915). Analysis: Decedent hospice aide use was compared by residential settings; multivariable models controlling for sociodemographic, clinical/functional, and hospice characteristics examined factors associated with hospice aide care in different residential settings. Results: Hospice aide visits were least common in the community setting (64.4% vs. 76.6% vs. 72.6% with any hospice aide visits in community, assisted living, and nursing home, respectively, p = 0.001). In adjusted models, factors associated with hospice aide visits did not significantly differ by residential settings. Conclusions: Despite staff providing hands-on support in assisted livings and nursing homes, hospice aide visits were more common in residential as opposed to community settings, and factors associated with hospice aide visits were similar among settings. To maximize the potentially positive impact of hospice aides on overall care, additional work is needed to understand when hospice aides are used and how hospice aides collaborate with families and care teams. This will help to ensure that hospice care is appropriately tailored to individual care needs in all residential settings.
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Affiliation(s)
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zainab Toteh Osakwe
- Adelphi University College of Nursing and Public Health, New York, New York, USA
| | | | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Smith S, Brick A, Johnston B, Ryan K, McQuillan R, O'Hara S, May P, Droog E, Daveson B, Morrison RS, Higginson IJ, Normand C. Place of Death for Adults Receiving Specialist Palliative Care in Their Last 3 Months of Life: Factors Associated With Preferred Place, Actual Place, and Place of Death Congruence. J Palliat Care 2024:8258597241231042. [PMID: 38404130 DOI: 10.1177/08258597241231042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Objectives: Congruence between the preferred and actual place of death is recognised as an important quality indicator in end-of-life care. However, there may be complexities about preferences that are ignored in summary congruence measures. This article examined factors associated with preferred place of death, actual place of death, and congruence for a sample of patients who had received specialist palliative care in the last three months of life in Ireland. Methods: This article analysed merged data from two previously published mortality follow-back surveys: Economic Evaluation of Palliative Care in Ireland (EEPCI); Irish component of International Access, Rights and Empowerment (IARE I). Logistic regression models examined factors associated with (a) preferences for home death versus institutional setting, (b) home death versus hospital death, and (c) congruent versus non-congruent death. Setting: Four regions with differing levels of specialist palliative care development in Ireland. Participants: Mean age 77, 50% female/male, 19% living alone, 64% main diagnosis cancer. Data collected 2011-2015, regression model sample sizes: n = 342-351. Results: Congruence between preferred and actual place of death in the raw merged dataset was 51%. Patients living alone were significantly less likely to prefer home versus institution death (OR 0.389, 95%CI 0.157-0.961), less likely to die at home (OR 0.383, 95%CI 0.274-0.536), but had no significant association with congruence. Conclusions: The findings highlight the value in examining place of death preferences as well as congruence, because preferences may be influenced by what is feasible rather than what patients would like. The analyses also underline the importance of well-resourced community-based supports, including homecare, facilitating hospital discharge, and management of complex (eg, non-cancer) conditions, to facilitate patients to die in their preferred place.
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Affiliation(s)
- Samantha Smith
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Aoife Brick
- Social Research Division, Economic and Social Research Institute, Dublin, Ireland
- Department of Economics, Trinity College Dublin, Dublin, Ireland
| | - Bridget Johnston
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Karen Ryan
- School of Medicine, University College Dublin, Dublin, Ireland
- St Francis Hospice, Dublin, Ireland
| | - Regina McQuillan
- St Francis Hospice, Dublin, Ireland
- Department of Palliative Care, Beaumont Hospital, Dublin, Ireland
| | - Sinead O'Hara
- Healthcare Pricing Office, Health Service Executive, Dublin, Ireland
| | - Peter May
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Elsa Droog
- National Office of Quality & Patient Safety, Health Service Executive, Cork, Ireland
| | - Barbara Daveson
- Palliative Care Outcomes Collaboration, University of Wollongong, Wollongong, New South Wales, Australia
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, USA and James J Peters VA Medical Center, Bronx, USA
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Charles Normand
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
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Reckrey JM, Kleijwegt H, Morrison RS, Nothelle S, Kelley AS, Ornstein KA. Paid Care for People with Functional Impairment and Serious Illness: Results from the Health and Retirement Study. J Gen Intern Med 2023; 38:3355-3361. [PMID: 37349637 PMCID: PMC10681964 DOI: 10.1007/s11606-023-08262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Paid caregivers (e.g., home health aides) care for individuals living at home with functional impairment and serious illnesses (health conditions with high risk of mortality that impact function and quality of life). OBJECTIVE To characterize those who receive paid care and identify factors associated with receipt of paid care in the context of serious illness and socioeconomic status. DESIGN Retrospective cohort study. PARTICIPANTS Community-dwelling participants ≥ 65 years enrolled in the Health and Retirement Study (HRS) between 1998 and 2018 with new-onset functional impairment (e.g., bathing, dressing) and linked fee-for-service Medicare claims (n = 2521). MAIN MEASURES Dementia was identified using HRS responses and non-dementia serious illness (e.g., advanced cancer, end-stage renal disease) was identified using Medicare claims. Paid care support was identified using HRS survey report of paid help with functional tasks. KEY RESULTS While about 27% of the sample received paid care, those with both dementia and non-dementia serious illnesses in addition to functional impairment received the most paid care (41.7% received ≥ 40 h of paid care per week). In multivariable models, those with Medicaid were more likely to receive any paid care (p < 0.001), but those in the highest income quartile received more hours of paid care (p = 0.05) when paid care was present. Those with non-dementia serious illness were more likely to receive any paid care (p < 0.001), but those with dementia received more hours of care (p < 0.001) when paid care was present. CONCLUSIONS Paid caregivers play a significant role in meeting the care needs of those with functional impairment and serious illness and high paid care hours are common among those with dementia in particular. Future work should explore how paid caregivers can collaborate with families and healthcare teams to improve the health and well-being of the seriously ill throughout the income spectrum.
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Affiliation(s)
| | | | | | | | - Amy S Kelley
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Ornstein
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Equity in Aging, Johns Hopkins University School of Nursing, Baltimore, MD, USA
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Blum M, Zeng L, Chai E, Morrison RS, Gelfman LP. Using Functional Status at the Time of Palliative Care Consult to Identify Opportunities for Earlier Referral. J Palliat Med 2023; 26:1398-1400. [PMID: 37440176 PMCID: PMC10541928 DOI: 10.1089/jpm.2023.0265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/14/2023] Open
Abstract
Background: In order to improve early access to palliative care, strategies for monitoring referral practices in real-time are needed. Objective: To evaluate how Australia-Modified Karnofsky Performance Status (AKPS) at the time of initial palliative care consult differs between serious illnesses and could be used to identify opportunities for earlier referral. Methods: We retrospectively evaluated data from an inpatient palliative care consult registry. Serious illnesses were classified using ICD-10 codes. AKPS was assessed by palliative care clinicians during consult. Results: The AKPS distribution varied substantially between the different serious illnesses (p < 0.001). While patients with cancer and heart disease often had preserved functional status, the majority of patients with dementia, neurological, lung, liver, and renal disease were already completely bedbound at the time of initial palliative care consult. Conclusion: Measuring functional status at the time of palliative care referral could be helpful for monitoring referral practices and identifying opportunities for earlier referral.
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Affiliation(s)
- Moritz Blum
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Li Zeng
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center (GRECC), Bronx, New York, USA
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center (GRECC), Bronx, New York, USA
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Aldridge MD, Hunt LJ, Harrison KL, McKendrick K, Li L, Morrison RS. Health Care Costs Associated With Hospice Use For People With Dementia In The US. Health Aff (Millwood) 2023; 42:1250-1259. [PMID: 37669483 DOI: 10.1377/hlthaff.2023.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Policy makers in the US are increasingly concerned that greater use of the Medicare hospice benefit by people with dementia is driving up costs. Yet this perspective fails to incorporate potential cost savings associated with hospice. We estimated the association between hospice use by people with dementia and health care costs, using Medicare Current Beneficiary Survey data from the period 2002-19. For community-dwelling people with dementia, Medicare costs were lower for those who used hospice than for those who did not, whether hospice enrollment was in the last three days ($2,200) or last three months ($7,200) of life, primarily through lower inpatient care costs in the last days of life. In nursing homes, total and Medicare costs were lower for hospice users with dementia who enrolled within a month of death than for those who did not use hospice. Total costs for the entire last year of life for those who used any days of hospice in the last year compared with no hospice did not differ, although Medicare costs were higher and Medicaid costs lower for those in nursing homes. Medicare policies that reduce hospice access and incentivize hospice disenrollment may actually increase Medicare costs, given that hospice cost savings generally derive from a person's last days or weeks of life.
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Affiliation(s)
- Melissa D Aldridge
- Melissa D. Aldridge , Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center, Bronx, New York
| | - Lauren J Hunt
- Lauren J. Hunt, University of California San Francisco, San Francisco, California
| | | | | | - Lihua Li
- Lihua Li, Icahn School of Medicine at Mount Sinai
| | - R Sean Morrison
- R. Sean Morrison, Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center
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Buehler NJ, Frydman JL, Morrison RS, Gelfman LP. An Update: National Institutes of Health Research Funding for Palliative Medicine 2016-2020. J Palliat Med 2023; 26:509-516. [PMID: 36306522 PMCID: PMC10066773 DOI: 10.1089/jpm.2022.0316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 01/27/2023] Open
Abstract
Background: The evidence base to support palliative care clinical practice is inadequate and opportunities to improve the evidence base remain despite the field's rapid growth. Objective: The aim of this study was to examine current National Institutes of Health (NIH) funding of palliative medicine research and trends over time. Design: We sought to identify NIH funding of palliative medicine (2016-2020) in two stages: (1) we searched the NIH grant database, RePORTER, for grants with the keywords, "palliative care," "end-of-life care," "hospice," and "end of life," and (2) identified palliative care researchers likely to have secured NIH funding using three strategies. Methods: We abstracted (1) the first and last authors' names from original investigations published in major palliative medicine journals from 2016 to 2018; (2) names from a PubMed-generated list of original articles published in major medicine, nursing, and subspecialty journals using the above keywords; and (3) palliative medicine journal editorial board members and members of key palliative medicine initiatives. We cross-matched the pooled names against NIH grants funded from 2016 to 2021. Results: A crosswalk analysis of the author search and NIH RePORTER search identified 1658 grants. Of those, 541 were categorized as relevant to palliative medicine, which represented 419 unique principal investigators (mean of 1.34 grants per investigator). Compared with 2011-2015, the number of NIH-funded grants increased by 25%, NIH dollars increased by 35%, and the distribution of grant types remained stable. Conclusions: Despite the challenging NIH funding climate, the number of NIH grants and funding to palliative care have increased. Given the increased funding allocation toward Alzheimer's dementia and related dementia research at the congressional level, this increase in funding reflects this funding allocation and does not represent overall growth. Dedicated federal funding for palliative care research remains critical to grow the evidence base for persons living with serious illnesses and their families.
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Affiliation(s)
| | - Julia L. Frydman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- The National Palliative Care Research Center, New York, New York, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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Baim-Lance A, Ferreira KB, Cohen HJ, Ellenberg SS, Kuchel GA, Ritchie C, Sachs GA, Kitzman D, Morrison RS, Siu A. Improving the Approach to Defining, Classifying, Reporting and Monitoring Adverse Events in Seriously Ill Older Adults: Recommendations from a Multi-stakeholder Convening. J Gen Intern Med 2023; 38:399-405. [PMID: 35581446 PMCID: PMC9905384 DOI: 10.1007/s11606-022-07646-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Clinical trials are needed to study topics relevant to older adults with serious illness. Investigators conducting clinical trials with this population are challenged by how to appropriately define, classify, report, and monitor serious and non-serious adverse events (SAEs/AEs), given that some traditionally reported AEs (pressure ulcers, delirium) and SAEs (death, hospitalization) are common in persons with serious illness, and may be consistent with their goals of care. OBJECTIVES A multi-stakeholder group convened to establish greater clarity on and new approaches to address this critical issue. PARTICIPANTS Thirty-two study investigators, members of regulatory and sponsor agencies, and patient stakeholders took part. APPROACH The group met virtually four times and, using a collaborative approach, conducted a survey, select interviews, and reviewed regulatory guidance to collectively define the problem and identify a new approach. RESULTS SAE/AE challenges fell into two areas: (1) definitions and classifications, including (a) implausible relationships, (b) misalignment with patient-centered care goals, and (c) well-known associations, and (2) reporting and monitoring, including (a) limited guidance, (b) inconsistent standards across regulators, and (c) Data Safety Monitoring Board (DSMB) member knowledge gaps. Problems largely reflected practice norms rather than regulatory requirements that already support context-specific and aggregate reporting. Approaches can be improved by adopting principles that better align strategies for addressing adverse events with the type of intervention being tested, favoring routine and aggregate over expedited reporting, and prioritizing how SAE/AEs relate to patient-centered care goals. Reporting plans and decisions should follow an algorithm underpinned by these principles. CONCLUSIONS Adoption of the proposed approach-and supporting it with education and better alignment with regulatory guidance and procedures-could improve the quality and efficiency of clinical trials' safety involving older adults with serious illness and other vulnerable populations.
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Affiliation(s)
- Abigail Baim-Lance
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA.
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA.
| | - Katelyn B Ferreira
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut, Farmington, CT, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine and the Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Greg A Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dalane Kitzman
- Department of Internal Medicine: Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA
| | - Albert Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA
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Hunt LJ, Morrison RS, Gan S, Espejo E, Ornstein KA, Boscardin WJ, Smith AK. Incidence of potentially disruptive medical and social events in older adults with and without dementia. J Am Geriatr Soc 2022; 70:1461-1470. [PMID: 35122662 PMCID: PMC9106866 DOI: 10.1111/jgs.17682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/07/2022] [Accepted: 01/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Potentially disruptive medical, surgical, and social events-such as pneumonia, hip fracture, and widowhood-may accelerate the trajectory of decline and impact caregiving needs in older adults, especially among people with dementia (PWD). Prior research has focused primarily on nursing home residents with dementia. We sought to assess the incidence of potentially disruptive events in community-dwelling people with and without dementia. METHODS Retrospective cohort study of participants aged 65+ enrolled in the Health and Retirement Study between 2010 and 2018 (n = 9346), including a subset who were married-partnered at baseline (n = 5105). Dementia was defined with a previously validated algorithm. We calculated age-adjusted and gender-stratified incidence per 1000 person-years and incidence rate ratios of: 1) hospitalization for pneumonia, 2) hip fracture, and 3) widowhood in people with and without dementia. RESULTS PWD (n = 596) were older (mean age 84 vs. 75) and a higher proportion were female (67% vs. 57%) than people without dementia (PWoD) (n = 8750). Age-adjusted incidence rates (per 1000 person-years) of pneumonia were higher in PWD (113.1; 95% CI 94.3, 131.9) compared to PWoD (62.1; 95% CI 54.7, 69.5), as were hip fractures (12.3; 95% CI 9.1, 15.6 for PWD compared to 8.1; 95% CI 6.9, 9.2 in PWoD). Point estimates of widowhood incidence were slightly higher for PWD (25.3; 95% CI 20.1, 30.5) compared to PWoD (21.9; 95% CI 20.3, 23.5), but differences were not statistically significant. The association of dementia with hip fracture-but not pneumonia or widowhood-was modified by gender (male incidence rate ratio [IRR] 2.24, 95% CI 1.34, 3.75 versus female IRR 1.31 95% CI 0.92,1.86); interaction term p = 0.02). CONCLUSIONS Compared to PWoD, community-dwelling PWD had higher rates of pneumonia and hip fracture, but not widowhood. Knowing how often PWD experience these events can aid in anticipatory guidance and care planning for this growing population.
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Affiliation(s)
- Lauren J Hunt
- Department of Physiological Nursing, University of California, San Francisco, California, USA.,Global Brain Health Institute, University of California, San Francisco, California, USA
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peters VA Medical Center, Bronx, New York, USA
| | - Siqi Gan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Edie Espejo
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - Katherine A Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA.,Department of Epidemiology & Biostatistics, University of California, San Francisco, California, USA
| | - Alexander K Smith
- James J. Peters VA Medical Center, Bronx, New York, USA.,Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
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11
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Reckrey JM, Ornstein KA, McKendrick K, Tsui EK, Morrison RS, Aldridge M. Receipt of Hospice Aide Visits Among Medicare Beneficiaries Receiving Home Hospice Care. J Pain Symptom Manage 2022; 63:503-511. [PMID: 34954065 PMCID: PMC8930441 DOI: 10.1016/j.jpainsymman.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Hospice aides provide essential direct care to hospice patients, yet there is minimal research examining hospice aide visits. OBJECTIVES describe the prevalence and frequency of hospice aide visits, and 2) evaluate patient, community, and hospice characteristics associated with these visits. METHODS Longitudinal cohort study of Medicare Current Beneficiary Survey (MCBS) participants who died between 2010-2018 and received routine hospice care in the 6 months prior to death (n = 674). We characterized prevalence and frequency of hospice aide visits over time and used generalized linear modelling to identify factors associated with visits. RESULTS 64% of hospice enrollees received hospice aide visits and average visit frequency (1.3 per week) remained stable throughout enrollment. The only patient characteristic associated with receipt of hospice aide visits was primary hospice diagnosis (respiratory diagnosis vs. dementia: OR 0.372, P = 0.040). Those living in community-based residential housing and those cared for by hospices with aides employed as staff were more likely to receive any hospice aide visits (OR 2.331, P = 0.047 and OR 4.612, P = 0.002, respectively.) CONCLUSION: Hospice aide visits are a common component of hospice care, but visit frequency does not increase as death approaches. Receipt of hospice aide visits was primarily associated with community and hospice agency (rather than patient) characteristics. Future work is needed to ensure that hospice aides are integrated in the hospice interdisciplinary team and that access to hospice aide visits is meaningfully driven by patient and family needs, rather than the practice norms and business models of individual hospice agencies.
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Affiliation(s)
- Jennifer M Reckrey
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York.
| | - Katherine A Ornstein
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York
| | - Emma K Tsui
- CUNY Graduate School of Health and Health Policy (E.K..T.), New York, New York
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York; James J. Peters VA Medical Center (R.S.M., M.A.), Bronx, New York, USA
| | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York; James J. Peters VA Medical Center (R.S.M., M.A.), Bronx, New York, USA
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12
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Affiliation(s)
| | - Diane E Meier
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert M Arnold
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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13
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Jacobson M, May P, Morrison RS. Improving Care of People With Serious Medical Illness—An Economic Research Agenda for Palliative Care. JAMA Health Forum 2022; 3:e214464. [DOI: 10.1001/jamahealthforum.2021.4464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mireille Jacobson
- Aging Program, University of Southern California Schaeffer Center for Health Policy & Economics, University of Southern California Leonard Davis School of Gerontology, Los Angeles
| | - Peter May
- Centre for Health Policy and Management, Trinity College Dublin, the Irish Longitudinal Study on Ageing, Dublin, Ireland
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, Patty and Jay Baker National Palliative Care Center, New York, New York
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14
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Frydman JL, Aldridge M, Moreno J, Singer J, Zeng L, Chai E, Morrison RS, Gelfman LP. Access to Palliative Care Consultation for Hospitalized Adults with COVID-19 in an Urban Health System: Were There Disparities at the Peak of the Pandemic? J Palliat Med 2022; 25:124-129. [PMID: 34637349 PMCID: PMC8721492 DOI: 10.1089/jpm.2021.0313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Palliative care (PC) services expanded rapidly to meet the needs of coronavirus disease 2019 (COVID-19) patients, yet little is known about which patients were referred for PC consultation during the pandemic. Objective: Examine factors predictive of PC consultation for COVID-19 patients. Design: Retrospective cohort study of COVID-19 patients discharged from four hospitals (March 1-June 30, 2020). Exposures: Patient demographic, socioeconomic, and clinical factors and hospital-level characteristics. Outcome Measurement: Inpatient PC consultation. Results: Of 4319 hospitalized COVID-19 patients, 581 (14%) received PC consultation. Increasing age, serious illness (cancer, chronic obstructive pulmonary disease, and dementia), greater illness severity, and admission to the quaternary hospital were associated with receipt of PC consultation. There was no association between PC consultation and race/ethnicity, household crowding, insurance status, or hospital-factors, including inpatient, emergency department, and intensive care unit census. Conclusions: Although site variation existed, the highest acuity patients were most likely to receive PC consultation without racial/ethnic or socioeconomic disparities.
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Affiliation(s)
- Julia L. Frydman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Address correspondence to: Julia L. Frydman, MD, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Melissa Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Singer
- Enterprise Reporting, Mount Sinai Health System, New York, New York, USA
| | - Li Zeng
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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15
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Affiliation(s)
- Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters Bronx VA Medical Center, New York, New York
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters Bronx VA Medical Center, New York, New York
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16
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Hua M, Fonseca LD, Morrison RS, Wunsch H, Fullilove R, White DB. What Affects Adoption of Specialty Palliative Care in Intensive Care Units: A Qualitative Study. J Pain Symptom Manage 2021; 62:1273-1282. [PMID: 34182102 PMCID: PMC8648909 DOI: 10.1016/j.jpainsymman.2021.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/10/2021] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Although many patients with critical illness may benefit from involvement of palliative care specialists, adoption of these services in the intensive care unit (ICU) is variable. OBJECTIVE To characterize reasons for variable buy-in for specialty palliative care in the ICU, and identify factors associated with routine involvement of specialists in appropriate cases. METHODS Qualitative study using in-depth, semi-structured interviews with ICU attendings, nurses, and palliative care clinicians, purposively sampled from eight ICUs (medical, surgical, cardiothoracic, neurological) with variable use of palliative care services within two urban, academic medical centers. Interviews were transcribed and coded using an iterative and inductive approach with constant comparison. RESULTS We identified three types of specialty palliative care adoption in ICUs, representing different phases of buy-in. The "nascent" phase was characterized by the need for education about palliative care services and clarification of which patients may be appropriate for involvement. During the key "transitional" phase, use of specialists depended on development of "comfort and trust", which centered on four aspects of the ICU-palliative care clinician relationship: 1) increasing familiarity between clinicians; 2) navigating shared responsibility with primary clinicians; 3) having a collaborative approach to care; and 4) having successful experiences. In the "mature" phase, ICU and palliative care clinicians worked to strengthen their existing collaboration, but further adoption was limited by the availability and resources of the palliative care team. CONCLUSION This conceptual framework identifying distinct phases of adoption may assist institutions aiming to foster sustained adoption of specialty palliative care in an ICU setting.
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Affiliation(s)
- May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA.
| | - Laura D Fonseca
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA; James J Peters VA, Bronx, New York, USA
| | - Hannah Wunsch
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Fullilove
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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17
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Affiliation(s)
- R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters VA Medical Center, Bronx, New York
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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18
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Meier DE, Morrison RS. All you need is love: Yet another social determinant of health. J Am Geriatr Soc 2021; 69:3020-3022. [PMID: 34409585 DOI: 10.1111/jgs.17421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Diane E Meier
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, Center to Advance Palliative Care, New York, New York, USA.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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19
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Pelleg A, Chai E, Morrison RS, Farquhar DW, Berglund K, Gelfman LP. Expanding the Palliative Care Workforce during the COVID-19 Pandemic: An Evaluation of Core Palliative Care Skills in Health Social Workers. J Palliat Med 2021; 24:1705-1709. [PMID: 34191595 DOI: 10.1089/jpm.2021.0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Meeting the needs of seriously ill SARS-CoV-2 (COVID-19) patients requires novel models of deploying health social workers (SWs) to expand the palliative care workforce. To inform such expansion, understanding the current state of health SWs' core palliative care skills is necessary. Methods: Following minimal training, health SWs in one New York City hospital were surveyed about their frequency, competence, and confidence in using core palliative care skills. Results: Of the 170 health SWs surveyed, 46 (27%) responded, of whom 21 (46%) and 24 (52%) had palliative care training before and during the COVID-19 surge, respectively. Health SWs reported a "moderate improvement" in the use of three skills: "identify a medical decision maker," "assess prognostic understanding," and "coordinate care." There was "minimal decrease" to "no improvement" to "minimal improvement" in competence and confidence of skill use. Conclusion: Our findings suggest that educational initiatives can improve health SWs' use of core palliative care skills.
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Affiliation(s)
- Ayla Pelleg
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatrics Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Diane W Farquhar
- Department of Social Work Services, Mount Sinai Medical Center, New York, New York, USA
| | - Keisha Berglund
- Department of Social Work Services, Mount Sinai Medical Center, New York, New York, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatrics Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
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20
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Gelfman LP, Mather H, McKendrick K, Wong AY, Hutchinson MD, Lampert RJ, Lipman HI, Matlock DD, Swetz KM, Pinney SP, Morrison RS, Goldstein NE. Non-Concordance between Patient and Clinician Estimates of Prognosis in Advanced Heart Failure. J Card Fail 2021; 27:700-705. [PMID: 34088381 PMCID: PMC8186811 DOI: 10.1016/j.cardfail.2021.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Despite efforts to enhance serious illness communication, patients with advanced heart failure (HF) lack prognostic understanding. OBJECTIVES To determine rate of concordance between HF patients' estimation of their prognosis and their physician's estimate of the patient's prognosis, and to compare patient characteristics associated with concordance. DESIGN Cross-sectional analysis of a cluster randomized controlled trial with 24-month follow-up and analysis completed on 09/01/2020. Patients were enrolled in inpatient and outpatient settings between September 2011 to February 2016 and data collection continued until the last quarter of 2017. SETTING Six teaching hospitals in the U.S. PARTICIPANTS Patients with advanced HF and implantable cardioverter defibrillators (ICDs) at high risk of death. Of 537 patients in the parent study, 407 had complete data for this analysis. INTERVENTION A multi-component communication intervention on conversations between HF clinicians and their patients regarding ICD deactivation and advance care planning. MAIN OUTCOME(S) AND MEASURE(S) Patient self-report of prognosis and physician response to the "surprise question" of 12-month prognosis. Patient-physician prognostic concordance (PPPC) measured in percentage agreement and kappa. Bivariate analyses of characteristics of patients with and without PPPC. RESULTS Among 407 patients (mean age 62.1 years, 29.5% female, 42.4% non-white), 300 (73.7%) dyads had non-PPPC; of which 252 (84.0%) reported a prognosis >1 year when their physician estimated <1 year. Only 107 (26.3%) had PPPC with prognosis of ≤ 1 year (n=20 patients) or > 1 year (n=87 patients); (Κ = -0.20, p = 1.0). Of those with physician estimated prognosis of < 1 year, non-PPPC was more likely among patients with lower symptom burden- number and severity (both p ≤.001), without completed advance directive (p=.001). Among those with physician prognosis estimate > 1 year, no patient characteristic was associated with PPPC or non-PPPC. CONCLUSIONS AND RELEVANCE Non-PPPC between HF patients and their physicians is high. HF patients are more optimistic than clinicians in estimating life expectancy. These data demonstrate there are opportunities to improve the quality of prognosis disclosure between patients with advanced HF and their physicians. Interventions to improve PPPC might include serious illness communication training.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY.
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, AZ
| | - Rachel J Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine
| | - Hannah I Lipman
- Hackensack Meridian Health, Hackensack, NJ; Hackensack Meridian School of Medicine
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center; Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, AL
| | - Sean P Pinney
- Division of Cardiology, UChicago Medicine, Chicago, IL
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
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21
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Rogers MM, Meier DE, Morrison RS, Moreno J, Aldridge M. Factors Associated with the Adoption and Closure of Hospital Palliative Care Programs in the United States. J Palliat Med 2021; 24:712-718. [PMID: 33058737 PMCID: PMC8064954 DOI: 10.1089/jpm.2020.0282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 11/13/2022] Open
Abstract
Background: In the United States, the percentage of hospitals over 50 beds with palliative care programs has risen substantially from 7% of hospitals in 2001 to 72% in 2017. Yet the dynamic nature of program adoption and closure over time is not known. Objective: To examine the rate of palliative care program adoption and closure and associated hospital and geographic characteristics in a national sample of U.S. hospitals. Design: Adoption and closure rates were calculated for 3696 U.S. hospitals between 2009 and 2017. We used multivariable logistic regression models to examine the association between adoption and closure status and hospital, geographic, and community characteristics. Setting/Subjects: All nonfederal general medical and surgical, cancer, heart, and obstetric or gynecological hospitals, of all sizes, in the United States in operation in both 2009 and 2017. Results: By 2017, 34.9% (812/2327) of the hospitals without palliative care in 2009 had adopted palliative care programs, and 15.0% (205/1369) of the hospitals with programs had closed them. In multivariable models, hospitals in metropolitan areas, nonprofit and public hospitals (compared to for-profit hospitals), and those with residency training approval by the Accreditation Council for Graduate Medical Education were significantly more likely to adopt and significantly less likely to close palliative care programs during the study period. Conclusions: This study indicates that palliative care is not equitably adopted nor sustained by hospitals in the United States. Federal and state interventions may be required to ensure that high-quality care is available to our nation's sickest patients.
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Affiliation(s)
- Maggie M. Rogers
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diane E. Meier
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters VA Medical Center, Bronx, New York, USA
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22
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Morrison RS. Thank You Diane E. Meier, Director Emeritus of the Center to Advance Palliative Care. J Palliat Med 2021; 24:478-479. [PMID: 33685236 DOI: 10.1089/jpm.2021.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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23
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Chang AK, Edwards RR, Morrison RS, Argoff C, Ata A, Holt C, Bijur PE. Disparities in Acute Pain Treatment by Cognitive Status in Older Adults With Hip Fracture. J Gerontol A Biol Sci Med Sci 2021; 75:2003-2007. [PMID: 31560758 DOI: 10.1093/gerona/glz216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We examined the disparities in emergency department (ED) pain treatment based on cognitive status in older adults with an acute hip fracture. METHODS Observational study in an academic ED in the Bronx, New York. One hundred forty-four adults aged 65 years and older with acute hip fracture were administered the Telephone Interview for Cognitive Status (TICS) while in the ED. The primary outcome was receipt of any parenteral analgesic. The risk factor of interest was cognitive impairment (TICS ≤ 25). Secondary outcomes included receipt of any opioid, receipt of any analgesic, total dose of analgesics in intravenous morphine equivalent units (MEQ), and time to receiving first analgesic. RESULTS Of the 87 (60%) study patients who were cognitively impaired, 60% received a parenteral analgesic compared to 79% of the 57 cognitively unimpaired patients (RR 0.76 [95% CI 0.61, 0.94]). The effect of cognitive impairment on receiving any opioids (RR: 0.81, 95% CI 0.67, 0.98) and any analgesic (RR: 0.85; 95% CI: 0.71, 1.01) was similar. The median analgesic dose in cognitively impaired patients was significantly lower than in cognitively unimpaired patients (4 MEQ vs 8 MEQ, p = .003). CONCLUSION Among older adults presenting to the ED with acute hip fracture, cognitive impairment was independently associated with lower likelihood of receiving analgesia and lower amount of opioid analgesia.
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Affiliation(s)
- Andrew K Chang
- Department of Emergency Medicine, Albany Medical College, New York
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Charles Argoff
- Department of Neurology, Albany Medical College, New York
| | - Ashar Ata
- Department of Emergency Medicine, Albany Medical College, New York
| | - Christian Holt
- Department of Emergency Medicine, Albany Medical College, New York
| | - Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York
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24
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Dzeng E, Morrison RS. We Need a Paradigm Shift Around End-of-Life Decision Making. J Am Geriatr Soc 2021; 69:327-329. [PMID: 33170951 PMCID: PMC9376965 DOI: 10.1111/jgs.16899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 11/29/2022]
Abstract
This editorial comments on the article by Cohen et al. in this issue.
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Affiliation(s)
- Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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25
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Gelfman LP, Morrison RS, Moreno J, Chai E. Palliative Care as Essential to a Hospital System's Pandemic Preparedness Planning: How to Get Ready for the Next Wave. J Palliat Med 2020; 24:656-658. [PMID: 33373533 DOI: 10.1089/jpm.2020.0670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The sudden and unprecedented increase in seriously ill patients with COVID-19, coupled with both the lack of core palliative care training and expertise among frontline providers and the specialty-trained palliative care workforce shortage, produced immediate challenges to meet the needs of this novel seriously ill patient population. In this article, we describe the rapid expansion and creation of new specialty palliative care services across a health system to meet demands of the COVID-19 surge in New York City. During April 2020, 1019 patients received inpatient specialty palliative care consultations across the Mount Sinai Health System. This overview demonstrates how palliative care services can be titrated up rapidly to meet the acute increase in hospitalized persons with serious illness due to COVID-19, and how these services tailored to the changing needs across a health system.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Higginson IJ, Yi D, Johnston BM, Ryan K, McQuillan R, Selman L, Pantilat SZ, Daveson BA, Morrison RS, Normand C. Associations between informal care costs, care quality, carer rewards, burden and subsequent grief: the international, access, rights and empowerment mortality follow-back study of the last 3 months of life (IARE I study). BMC Med 2020; 18:344. [PMID: 33138826 PMCID: PMC7606031 DOI: 10.1186/s12916-020-01768-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND At the end of life, formal care costs are high. Informal care (IC) costs, and their effects on outcomes, are not known. This study aimed to determine the IC costs for older adults in the last 3 months of life, and their relationships with outcomes, adjusting for care quality. METHODS Mortality follow-back postal survey. SETTING Palliative care services in England (London), Ireland (Dublin) and the USA (New York, San Francisco). PARTICIPANTS Informal carers (ICrs) of decedents who had received palliative care. DATA ICrs reported hours and activities, care quality, positive aspects and burdens of caregiving, and completed the Texas Revised Inventory of Grief (TRIG). ANALYSIS All costs (formal, informal) were calculated by multiplying reported hours of activities by country-specific costs for that activity. IC costs used country-specific shadow prices, e.g. average hourly wages and unit costs for nursing care. Multivariable logistic regression analysis explored the association of potential explanatory variables, including IC costs and care quality, on three outcomes: positive aspects and burdens of caregiving, and subsequent grief. RESULTS We received 767 completed surveys, 245 from London, 282 Dublin, 131 New York and 109 San Francisco. Most respondents were women (70%); average age was 60 years. On average, patients received 66-76 h per week from ICrs for 'being on call', 52-55 h for ICrs being with them, 19-21 h for personal care, 17-21 h for household tasks, 15-18 h for medical procedures and 7-10 h for appointments. Mean (SD) IC costs were as follows: USA $32,468 (28,578), England $36,170 (31,104) and Ireland $43,760 (36,930). IC costs accounted for 58% of total (formal plus informal) costs. Higher IC costs were associated with less grief and more positive perspectives of caregiving. Poor home care was associated with greater caregiver burden. CONCLUSIONS Costs to informal carers are larger than those to formal care services for people in the last three months of life. If well supported ICrs can play a role in providing care, and this can be done without detriment to them, providing that they are helped. Improving community palliative care and informal carer support should be a focus for future investment.
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Affiliation(s)
- Irene J Higginson
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK. .,King's College Hospital Foundation Trust, Bessemer Road, London, SE5 9PJ, UK.
| | - Deokhee Yi
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.
| | - Bridget M Johnston
- The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
| | - Karen Ryan
- Mater Misericordiae Hospital, Eccles Street, Dublin 7, Ireland
| | | | - Lucy Selman
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephen Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Barbara A Daveson
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Charles Normand
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.,The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
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Morrison RS. Senior Associate Editor's Response to Readers' Comments to Morrison: Advance Directives/Care Planning: Clear, Simple, and Wrong (DOI: 10.1089/jpm.2020.0272). J Palliat Med 2020; 24:14-15. [PMID: 33095092 DOI: 10.1089/jpm.2020.0526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Abstract
IMPORTANCE Medicare Advantage (MA) insures an increasing proportion of Medicare beneficiaries, but evidence is lacking on patient or family perceptions of the quality of end-of-life care in MA vs traditional Medicare. OBJECTIVE To determine if there is a difference in quality of care reported by family and friends of individuals who died while insured by MA vs traditional Medicare at the end of life. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the 2011 to 2017 Medicare-linked National Health and Aging Trends Study to conduct population-based survey research representing 8 668 829 Medicare enrollees. Included individuals were 2119 enrollees who died when aged 65 years or older, with quality of care reported by a family member or close friend familiar with the individual's last month of life. Analysis was conducted in July 2020. EXPOSURES MA enrollment at the time of death or before hospice enrollment. MAIN OUTCOMES AND MEASURES Perception of end-of-life care was measured with 9 validated items, with the primary outcome variable being overall care rated not excellent. We conducted a propensity score-weighted multivariable model to examine the association of each item with MA vs traditional Medicare enrollment. The propensity score and multivariable model included covariates capturing demographic and socioeconomic factors, function and health, and relationship of the respondent to the individual who died. The sample was then stratified by hospice enrollment and setting of care in the last month. RESULTS Of 2119 people in the sample, 670 individuals were enrolled in MA at the time of death or prior to hospice (32.7%) and 1449 were enrolled in traditional Medicare (67.3%). In survey-weighted percentages, 53.6% (95% CI, 51.0% to 56.1%) were women and 43.4% (95% CI, 41.5% to 45.3%) were older than 85 years at the time of death. In the adjusted model, family and friends of individuals in MA were more likely to report that care was not excellent (odds ratio, 1.28; 95% CI, 1.01 to 1.61; P = .04) and that they were not kept informed (odds ratio, 1.48; 95% CI, 1.06 to 2.05; P = .02). For those in nursing homes, there was an estimated probability of 57.2% of respondents reporting that care was not excellent for individuals with traditional Medicare, compared with 77.9% of respondents for individuals with MA (marginal increase for those in MA, 0.21; 95% CI, 0.08 to 0.32; P = .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare. These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.
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Affiliation(s)
- Claire K. Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amy S. Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - R. Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vicki A. Freedman
- Michigan Center on the Demography of Aging, Institute for Social Research, University of Michigan, Ann Arbor
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland
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Reckrey JM, Tsui EK, Morrison RS, Geduldig ET, Stone RI, Ornstein KA, Federman AD. Beyond Functional Support: The Range Of Health-Related Tasks Performed In The Home By Paid Caregivers In New York. Health Aff (Millwood) 2020; 38:927-933. [PMID: 31158023 DOI: 10.1377/hlthaff.2019.00004] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paid caregivers (for example, home health aides and personal care attendants) are formally tasked with helping older adults with functional impairment meet their basic needs at home. This study used thirty semistructured interviews with dyads of patients or their proxies and their paid caregivers in New York City to understand the range of health-related tasks that paid caregivers perform in the home and determine whether these tasks are taught in the New York State Department of Health's curriculum. We found that patients, proxies, and paid caregivers all reported that paid caregivers performed a wide range of health-related tasks that were often not part of their formal training. Creating clear competencies for paid caregivers that reflect the full breadth of health-related tasks they may perform in the home could help maximize the positive impact of the paid caregiver workforce on the lives of patients living at home with functional impairment.
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Affiliation(s)
- Jennifer M Reckrey
- Jennifer M. Reckrey ( ) is an associate professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City
| | - Emma K Tsui
- Emma K. Tsui is an assistant professor of community health and social sciences at the City University of New York School of Public Health, in New York City
| | - R Sean Morrison
- R. Sean Morrison is a professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Emma T Geduldig
- Emma T. Geduldig is a student in the Department of Medical Education, Icahn School of Medicine at Mount Sinai
| | - Robyn I Stone
- Robyn I. Stone is senior vice president for research at LeadingAge, in Washington, D.C
| | - Katherine A Ornstein
- Katherine A. Ornstein is an assistant professor in the Department of Geriatrics and Palliative Medicine and the Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai
| | - Alex D Federman
- Alex D. Federman is a professor in the Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai
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Gelfman LP, Sudore RL, Mather H, McKendrick K, Hutchinson MD, Lampert RJ, Lipman HI, Matlock DD, Swetz KM, Pinney SP, Morrison RS, Goldstein NE. Prognostic Awareness and Goals of Care Discussions Among Patients With Advanced Heart Failure. Circ Heart Fail 2020; 13:e006502. [PMID: 32873058 DOI: 10.1161/circheartfailure.119.006502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prognostic awareness (PA)-the understanding of limited life expectancy-is critical for effective goals of care discussions (GOCD) in which patients discuss their goals and values in the context of their illness. Yet little is known about PA and GOCD in patients with advanced heart failure (HF). This study aims to determine the prevalence of PA among patients with advanced HF and patient characteristics associated with PA and GOCD. METHODS We assessed the prevalence of self-reported PA and GOCD using data from a multisite communication intervention trial among patients with advanced HF with an implantable cardiac defibrillator at high risk of death. RESULTS Of 377 patients (mean age 62 years, 30% female, 42% nonwhite), 78% had PA. Increasing age was a negative predictor of PA (odds ratio, 0.95 [95% CI, 0.92-0.97]; P<0.01). No other patient characteristics were associated with PA. Of those with PA, 26% had a GOCD. Higher comorbidities and prior advance directives were associated with GOCD but were of only borderline statistical significance in a fully adjusted model. Symptom severity (odds ratio, 1.77 [95% CI, 1.19-2.64]; P=0.005) remained a robust and statistically significant positive predictor of having a GOCD in the fully adjusted model. CONCLUSIONS In a sample of patients with advanced HF, the frequency of PA was high, but fewer patients with PA discussed their end-of-life care preferences with their physician. Improved efforts are needed to ensure all patients with advanced HF have an opportunity to have GOCD with their doctors. Clinicians may need to target older patients with HF and continue to focus on those with signs of worsening illness (higher symptoms). Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01459744.
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Affiliation(s)
- Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
| | - Rebecca L Sudore
- Division of Geriatrics (R.L.S.), Department of Medicine, University of California San Francisco.,Innovation and Implementation Center for Aging and Palliative Care (I-CAP), Division of Geriatrics (R.L.S.), Department of Medicine, University of California San Francisco.,San Francisco Veterans Affairs Health Care System, CA (R.L.S.)
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ (M.D.H.)
| | - Rachel J Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT (R.J.L.)
| | - Hannah I Lipman
- Hackensack University Medical Center, Hackensack, NJ (H.I.L.).,Hackensack Meridian School of Medicine at Seton Hall University, Hackensack, NJ (H.I.L.)
| | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (D.D.M.).,VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO (D.D.M.)
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama, Birmingham, AL (K.M.S.)
| | - Sean P Pinney
- Division of Cardiology, Samuel Bronfman Department of Medicine (S.P.P.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine (L.P.G., H.M., K.M., R.S.M., N.E.G.), Icahn School of Medicine at Mount Sinai, New York, NY.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (L.P.G., R.S.M., N.E.G.)
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Wichmann AB, Goltstein LCMJ, Obihara NJ, Berendsen MR, Van Houdenhoven M, Morrison RS, Johnston BM, Engels Y. QALY-time: experts' view on the use of the quality-adjusted LIFE year in COST-effectiveness analysis in palliative care. BMC Health Serv Res 2020; 20:659. [PMID: 32678021 PMCID: PMC7364560 DOI: 10.1186/s12913-020-05521-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
Background The Quality-Adjusted Life Year (QALY) is internationally recognized as standard metric of health outcomes in cost-effectiveness analyses (CEAs) in healthcare. The ongoing debate concerning the appropriateness of its use for decision-making in palliative care has been recently mapped in a review. The aim was to report on and draw conclusions from two expert meetings that reflected on earlier mapped issues in order to reach consensus, and to advise on the QALY’s future use in palliative care. Methods A nominal group approach was used. In order to facilitate group decision making, three statements regarding the use of the QALY in palliative care were discussed in a structured way. Two groups of international policymakers, healthcare professionals and researchers participated. Data were analysed qualitatively using inductive coding. Results 1) Most experts agreed that the recommended measurement tool for the QALYs ‘Q’ component, the EuroQol-5D (EQ-5D), is inappropriate for palliative care. A more sensitive tool, which might be based on the capabilities approach, could be used or developed. 2) Valuation of time should be incorporated in the ‘Q’ part, leaving the linear clock time in the ‘LY’ component. 3) Most experts agreed that the QALY, in its current shape, is not suitable for palliative care. Conclusions 1) Although the EQ-5D does not suffice, a generic tool is needed for the QALY. As long as no suitable alternative is available, other tools can be used besides or serve as basis for the EQ-5D because of issues in conceptual overlap. 2) Future research should further investigate the valuation of time issue, and how best to integrate it in the ‘Q’ component. 3) A generic outcome measure of effectiveness is essential to justly allocate healthcare resources. However, experts emphasized, the QALY is and should be one of multiple criteria for choices in the healthcare insurance package.
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Affiliation(s)
- Anne B Wichmann
- Radboud university medical centre, Department of Anaesthesiology, Pain and Palliative Medicine, Nijmegen, The Netherlands.
| | | | - Ndidi J Obihara
- Radboud University, Honours Academy, Nijmegen, The Netherlands
| | | | | | | | - Bridget M Johnston
- Trinity College Dublin, Centre for Health Policy and Management, Dublin, Ireland
| | - Y Engels
- Radboud university medical centre, Department of Anaesthesiology, Pain and Palliative Medicine, Nijmegen, The Netherlands
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Kwok IB, Mather H, McKendrick K, Gelfman L, Hutchinson MD, Lampert RJ, Lipman HI, Matlock DD, Swetz KM, Kalman J, Pinney S, Morrison RS, Goldstein NE. Evaluation of a Novel Educational Intervention to Improve Conversations About Implantable Cardioverter-Defibrillators Management in Patients with Advanced Heart Failure. J Palliat Med 2020; 23:1619-1625. [PMID: 32609036 DOI: 10.1089/jpm.2020.0022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Implantable cardioverter-defibrillators (ICDs) reduce the incidence of sudden cardiac death for high-risk patients with heart failure (HF), but shocks from these devices can also cause pain and anxiety at the end of life. Although professional society recommendations encourage proactive discussions about ICD deactivation, clinicians lack training in conducting these conversations, and they occur infrequently. Methods: As part of a six-center randomized controlled trial, we evaluated the educational component of a multicomponent intervention shown to increase conversations about ICD deactivation by clinicians who care for a subset of patients with advanced HF. This consisted of a 90-minute training workshop designed to improve the quality and frequency of conversations about ICD management. To characterize its utility as an isolated intervention, we compared HF clinicians' pre- and postworkshop scores (on a 5-point Likert scale) assessing self-reported confidence and skills in specific practices of advance care planning, ICD deactivation discussions, and empathic communication. Results: Forty intervention-group HF clinicians completed both pre- and postworkshop surveys. Preworkshop scores showed high baseline levels of confidence (4.36, standard deviation [SD] = 0.70) and skill (4.08, SD = 0.72), whereas comparisons of pre- and postworkshop scores showed nonsignificant decreases in confidence (-1.16, p = 0.252) and skill (-0.20, p = 0.843) after the training session. Conclusions: Our findings showed no significant changes in self-assessment ratings immediately after the educational intervention. However, our data did demonstrate that HF clinicians had high baseline self-perceptions of their skills in advance care planning conversations and appear to be well-primed for further professional development to improve communication in the setting of advanced HF.
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Affiliation(s)
- Ian B Kwok
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel Hospital, New York, New York, USA
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatrics Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Rachel J Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hannah I Lipman
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, New Jersey, USA.,Center for Bioethics, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Daniel D Matlock
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado, USA
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Jill Kalman
- Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Sean Pinney
- Division of Cardiology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatrics Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatrics Research Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
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Affiliation(s)
- R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Reckrey JM, Geduldig ET, Lindquist LA, Morrison RS, Boerner K, Federman AD, Brody AA. Paid Caregiver Communication With Homebound Older Adults, Their Families, and the Health Care Team. Gerontologist 2020; 60:745-753. [PMID: 31112604 DOI: 10.1093/geront/gnz067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although paid caregivers (e.g., home health aides and home care workers) provide essential care for homebound older adults with serious illness in their homes, little is known about how and to whom paid caregivers communicate about the health needs they encounter. This study explored how paid caregivers (i) communicate when older adults experience symptoms or clinical changes and (ii) interact with the health care team. RESEARCH DESIGN AND METHODS We conducted separate one-on-one, semi-structured interviews (n = 30) lasting 40-60 min with homebound older adults (or their proxies if they had cognitive impairment) and their paid caregivers (provided they had worked with the older adult for ≥8 hr per week for ≥6 months). Interviews were audio-recorded, transcribed, and coded. RESULTS Thematic analysis identified four themes: (i) older adults or their families were the gatekeepers to paid caregiver communication with the health care team; (ii) communication between older adults, their families, and paid caregivers was enhanced when close relationships were present; (iii) paid caregivers responded to health care team inquiries but rarely communicated proactively; and (4) most older adults, families, and paid caregivers were satisfied with existing paid caregiver communication with the health care team. DISCUSSION AND IMPLICATIONS Rather than discuss concerns with the health care team, paid caregivers communicated directly with older adults or their families about the health needs they encounter. Understanding how communication occurs in the home is the first step to maximizing the potentially positive impact of paid caregivers on the health of older adults living at home.
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Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emma T Geduldig
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lee A Lindquist
- Department of Medicine, Division of General Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J Peters Bronx VA Geriatric Research Education and Clinical Center, New York, New York
| | - Kathrin Boerner
- Department of Gerontology, University of Massachusetts Boston, New York
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Abraham A Brody
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J Peters Bronx VA Geriatric Research Education and Clinical Center, New York, New York.,New York University Rory Meyers College of Nursing
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Hudson P, Morrison RS, Schulz R, Brody AA, Dahlin C, Kelly K, Meier DE. Improving Support for Family Caregivers of People with a Serious Illness in the United States: Strategic Agenda and Call to Action. Palliat Med Rep 2020; 1:6-17. [PMID: 34223450 PMCID: PMC8241318 DOI: 10.1089/pmr.2020.0004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 11/29/2022] Open
Abstract
Background: An estimated 30% of the adult American population are caregivers and many of the people they support live with serious illnesses. Caregivers provide an average of 20 hours of services per week and are heavily involved in assisting with activities of daily living. This input represents considerable economic value to the health care system and to the well-being of communities. However, the impact of the burden on caregivers is considerable with negative outcomes on their physical, psychological, social, and financial well-being. The current landscape of caregiver policy in the United States is not well coordinated and does not meet the needs of this population. Objective: To develop a strategy to enhance the future of family caregiver support of people with serious illness within the United States. Methods: (1) Creation of project steering and key stakeholder groups; (2) survey and in-depth interviews with key stakeholders; (3) review of key family caregiver reports, systematic reviews, policies, and financial initiatives. Results: A strategy to provide clear direction to enhance the future of family caregiver support of people with serious illness within the United States was developed focusing explicitly on policy, research, training, service delivery, and public engagement. Conclusions: The strategy is an initial step aimed at enhancing support for family caregivers of people living with serious illness. It outlines key recommendations and a “call to action.” Subsequent work will be needed on prioritization of tasks, gaining buy-in at all levels of the policy-making apparatus, operationalization, and implementation.
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Affiliation(s)
- Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital, Melbourne, Australia.,The University of Melbourne, Melbourne, Australia.,Vrije University Brussels, Belgium
| | - R Sean Morrison
- National Palliative Care Research Center, Icahn School of Medicine of Mount Sinai, New York, New York, USA.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine of Mount Sinai, New York, New York, USA.,Lilian and Benjamin Hertzberg Palliative Care Institute, Mount Sinai Hospital, New York, New York, USA
| | - Richard Schulz
- Center for Social and Urban Research, Education, and Policy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Psychiatry, School of Medicine, Education, and Policy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Caregiving Research, Education, and Policy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Abraham Aizer Brody
- Rory Meyers College of Nursing, New York University, New York, New York, USA.,Hartford Institute for Geriatric Nursing, New York University, New York, New York, USA
| | - Constance Dahlin
- Center to Advance Palliative Care, New York, New York, USA.,Hospice and Palliative Nurses Association, Pittsburgh, Pennsylvania, USA.,North Shore Medical Center, Salem, Massachusetts, USA
| | - Kathleen Kelly
- Family Caregiver Alliance, National Center on Caregiving, San Francisco, California, USA
| | - Diane E Meier
- North Shore Medical Center, Salem, Massachusetts, USA.,Patty and Jay Baker National Palliative Care Center, Icahn School of Medicine of Mount Sinai, New York, New York, USA.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine of Mount Sinai, New York, New York, USA.,Medical Ethics, Icahn School of Medicine of Mount Sinai, New York, New York, USA
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Rogers M, Meier DE, Morrison RS, Moreno J, Aldridge M. Hospital Characteristics Associated with Palliative Care Program Prevalence. J Palliat Med 2020; 23:1296-1299. [PMID: 32349621 DOI: 10.1089/jpm.2019.0580] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Over the past two decades, the number of hospitals with palliative care has increased significantly. Objective: This study analyzes the availability of palliative care in U.S. hospitals and examines the variation by hospital characteristics, community-level socioeconomic demographics, health care markets, and geographic characteristics. Methods: Data were obtained from the American Hospital Association Annual Survey Database for 2017 and supplemented with 2016 for nonresponders, the United States Census Bureau's 2017 American Community Survey, the Dartmouth Atlas of Health Care's 2016 Spending and 2011 Hospital and Physician Capacity datasets, the National Palliative Care Registry™, state-level directories on palliative care, and web-based searches. Multivariable logistic regression and average marginal effects were used to examine predictors of hospital palliative care programs. Results: Seventy-two percent of hospitals with 50 or more beds had palliative care programs. Hospital and geographic characteristics were significantly associated with the presence of palliative care. Most notably, nonprofit hospitals were 24.5 percentage points more likely than for-profit hospitals to have palliative care, and metropolitan areas were 15.4 percentage points more likely than rural areas, controlling for other variables. Conclusion: This study demonstrates that availability of palliative care in U.S. hospitals is determined by where patients live and the type of hospital to which they are admitted. Equitable and reliable availability to quality palliative care must improve across the nation.
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Affiliation(s)
- Maggie Rogers
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diane E Meier
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peter Veterans Affairs Medical Center, Bronx, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peter Veterans Affairs Medical Center, Bronx, New York, USA
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Yi D, Johnston BM, Ryan K, Daveson BA, Meier DE, Smith M, McQuillan R, Selman L, Pantilat SZ, Normand C, Morrison RS, Higginson IJ. Drivers of care costs and quality in the last 3 months of life among older people receiving palliative care: A multinational mortality follow-back survey across England, Ireland and the United States. Palliat Med 2020; 34:513-523. [PMID: 32009542 DOI: 10.1177/0269216319896745] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Care costs rise towards the end of life. International comparison of service use, costs and care experiences can inform quality and improve access. AIM The aim of this study was to compare health and social care costs, quality and their drivers in the last 3 months of life for older adults across countries. Null hypothesis: no difference between countries. DESIGN Mortality follow-back survey. Costs were calculated from carers' reported service use and unit costs. SETTING Palliative care services in England (London), Ireland (Dublin) and the United States (New York, San Francisco). PARTICIPANTS Informal carers of decedents who had received palliative care participated in the study. RESULTS A total of 767 questionnaires were returned: 245 in England, 282 in Ireland and 240 in the United States. Mean care costs per person with cancer/non-cancer were US$37,250/US$37,376 (the United States), US$29,065/US$29,411 (Ireland), US$15,347/US$16,631 (England) and differed significantly (F = 25.79/14.27, p < 0.000). Cost distributions differed and were most homogeneous in England. In all countries, hospital care accounted for > 80% of total care costs; community care 6%-16%, palliative care 1%-15%; 10% of decedents used ~30% of total care costs. Being a high-cost user was associated with older age (>80 years), facing financial difficulties and poor experiences of home care, but not with having cancer or multimorbidity. Palliative care services consistently had the highest satisfaction. CONCLUSION Poverty and poor home care drove high costs, suggesting that improving community palliative care may improve care value, especially as palliative care expenditure was low. Major diagnostic variables were not cost drivers. Care costs in the United States were high and highly variable, suggesting that high-cost low-value care may be prevalent.
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Affiliation(s)
- Deokhee Yi
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Bridget M Johnston
- The Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Karen Ryan
- Mater Misericordiae Hospital, Eccles Street, Dublin, Ireland
| | - Barbara A Daveson
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Diane E Meier
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Melinda Smith
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | | | - Lucy Selman
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Steven Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Charles Normand
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,The Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Irene J Higginson
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,King's College Hospital NHS Foundation Trust, Bessemer Road, London, UK
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May P, Normand C, Morrison RS. Economics of Palliative Care for Cancer: Interpreting Current Evidence, Mapping Future Priorities for Research. J Clin Oncol 2020; 38:980-986. [DOI: 10.1200/jco.18.02294] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The National Cancer Institute estimates that $154 billion will be spent on care for people with cancer in 2019, distributed across the year after diagnosis (31%), the final year of life (31%), and continuing care between those two (38%). Projections of future costs estimate persistent growth in care expenditures. Early research studies on the economics of palliative care have reported a general pattern of cost savings during inpatient hospital admissions and the end-of-life phase. Recent research has demonstrated more complex dynamics, but expanding palliative care capacity to meet clinical guidelines and population health needs seems to save costs. Quantifying these cost savings requires additional research, because there is significant variance in estimates of the effects of treatment on costs, depending on the timing of intervention, the primary diagnosis, and the overall illness burden. Because ASCO guidelines state that palliative care should be provided concurrently with other treatment from the point of diagnosis onward for all metastatic cancer, new and ambitious research is required to evaluate the cost effects of palliative care across the entire disease trajectory. We propose a series of ways to reach the guideline goals.
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Affiliation(s)
- Peter May
- Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing (TILDA), Dublin, Ireland
| | - Charles Normand
- Trinity College Dublin, Dublin, Ireland
- King’s College London, London, United Kingdom
| | - R. Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York, NY
- James J. Peters VA Medical Center, New York, NY
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Abstract
OBJECTIVE To identify barrier to achieving universal access to high quality palliative care in Canada, review published national strategies and frameworks to promote palliative care, examine key aspects that have been linked to successful outcomes, and make recommendations for Canada. BACKGROUND In 2014, the World Health Organization called on members to develop and implement policies to ensure palliative care is integrated into national health services. METHODS Rapid review supplemented by the author's personal files, outreach to colleagues within the international palliative care community, review of European Association for Palliative Care publications, and a subsequent search of the table of contents of the major palliative care journals. RESULTS Frameworks were found for 10 countries ranging from detailed and comprehensive multi-year strategies to more general approaches including laws guaranteeing access to palliative care services for "dying" patients or recommendations for the development of clinical infrastructure. Few formal evaluations were found minimal comparative data exist regarding the quality of care, access to palliative care services, timing of access in the disease trajectory, and patient and family satisfaction with care. Factors that appear to be associated with success include: 1) input and early involvement of senior policy makers; 2) comprehensive strategies that address major barriers to universal access and that involve the key constituents; 3) a focus on enhancing the evidence base and developing a national system of quality reporting; and 4) substantial and sustained government investment. DISCUSSION Comprehensive national strategies appear to improve access to high quality palliative care for persons with serious illness and their families. Such strategies require sustained government funding and address barriers related to infrastructure, professional and public education, workforce shortages, and an inadequate evidence base.
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Affiliation(s)
- R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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Hua M, Lu Y, Ma X, Morrison RS, Li G, Wunsch H. Association Between the Implementation of Hospital-Based Palliative Care and Use of Intensive Care During Terminal Hospitalizations. JAMA Netw Open 2020; 3:e1918675. [PMID: 31913493 PMCID: PMC6991248 DOI: 10.1001/jamanetworkopen.2019.18675] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/10/2019] [Indexed: 11/14/2022] Open
Abstract
Importance The use of intensive care at the end of life continues to be common. Although the provision of palliative care has been advocated as a way to mitigate the use of high-intensity care, it is unknown whether implementation of hospital-based palliative care services is associated with reduced use of intensive care at the end of life. Objective To determine whether implementation of hospital-based palliative care services is associated with decreased intensive care unit (ICU) use during terminal hospitalizations. Design, Setting, and Participants This cohort study included 51 hospitals in New York State that either did or did not implement a palliative care program between 2008 and 2014. Hospitals that consistently had a palliative care program during the study period were excluded. Participants were adult patients who died during hospitalization. Data analysis was performed between January 2018 and July 2019. Exposure Implementation of a palliative care program. Main Outcomes and Measures The primary outcome was ICU use. A difference-in-differences analysis was performed using multilevel regression to assess the association between implementing a palliative care program and ICU use during terminal hospitalizations while adjusting for patient and hospital characteristics and time trends. Results During the study period, 73 370 patients (mean [SD] age, 76.5 [14.1] years; 38 467 [52.4%] women) died during hospitalization, of whom 37 628 (51.3%) received care in hospitals that implemented palliative care services and 35 742 (48.7%) received care in a hospital without palliative care implementation. Patients who received care in hospitals after implementation of palliative care services were less likely to receive intensive care than patients admitted to the same hospitals before implementation (49.3% vs 52.8%; difference 3.5%; 95% CI, 2.5%-4.5%; P < .001). Compared with hospitals that never had a palliative care program, the implementation of palliative care was associated with a 10% reduction in ICU use during terminal hospitalizations (adjusted relative risk, 0.90; 95% CI, 0.85-0.95; P < .001). Conclusions and Relevance The implementation of hospital-based palliative care services in New York State was associated with a modest reduction in ICU use during terminal hospitalizations.
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Affiliation(s)
- May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Yewei Lu
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Xiaoyue Ma
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Guohua Li
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hannah Wunsch
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Department of Anesthesia and Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Reckrey JM, Morrison RS, Boerner K, Szanton SL, Bollens-Lund E, Leff B, Ornstein KA. Living in the Community With Dementia: Who Receives Paid Care? J Am Geriatr Soc 2020; 68:186-191. [PMID: 31696511 PMCID: PMC6957088 DOI: 10.1111/jgs.16215] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Paid caregivers (eg, home health aides and personal care attendants) provide hands-on care that helps individuals with dementia live in the community. This study (a) characterizes paid caregiving among community-dwelling individuals with dementia and (b) identifies factors associated with receipt of paid care. DESIGN Cross-sectional analysis. SETTING The 2015 National Health and Aging Trends Study (NHATS), a nationally representative study of Medicare recipients aged 65 years and older. PARTICIPANTS Community-dwelling individuals with dementia (n = 899). MEASUREMENTS Paid and family caregiving support was determined by participant or proxy report of help received with functional tasks. Multivariable logistic regression was used to examine factors associated with receipt of paid care. NHATS population sampling weights were used to produce national paid caregiving prevalence estimates. RESULTS Only 25.5% of community-dwelling individuals with dementia received paid care, and 10.8% received 20 hours or more of paid care per week. For those who received it, paid care accounted for approximately half of the 83 total caregiving hours (paid and family) that they received each week. Among the subgroup of individuals with advanced dementia (those with impairment in dressing, bathing, toileting, and managing medications and finances), nearly half (48.3%) received paid care. Multivariable analysis, adjusting for sociodemographic, family caregiving support, functional, and clinical characteristics, found that the odds of receiving paid care were higher among men (odds ratio [OR] = 1.91; 95% confidence interval [CI] = 1.24-2.95), the unmarried (OR = 2.20; 95% CI = 1.31-3.70), those with Medicaid (OR = 2.16; 95% CI = 1.27-3.66), and those requiring more help with activities of daily living (ADLs) (OR = 1.32; 95% CI = 1.18-1.48) and instrumental ADLs (OR = 1.29; 95% CI = 1.14-1.46). CONCLUSIONS New ways of making paid caregiving more accessible throughout the income spectrum are required to support family caregivers and respect the preferences of individuals with dementia to remain living in the community. J Am Geriatr Soc 68:186-191, 2019.
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Affiliation(s)
- Jennifer M. Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - R. Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
- James J. Peters VA Medical Center, McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston
| | - Kathrin Boerner
- Department of Gerontology, McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston
| | - Sarah L. Szanton
- Johns Hopkins School of Nursing, Center for Transformative Geriatric Research, Johns Hopkins School of Medicine
| | - Evan Bollens-Lund
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Bruce Leff
- Department of Medicine, Division of Geriatrics, Center for Transformative Geriatric Research, Johns Hopkins School of Medicine
| | - Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
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Reckrey JM, Tsui E, Morrison RS, Geduldig E, Stone R, Ornstein K, Federman A. THE HEALTH-RELATED TASKS PAID CAREGIVERS IN NEW YORK STATE PERFORM IN THE HOME. Innov Aging 2019. [PMCID: PMC6846062 DOI: 10.1093/geroni/igz038.790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Paid caregivers (e.g. home health aides, personal care attendants) are formally tasked with helping older adults with functional impairment meet their basic needs at home. This study used semi-structured interviews (n=30) with dyads of patients or their proxies and their paid caregivers in New York City to 1) understand the range of health-related tasks paid caregivers perform in the home and 2) determine if these tasks are taught in the New York State government’s Department of Health curricula. We found that patients, proxies, and paid caregivers all described that paid caregivers performed a wide range of health-related tasks that were often not a part of their formal training. Creating clear competencies for paid caregivers that reflect the full breadth of health-related tasks they may perform at home will help maximize the potentially positive impact of the paid caregiver workforce on the lives of patients living at home with functional impairment.
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Affiliation(s)
- Jennifer M Reckrey
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Emma Tsui
- CUNY Graduate School of Public Health and Health Policy, New York, New York, United States
| | - R S Morrison
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Emma Geduldig
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Robyn Stone
- Leading Age, Washington, District of Columbia, United States
| | - Katherine Ornstein
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Alex Federman
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Goldstein NE, Mather H, McKendrick K, Gelfman LP, Hutchinson MD, Lampert R, Lipman HI, Matlock DD, Strand JJ, Swetz KM, Kalman J, Kutner JS, Pinney S, Morrison RS. Improving Communication in Heart Failure Patient Care. J Am Coll Cardiol 2019; 74:1682-1692. [PMID: 31558252 PMCID: PMC7000126 DOI: 10.1016/j.jacc.2019.07.058] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function. OBJECTIVES The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation. METHODS In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion. RESULTS A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. SECONDARY OUTCOMES Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives. CONCLUSIONS The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744).
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Affiliation(s)
- Nathan E Goldstein
- Brookdale 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.
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laura P Gelfman
- Brookdale 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
| | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, Arizona
| | - Rachel Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Hannah I Lipman
- Hackensack University Medical Center, Hackensack, New Jersey; Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
| | - Daniel D Matlock
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Jacob J Strand
- Division of General Internal Medicine, Department of Medicine, Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, Alabama
| | - Jill Kalman
- Lenox Hill Hospital, Northwell Health, New York, New York
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Sean Pinney
- Division of Cardiology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - R Sean Morrison
- Brookdale 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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Rogers M, Meier DE, Heitner R, Aldridge M, Hill Spragens L, Kelley A, Nemec SR, Morrison RS. The National Palliative Care Registry: A Decade of Supporting Growth and Sustainability of Palliative Care Programs. J Palliat Med 2019; 22:1026-1031. [PMID: 31329016 DOI: 10.1089/jpm.2019.0262] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Palliative care program service delivery is variable, and programs often lack data to support and guide program development and growth. Objective: To review the development and key features of the National Palliative Care Registry™ ("the Registry") and describe recent findings from its surveys on hospital palliative care. Description: Established in 2008, the Registry data elements align with National Consensus Project (NCP) guidelines related to palliative care program structures and operations. The Registry provides longitudinal and comparative data that palliative care programs can use to support programmatic growth. Results: As of 2018, >1000 hospitals and 120 community sites have submitted data on their palliative care programs to the Registry. Over the past decade, the percentage of hospital admissions seen by palliative care teams (penetration) has increased from 2.5% to 5.3%. Higher penetration is correlated with teaching hospital status, having a palliative care trigger, and hospital size (p < 0.05). Although overall staffing has expanded, only 42% of Registry programs include the recommended four key disciplines: physician, advanced practice or other registered nurse, social worker, and chaplain. Compliance with NCP guidelines on key structures and processes vary across adult and pediatric programs. Conclusions: The Registry allows palliative care programs to optimize core structures and processes and understand their performance relative to their peers.
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Affiliation(s)
- Maggie Rogers
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Diane E Meier
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachael Heitner
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lynn Hill Spragens
- Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Spragens & Gualtieri-Reed, Chapel Hill, North Carolina
| | - Amy Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Abstract
The homebound population relies on both paid and family caregivers to meet their complex care needs. In order to examine the association between intensity of caregiving support and leaving the home, we identified a population of community-dwelling, homebound Medicare beneficiaries age ≥65 (n = 1,852) enrolled in the 2015 National Health and Aging Trends Study and measured the support they received from paid and family caregivers. Those who had ≥20 h of caregiving support per week had 50% less odds of being "exclusively homebound" (rarely or never leave home) (OR 0.56, p < .01). Policies that facilitate increased support for family caregivers and better access to paid caregivers may allow homebound individuals who would otherwise be isolated at home to utilize existing community-based long-term care services and supports.
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Affiliation(s)
- Jennifer M Reckrey
- Associate Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA.,Associate Professor, Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Alex D Federman
- Professor, Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Evan Bollens-Lund
- Data Analytics Manager, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - R Sean Morrison
- Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Katherine A Ornstein
- Associate Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
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Kanbergs A, Ahalt C, Cenzer IS, Morrison RS, Williams BA. "No One Wants to Die Alone": Incarcerated Patients' Knowledge and Attitudes About Early Medical Release. J Pain Symptom Manage 2019; 57:809-815. [PMID: 30593912 DOI: 10.1016/j.jpainsymman.2018.12.335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022]
Abstract
CONTEXT Deaths among incarcerated individuals have steadily increased in the U.S., exceeding 5000 in 2014. Nearly every state has a policy to allow patients with serious life-limiting illness to apply for release from prison or jail to die in the community ("early medical release"). Although studies show these policies are rarely used, patient-level barriers to their use are unknown. OBJECTIVES To assess incarcerated patients' knowledge of early medical release policies and to identify patient-level barriers to accessing these policies. METHODS A cross-sectional survey of 46 male patients in two state prisons and one large urban jail who had visited a primary care provider at least three times within three months was conducted. RESULTS Participants' average age was 64 years, and 89% had more than one chronic illness. Fewer than half (43%) demonstrated the knowledge needed to apply for early medical release and 22% demonstrated no relevant knowledge. Participants with sufficient knowledge were significantly more likely to endorse anxiety (35% vs. 0%, P = .003) and loneliness (65% vs. 30%, P = .017). CONCLUSION Many medically complex incarcerated patients in this study did not demonstrate sufficient knowledge to apply for early medical release suggesting that patient education may help expand access to these policies. Moreover, seriously ill patients with knowledge of early medical release may benefit from enhanced psychosocial support given their disproportionate burdens of anxiety and loneliness. Our findings highlight the pressing need for larger studies to assess whether improved patient education and support can expand access to early medical release.
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Affiliation(s)
- Alexa Kanbergs
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Cyrus Ahalt
- University of California San Francisco, Division of Geriatrics, San Francisco, California, USA
| | - Irena Stijacic Cenzer
- University of California San Francisco, Division of Geriatrics, San Francisco, California, USA
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Brie A Williams
- University of California San Francisco, Division of Geriatrics, San Francisco, California, USA.
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Affiliation(s)
- R Sean Morrison
- 1 Brookdale Department of Geriatrics, Hertzberg Palliative Care Institute , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Susan Zieman
- 2 National Institute on Aging , Bethesda, Maryland
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Ko FC, Rubenstein WJ, Lee EJ, Siu AL, Sean Morrison R. TNF-α and sTNF-RII Are Associated with Pain Following Hip Fracture Surgery in Older Adults. Pain Med 2019; 19:169-177. [PMID: 28460020 DOI: 10.1093/pm/pnx085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective To explore whether plasma inflammatory mediators on postoperative day 3 (POD3) are associated with pain scores in older adults after hip fracture surgery. Design Cross-sectional study. Setting Mount Sinai Hospital, New York, New York. Subjects Forty patients age 60 years or older who presented with acute hip fracture at Mount Sinai Hospital between November 2011 and April 2013. Methods Plasma levels of six inflammatory mediators of the nuclear factor kappa B pathway were measured using blood collected on POD3. Self-reported pain scores (i.e., pain with resting, walking, and transferring) were assessed at baseline (prefracture) and on POD3. Linear regression models using log-transformed data were performed to determine associations between inflammatory mediators and postoperative pain. Results Interleukin 18 (IL-18) was positively associated with POD3 resting pain score in the unadjusted model (β = 0.66, P = 0.03). Tumor necrosis factor α (TNF-α) and soluble TNF receptor II (sTNF-RII) were positively associated with POD3 resting pain score in the adjusted model (β = 0.99, P = 0.03, and β = 0.86, P = 0.04, respectively). Moreover, TNF-α was positively associated with POD3 walking pain score in the adjusted model (β = 1.59, P = 0.05). Pain with transferring was not associated with these inflammatory mediators. Conclusions These findings suggest that TNF-α and its receptors may influence pain following hip fracture. Further study of the TNF-α pathway may inform future clinical applications that monitor and treat pain in the vulnerable elderly who are unable to accurately report pain.
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Affiliation(s)
- Fred C Ko
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,GRECC, James J. Peters VA Medical Center, New York, New York, USA
| | - William J Rubenstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Eric J Lee
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,GRECC, James J. Peters VA Medical Center, New York, New York, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,GRECC, James J. Peters VA Medical Center, New York, New York, USA
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Affiliation(s)
- Aluko A. Hope
- RS Morrison (corresponding author) Department of Geriatrics and Palliative Medicine, and Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, 1 Gustave Levy Place, Box 1070, New York, New York, USA
| | - R. Sean Morrison
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, and Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York, USA
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