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Wen FH, Chen JS, Chou WC, Hsieh CH, Chang WC, Shen WC, Tang ST. Quality of life and psychological distress are differentially associated with distinct symptom-functional states in terminally ill cancer patients' last year of life. Psychooncology 2018; 27:2111-2118. [DOI: 10.1002/pon.4775] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Fur-Hsing Wen
- Department of International Business; Soochow University; Taipei Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan City Taiwan
- Chang Gung University College of Medicine; Taoyuan City Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan City Taiwan
- Chang Gung University College of Medicine; Taoyuan City Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan City Taiwan
- Chang Gung University College of Medicine; Taoyuan City Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan City Taiwan
- Chang Gung University College of Medicine; Taoyuan City Taiwan
| | - Wen Chi Shen
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan City Taiwan
- Chang Gung University College of Medicine; Taoyuan City Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan City Taiwan
- Department of Nursing; Chang Gung Memorial Hospital at Kaohsiung; Taoyuan City Taiwan
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Alhasoun F, Aleissa F, Alhazzani M, Moyano LG, Pinhanez C, González MC. Age density patterns in patients medical conditions: A clustering approach. PLoS Comput Biol 2018; 14:e1006115. [PMID: 29944648 PMCID: PMC6037375 DOI: 10.1371/journal.pcbi.1006115] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/09/2018] [Accepted: 03/29/2018] [Indexed: 11/30/2022] Open
Abstract
This paper presents a data analysis framework to uncover relationships between health conditions, age and sex for a large population of patients. We study a massive heterogeneous sample of 1.7 million patients in Brazil, containing 47 million of health records with detailed medical conditions for visits to medical facilities for a period of 17 months. The findings suggest that medical conditions can be grouped into clusters that share very distinctive densities in the ages of the patients. For each cluster, we further present the ICD-10 chapters within it. Finally, we relate the findings to comorbidity networks, uncovering the relation of the discovered clusters of age densities to comorbidity networks literature. Age and sex of a patient can be directly related to susceptibilities to certain medical conditions. We present a method to generate clusters of human phenotype, based on the age of the population. This method helps extract knowledge on age and sex from the data. The age and sex correlations with disease conditions can help in a task of predicting the susceptibility of incoming patients to conditions.
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Affiliation(s)
- Fahad Alhasoun
- Center for Computational Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | - Faisal Aleissa
- Center for Complex Engineering Systems at KACST and MIT, Cambridge, Massachusetts, United States of America
| | - May Alhazzani
- Media Lab, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
| | | | | | - Marta C. González
- Center for Computational Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Department of City and Regional Planning, University of California, Berkeley, Berkeley, California, United States of America
- Lawrence Berkeley National Laboratory, Berkeley, California, United States of America
- * E-mail:
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Wen FH, Chen JS, Chou WC, Hsieh CH, Chang WC, Hou MM, Tang ST. Distinct Patterns of Conjoint Symptom Distress and Functional Impairment in the Last Year of Life Predict Terminally Ill Cancer Patients' Survival. J Pain Symptom Manage 2018; 55:1443-1451.e2. [PMID: 29545065 DOI: 10.1016/j.jpainsymman.2018.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 12/30/2022]
Abstract
CONTEXT/OBJECTIVES Our study addressed important knowledge gaps about trajectories of distinct conjoint symptom-functional states, that is, patterns for different levels of combined symptom distress and functional impairment, over cancer patients' last year and their ability to predict survival. METHODS We identified distinct symptom-functional states and explored their changes over 317 terminally ill cancer patients' last year by a transition model using hidden Markov modeling. These distinct symptom-functional states' ability to predict current survival probability, measured in the previous assessment, was evaluated by multivariate Cox regression models. RESULTS We identified five worsening, conjoint symptom-functional states: 1) mild symptom distress with high functioning, 2) moderate symptom distress with mild functional impairment, 3) severe symptom distress with moderate functional impairment, 4) moderate symptom distress with severe functional impairment, and 5) profound symptom distress and functional impairment. Trajectories of these five states differed substantially by direction (downward vs. upward) and speed. Participants in States 1-4 had substantially lower risk of subsequent death than those in State 5 (adjusted hazard ratios [95% CI] ranged from 0.048 [0.028-0.081] to 0.434 [0.316-0.579]). The risk of subsequent death differed significantly between patients in any two distinct symptom-functional states, except between those in States 3 and 4. CONCLUSION Our identification of five distinct symptom-functional states and their unique transition patterns and prediction of mortality provides all stakeholders with guides for end-of-life care. Goals of end-of-life care should change toward palliative care and effective symptom management for patients with at least moderate symptom distress and substantial functional impairment.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taiwan, R.O.C
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, R.O.C.; Chang Gung University College of Medicine, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, R.O.C.; Chang Gung University College of Medicine, Taiwan, R.O.C
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, R.O.C.; Chang Gung University College of Medicine, Taiwan, R.O.C
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, R.O.C.; Chang Gung University College of Medicine, Taiwan, R.O.C
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, R.O.C.; Chang Gung University College of Medicine, Taiwan, R.O.C
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, R.O.C.; School of Nursing, Chang Gung University, Taiwan, R.O.C.; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Taiwan, R.O.C..
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Wachterman MW, Hailpern SM, Keating NL, Kurella Tamura M, O'Hare AM. Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis. JAMA Intern Med 2018; 178:792-799. [PMID: 29710217 PMCID: PMC5988968 DOI: 10.1001/jamainternmed.2018.0256] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Patients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with health care utilization and costs. OBJECTIVE To examine the association between hospice length of stay and health care utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional observational study was conducted via the United States Renal Data System registry. Participants were all 770 191 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were April 2016 to December 2017. MAIN OUTCOMES AND MEASURES Hospital admission, intensive care unit (ICU) admission, and receipt of an intensive procedure during the last month of life; death in the hospital; and costs to the Medicare program in the last week of life. RESULTS Among 770 191 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for 3 days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for 3 days or fewer were less likely to die in the hospital (13.5% vs 55.1%; P < .001) or to undergo an intensive procedure in the last month of life (17.7% vs 31.6%; P < .001) but had higher rates of hospitalization (83.6% vs 74.4%; P < .001) and ICU admission (54.0% vs 51.0%; P < .001) and similar Medicare costs in the last week of life ($10 756 vs $10 871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred more than 15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were $3221). CONCLUSIONS AND RELEVANCE Overall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan M Hailpern
- Division of Nephrology, Kidney Research Institute, Department of Medicine, University of Washington, Seattle
| | - Nancy L Keating
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, California.,Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Ann M O'Hare
- Division of Nephrology, Kidney Research Institute, Department of Medicine, University of Washington, Seattle.,Hospital and Specialty Medical Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Hui D, Cherny N, Latino N, Strasser F. The 'critical mass' survey of palliative care programme at ESMO designated centres of integrated oncology and palliative care. Ann Oncol 2018; 28:2057-2066. [PMID: 28911084 DOI: 10.1093/annonc/mdx280] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background The ESMO Designated Centres (ESMO-DCs) of Integrated Oncology and Palliative Care (PC) Incentive Programme has grown steadily. We aimed to characterise the level of PC clinical services, education and research at ESMO-DCs. Methods We sent all 184 ESMO-DCs an electronic survey consisting of 78 questions examining the DC characteristics, palliative care clinical programme (structure, processes, and outcomes), primary PC delivery by oncologists, education, research and attitudes and beliefs towards the ESMO-DC programme. Results The response rate was 83% (152/184). 115 (76%) ESMO-DCs were from Europe, 87 (57%) were tertiary care centres. 136 (90%) had inpatient consultation teams, 135 (89%) had outpatient PC clinics, 107 (71%) had dedicated acute care beds, and 75 (50%) offered community-based PC. An estimated 70% (interquartile range [IQR] 28-80%) of patients with advanced cancer had a PC consultation before death, occurring 90 days before death (median, IQR 40-150 days) for outpatients and 21 days (IQR 14-45 days) for inpatients. 59 (39%) offered PC fellowship programme; 47 (32%) had mandatory PC rotations for oncology fellows. Ninety-nine (65%) had double-boarded palliative oncologists. 118 (78%) of the ESMO-DCs reported that routine symptom screening was offered in the oncology clinic and 30% of patients had documented end-of-life discussions by their oncologists. Most centres (>80%) perceived the ESMO-DC programme to increase their status. Conclusions The ESMO-DCs had a high level of PC infrastructure and provided access to a large proportion of patients with advanced cancer. The survey supports that the 13 criteria required for ESMO designation set a robust framework for integration, stimulated investment of resources into some palliative care programmes prior to accreditation, and raised the interest about palliative care among clinicians, trainees and patients.
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Affiliation(s)
- D Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - N Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - N Latino
- European Society for Medical Oncology Head Office, Viganello-Lugano
| | - F Strasser
- Oncological Palliative Medicine, Clinic Oncology/Hematology, Cantonal Hospital, St. Gallen, Switzerland
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Clayton MF, Hulett J, Kaur K, Reblin M, Wilson A, Ellington L. Nursing Support of Home Hospice Caregivers on the Day of Patient Death. Oncol Nurs Forum 2018. [PMID: 28632241 DOI: 10.1188/17.onf.457-464] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To describe nurse-caregiver communication on the day of patient death.
. DESIGN A descriptive secondary analysis of 44 audio-recorded home hospice nursing visits on day of death.
. SETTING Nine hospices in Utah, Oregon, and Massachusetts.
. SAMPLE 42 caregiver-patient dyads, 27 hospice nurses.
. METHODS Transcripts of audio recordings were coded for supportive nursing communication and relative time spent in physical, psychosocial, and spiritual discussion.
. MAIN RESEARCH VARIABLES Tangible, emotional, informational, esteem, and networking supportive communication; nurses' self-reported communication effectiveness; caregiver religious affiliation.
. FINDINGS Nurses reported that their communication skills were less effective when discussing difficult topics as compared to their overall communication effectiveness. Eleven patients died before the nursing visit, 3 died during the visit, and 30 died post-visit. Nurses primarily engaged in discussions facilitating caregiver emotional, tangible, and informational support. More informational support was observed when patient death occurred during the nursing visit. Time spent in general conversation showed that physical care conversations predominated (80% of the average overall amount of conversation time), compared to lifestyle/psychosocial discussions (14%) and spiritual discussions (6%). Spiritual discussions were observed in only 7 of 44 hospice visits. Spiritual discussions, although short and infrequent, were significantly longer, on average, for caregivers without a religious affiliation.
. CONCLUSIONS Nurses support caregivers on the day of patient death using multiple supportive communication strategies. Spiritual discussions are minimal.
. IMPLICATIONS FOR NURSING Communication skills programs can potentially increase self-reported communication effectiveness. Emerging acute spiritual concerns, particularly for caregivers without a previous religious affiliation, should be anticipated. Spiritual support is included in the hospice model of holistic care.
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Affiliation(s)
| | | | | | - Maija Reblin
- H. Lee Moffitt Cancer Center and Research Institute
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Identifying temporal patterns in patient disease trajectories using dynamic time warping: A population-based study. Sci Rep 2018. [PMID: 29523868 PMCID: PMC5844976 DOI: 10.1038/s41598-018-22578-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Time is a crucial parameter in the assessment of comorbidities in population-based studies, as it permits to identify more complex disease patterns apart from the pairwise disease associations. So far, it has been, either, completely ignored or only, taken into account by assessing the temporal directionality of identified comorbidity pairs. In this work, a novel time-analysis framework is presented for large-scale comorbidity studies. The disease-history vectors of patients of a regional Spanish health dataset are represented as time sequences of ordered disease diagnoses. Statistically significant pairwise disease associations are identified and their temporal directionality is assessed. Subsequently, an unsupervised clustering algorithm, based on Dynamic Time Warping, is applied on the common disease trajectories in order to group them according to the temporal patterns that they share. The proposed methodology for the temporal assessment of such trajectories could serve as the preliminary basis of a disease prediction system.
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Ellington L, Clayton MF, Reblin M, Donaldson G, Latimer S. Communication among cancer patients, caregivers, and hospice nurses: Content, process and change over time. PATIENT EDUCATION AND COUNSELING 2018; 101:414-421. [PMID: 28964559 PMCID: PMC5857410 DOI: 10.1016/j.pec.2017.09.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/08/2017] [Accepted: 09/22/2017] [Indexed: 05/21/2023]
Abstract
OBJECTIVE First, to describe communication of home hospice nurse visits to cancer patient-caregiver dyads. Second, to assess change in communication related to domains of care over the course of visits. METHODS Multi-site prospective observational longitudinal study of audio-recorded home hospice visits (N=537 visits; 101 patient-caregiver dyads; 58 nurses). Communication was coded using the Roter Interaction Analysis System to describe content and process. Conversation representing three care domains (physical, psychosocial/daily life, and emotional) was calculated from RIAS categories across speakers and analyzed to assess change in communication over time. RESULTS On average, nurses spoke 54% of total utterances, caregivers 29%, and patients 17%. For all participants, the predominant conversational focus was on physical care. Linear mixed effects models indicated that combined participant emotional talk showed a small systematic decrease over time; however, the results for all domains indicated variability unexplained by time or speaker effects. CONCLUSIONS Home hospice conversations are predominantly focused on physical care. Systematic change in communication versus responsiveness to the dynamic effects of patient death and family response over time are discussed. PRACTICE IMPLICATIONS Communication strategies already in use by hospice nurses could be leveraged and expanded upon to better facilitate family competence and confidence.
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Affiliation(s)
- Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, USA
| | | | - Maija Reblin
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, USA.
| | - Gary Donaldson
- College of Nursing, University of Utah, Salt Lake City, USA
| | - Seth Latimer
- College of Nursing, University of Utah, Salt Lake City, USA
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Demographics, Resource Utilization, and Outcomes of Elderly Patients With Chronic Liver Disease Receiving Hospice Care in the United States. Am J Gastroenterol 2017; 112:1700-1708. [PMID: 29016566 DOI: 10.1038/ajg.2017.290] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/07/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Hospice offers non-curative symptomatic management to improve patients' quality of life, satisfaction, and resource utilization. Hospice enrollment among patients with chronic liver disease (CLD) is not well studied. The aim of tis tudy is to examine the characteristics of Medicare enrollees with CLD, who were discharged to hospice. METHODS Medicare patients discharged to hospice between 2010 and 2014 were identified in Medicare Inpatient and Hospice Files. CLDs and other co-morbidities were identified by International Classification of Diseases-ninth revision codes. Generalized linear model was used to estimate regression coefficients with P-values. Logistic regression was used to calculate odds ratios and 95% confidence intervals. RESULTS A total of 2,179 CLD patients and 34,986 controls without CLD met the inclusion criteria. Non-alcoholic fatty liver disease, alcoholic liver disease, and hepatitis C virus (HCV) were the most frequent cause of CLD. CLD patients were younger (70 vs. 83 years), more likely to be male (57.7 vs. 39.3%), had longer hospital stay (length of stay, LOS) (19.4 vs. 13.0 days), higher annual charges ($175,000 vs. $109,000), higher 30-day re-hospitalization rates (51.6 vs. 34.2%), and shorter hospice LOS (13.7 vs. 17.7 days) than controls (all P<0.001). Presence of HCV and congestive heart failure were the strongest contributors to increased total annual costs (34% and 31% higher, P<0.001), increased total annual LOS (26% and 43% higher, P<0.001), and increased 30-day readmission risk (2.20 and 2.19 times, respectively). CONCLUSIONS Patients with CLD have longer and costly hospitalizations before hospice enrollment as compared with patients without CLD. It was highly likely that these patients were enrolled relatively late, which could potentially lead to less benefit from hospice.
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Emanuel L, Johnson R, Taromino C. Adjusting to a Diagnosis of Cancer: Processes for Building Patient Capacity for Decision-Making. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2017; 32:491-495. [PMID: 26960311 DOI: 10.1007/s13187-016-1008-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This short report contributes to the expanding body of qualitative research literature about the cognitive processes of newly diagnosed cancer patients as they adjust to a diagnosis of cancer. The study is based on secondary qualitative analysis of audio records collected as part of a larger NIH study (RO1D: An Interdisciplinary Perspective: A Social Science Examination of Oncofertility RL1 HD058296). Core categories illustrate the processes of "naming it," "dealing with dealing with it," and finding the "new norm" and were based on nine patient experiences. We observe that our substantive conceptual categories have equivalents in bereavement and grief literature where researchers have posited the theory that processing the diagnosis of a terminal illness is the equivalent to adjusting to a bereavement. These findings emphasize the importance of understanding real-time patient thoughts and feelings as soon after diagnosis as was possible with full patient consent.
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Affiliation(s)
- Linda Emanuel
- Buehler Center on Aging, Health and Society, Northwestern University, 750 N Lake Shore Drive, Suite 601, Chicago, IL, 60611, USA
| | - Rebecca Johnson
- Buehler Center on Aging, Health and Society, Northwestern University, 750 N Lake Shore Drive, Suite 601, Chicago, IL, 60611, USA.
| | - Caroline Taromino
- Buehler Center on Aging, Health and Society, Northwestern University, 750 N Lake Shore Drive, Suite 601, Chicago, IL, 60611, USA
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Yim CK, Barrón Y, Moore S, Murtaugh C, Lala A, Aldridge M, Goldstein N, Gelfman LP. Hospice Enrollment in Patients With Advanced Heart Failure Decreases Acute Medical Service Utilization. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003335. [PMID: 28292824 DOI: 10.1161/circheartfailure.116.003335] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with advanced heart failure (HF) enroll in hospice at low rates, and data on their acute medical service utilization after hospice enrollment is limited. METHODS AND RESULTS We performed a descriptive analysis of Medicare fee-for-service beneficiaries, with at least one home health claim between July 1, 2009, and June 30, 2010, and at least 2 HF hospitalizations between July 1, 2009, and December 31, 2009, who subsequently enrolled in hospice between July 1, 2009, and December 31, 2009. We estimated panel-negative binomial models on a subset of beneficiaries to compare their acute medical service utilization before and after enrollment. Our sample size included 5073 beneficiaries: 55% were female, 45% were ≥85 years of age, 13% were non-white, and the mean comorbidity count was 2.38 (standard deviation 1.22). The median number of days between the second HF hospital discharge and hospice enrollment was 45. The median number of days enrolled in hospice was 15, and 39% of the beneficiaries died within 7 days of enrollment. During the study period, 11% of the beneficiaries disenrolled from hospice at least once. The adjusted mean number of hospital, intensive care unit, and emergency room admissions decreased from 2.56, 0.87, and 1.17 before hospice enrollment to 0.53, 0.19, and 0.76 after hospice enrollment. CONCLUSIONS Home health care Medicare beneficiaries with advanced HF who enrolled in hospice had lower acute medical service utilization after their enrollment. Their pattern of hospice use suggests that earlier referral and improved retention may benefit this population. Further research is necessary to understand hospice referral and palliative care needs of advanced HF patients.
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Affiliation(s)
- Cindi K Yim
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Yolanda Barrón
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Stanley Moore
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Chris Murtaugh
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Anuradha Lala
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Melissa Aldridge
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Nathan Goldstein
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Laura P Gelfman
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA.
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Dabbouseh NM, Kaushal S, Peltier W, Johnston FM. Palliative Care Training in Cardiology Fellowship: A National Survey of the Fellows. Am J Hosp Palliat Care 2017; 35:284-292. [DOI: 10.1177/1049909117703728] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: To address perspectives of cardiology fellows on the current state of palliative education and palliative and hospice resource utilization within their fellowship experiences. Methods: We conducted an online national survey of cardiology fellows during the 2015 to 2016 academic year. Survey questions aimed to assess perceived importance of palliative care education, level of palliative care education during fellowship, and the structure of palliative care support at respondent institutions. Responses were collected anonymously. A total of 519 programs, including subspecialty programs, were contacted. Results: We received 365 responses, a number that represents roughly 14% of all cardiology fellows nationwide during the 2015 to 2016 academic year. Fellows reported discordance in the quality of education between general cardiology and palliative care principles as it relates to care of the patient approaching the end of life. Fellows infrequently received explicit training nor were observed or mentored in delivering end-of-life discussions. Respondents reported an underutilization of palliative care and hospice resources during fellowship training and also a perception that attending faculty were not routinely addressing goals of care. Conclusions: Our survey results highlight a need for enhanced palliative care and end-of-life training experiences for cardiology fellows and also suggest underutilization of hospice and palliative care resources for patients with advanced cardiac diseases. These findings create a platform for future work that might: (1) confirm this training deficit, (2) lead to exploration of educational models that could reconcile this deficit, and (3) potentially help improve palliative care support for patients and families facing advanced heart disease.
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Affiliation(s)
- Noura M. Dabbouseh
- Division of Cardiology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shivtej Kaushal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Wendy Peltier
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Palliative Care Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Fabian M. Johnston
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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Reid VL, McDonald R, Nwosu AC, Mason SR, Probert C, Ellershaw JE, Coyle S. A systematically structured review of biomarkers of dying in cancer patients in the last months of life; An exploration of the biology of dying. PLoS One 2017; 12:e0175123. [PMID: 28384249 PMCID: PMC5383239 DOI: 10.1371/journal.pone.0175123] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 03/21/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The Neuberger review made a number of recommendations to improve end of life care, including research into the biology of dying. An important aspect of the biology of dying is the identification of biomarkers as indices of disease processes. Biomarkers have the potential to inform the current, limited understanding of the dying process and assist clinicians in recognising dying, in particular how to distinguish dying from reversible acute deterioration. OBJECTIVES To critically appraise the literature on biological factors that may be used as prognostic indicators in advanced cancer patients and to identify candidate biomarkers of the dying process that can be measured serially in cancer patients' bodily fluids. METHODS A systematically structured review was conducted using three electronic databases. A hand search of six peer-reviewed journals and conference abstracts was also conducted. Studies reporting prognostic biomarkers in cancer patients with a median survival of ≤90 days and post-mortem studies were included. Final levels of evidence and recommendations were made using the Evidence Based Medicine modified GRADE system. RESULTS 30 articles were included. Seven prognostic biological factors demonstrated Grade A evidence (lymphocyte count, white blood cell count, serum C-reactive protein, albumin, sodium, urea and alkaline phosphatase). An additional eleven prognostic factors were identified with Grade B evidence (platelet count, international normalised ratio, serum vitamin B12, prealbumin, bilirubin, cholesterol, aspartate aminotransferase, alanine transaminase, lactate dehydrogenase, pseudocholinesterase and urate). A number of biomarkers were specifically identified in the last two weeks of life but limitations exist. No post-mortem studies met the inclusion criteria. CONCLUSION The biology of dying is an important area for future research, with the evidence focused on signs, symptoms and prognostic factors. This review identifies a number of common themes shared amongst advanced cancer patients and highlights candidate biomarkers which may be indicative of a common biological process to dying.
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Affiliation(s)
- Victoria Louise Reid
- The Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Liverpool, United Kingdom
| | - Rachael McDonald
- Renal Medicine, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Amara Callistus Nwosu
- The Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Liverpool, United Kingdom
| | - Stephen R. Mason
- The Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Liverpool, United Kingdom
| | - Chris Probert
- Department of Gastroenterology, University of Liverpool, Liverpool, United Kingdom
| | - John E. Ellershaw
- The Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Liverpool, United Kingdom
| | - Séamus Coyle
- The Marie Curie Palliative Care Institute Liverpool, University of Liverpool, Liverpool, United Kingdom
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Differences in Utilization of Life Support and End-of-Life Care for Medical ICU Patients With Versus Without Cancer. Crit Care Med 2017; 45:e379-e383. [DOI: 10.1097/ccm.0000000000002260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Comstock Barker P, Scherer JS. Illness Trajectories: Description and Clinical Use #326. J Palliat Med 2017; 20:426-427. [DOI: 10.1089/jpm.2016.0554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Liu TZ, Xu C, Rota M, Cai H, Zhang C, Shi MJ, Yuan RX, Weng H, Meng XY, Kwong JSW, Sun X. Sleep duration and risk of all-cause mortality: A flexible, non-linear, meta-regression of 40 prospective cohort studies. Sleep Med Rev 2017; 32:28-36. [PMID: 27067616 DOI: 10.1016/j.smrv.2016.02.005] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 01/22/2016] [Accepted: 02/10/2016] [Indexed: 01/10/2023]
Abstract
Approximately 27-37% of the general population experience prolonged sleep duration and 12-16% report shortened sleep duration. However, prolonged or shortened sleep duration may be associated with serious health problems. A comprehensive, flexible, non-linear meta-regression with restricted cubic spline (RCS) was used to investigate the dose-response relationship between sleep duration and all-cause mortality in adults. Medline (Ovid), Embase, EBSCOhost-PsycINFO, and EBSCOhost-CINAHL Plus databases, reference lists of relevant review articles, and included studies were searched up to Nov. 29, 2015. Prospective cohort studies investigating the association between sleep duration and all-cause mortality in adults with at least three categories of sleep duration were eligible for inclusion. We eventually included in our study 40 cohort studies enrolling 2,200,425 participants with 271,507 deaths. A J-shaped association between sleep duration and all-cause mortality was present: compared with 7 h of sleep (reference for 24-h sleep duration), both shortened and prolonged sleep durations were associated with increased risk of all-cause mortality (4 h: relative risk [RR] = 1.05; 95% confidence interval [CI] = 1.02-1.07; 5 h: RR = 1.06; 95% CI = 1.03-1.09; 6 h: RR = 1.04; 95% CI = 1.03-1.06; 8 h: RR = 1.03; 95% CI = 1.02-1.05; 9 h: RR = 1.13; 95% CI = 1.10-1.16; 10 h: RR = 1.25; 95% CI = 1.22-1.28; 11 h: RR = 1.38; 95% CI = 1.33-1.44; n = 29; P < 0.01 for non-linear test). With regard to the night-sleep duration, prolonged night-sleep duration was associated with increased all-cause mortality (8 h: RR = 1.01; 95% CI = 0.99-1.02; 9 h: RR = 1.08; 95% CI = 1.05-1.11; 10 h: RR = 1.24; 95% CI = 1.21-1.28; n = 13; P < 0.01 for non-linear test). Subgroup analysis showed females with short sleep duration a day (<7 h) were at high risk of all-cause mortality (4 h: RR = 1.07; 95% CI = 1.02-1.13; 5 h: RR = 1.08; 95% CI = 1.03-1.14; 6 h: RR = 1.05; 95% CI = 1.02-1.09), but males were not (4 h: RR = 1.01; 95% CI = 0.96-1.06; 5 h: RR = 1.02; 95% CI = 0.97-1.08; 6 h: RR = 1.02; 95% CI = 0.98-1.06). The current evidence suggests that insufficient or prolonged sleep may increase all-cause mortality. Women may be more susceptible to short sleep duration on all-cause mortality.
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Affiliation(s)
- Tong-Zu Liu
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China; Center for Evidence-Based Medicine, Wuhan University, Wuhan, China.
| | - Chang Xu
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China; Center for Evidence-based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Matteo Rota
- Department of Epidemiology, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Via G. La Masa 19, 20156 Milan, Italy
| | - Hui Cai
- Vanderbilt Epidemiology Center, Department of Medicine and Vanderbilt-Ingram Cancer Center, Nashville, United States
| | - Chao Zhang
- Center for Evidence-based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Ming-Jun Shi
- The French National Center for Scientific Research, UMR 144, Institute Curie, 75248 Paris, France
| | - Rui-Xia Yuan
- Department of Epidemiology and biostatistics, School of public health, Wuhan University and global health institute, Wuhan University, Wuhan, China
| | - Hong Weng
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Xiang-Yu Meng
- Center for Evidence-Based Medicine, Wuhan University, Wuhan, China
| | - Joey S W Kwong
- Chinese Evidence-Based Medicine Center, Chinese Cochrane Center, West China Hospital, Sichuan University, Chengdu, China; Center for Evidence-based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China.
| | - Xin Sun
- Chinese Evidence-Based Medicine Center, Chinese Cochrane Center, West China Hospital, Sichuan University, Chengdu, China.
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Romano AM, Gade KE, Nielsen G, Havard R, Harrison JH, Barclay J, Stukenborg GJ, Read PW, Blackhall LJ, Dillon PM. Early Palliative Care Reduces End-of-Life Intensive Care Unit (ICU) Use but Not ICU Course in Patients with Advanced Cancer. Oncologist 2017; 22:318-323. [PMID: 28220023 DOI: 10.1634/theoncologist.2016-0227] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/18/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Early palliative care for advanced cancer patients improves quality of life and survival, but less is known about its effect on intensive care unit (ICU) use at the end of life. This analysis assessed the effect of a comprehensive early palliative care program on ICU use and other outcomes among patients with advanced cancer. PATIENTS AND METHODS A retrospective cohort of patients with advanced cancer enrolled in an early palliative care program (n = 275) was compared with a concurrent control group of patients receiving standard care (n = 195) during the same time period by using multivariable logistic regression analysis. The multidisciplinary outpatient palliative care program used early end-of-life care planning, weekly interdisciplinary meetings to discuss patient status, and patient-reported outcomes assessment integrated within the electronic health record. RESULTS Patients in the control group had statistically significantly higher likelihood of ICU admission at the end of life (odds ratios [ORs]: last 6 months, 3.07; last month, 3.59; terminal admission, 4.69), higher likelihood of death in the hospital (OR, 4.14) or ICU (OR, 5.57), and lower likelihood of hospice enrollment (OR, 0.13). Use of chemotherapy or radiation did not significantly differ between groups, nor did length of ICU stay, code status, ICU procedures (other than cardiopulmonary resuscitation), disposition location, and outcomes after ICU admission. CONCLUSION Early palliative care significantly reduced ICU use at the end of life but did not change ICU events. This study supports early initiation of palliative care for advanced cancer patients before hospitalizations and intensive care. The Oncologist 2017;22:318-323 IMPLICATIONS FOR PRACTICE: Palliative care has shown clear benefit in quality of life and survival in advanced cancer patients, but less is known about its effect on intensive care. This retrospective cohort study at a university hospital showed that in the last 6 months of life, palliative care significantly reduced intensive care unit (ICU) and hospital admissions, reduced deaths in the hospital, and increased hospice enrollment. It did not, however, change patients' experiences within the ICU, such as number of procedures, code status, length of stay, or disposition. The findings further support that palliative care exerts its benefit before, rather than during, the ICU setting.
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Affiliation(s)
| | | | - Gradon Nielsen
- Department of Medicine, University of Rochester, Rochester, New York, USA
| | | | | | | | | | - Paul W Read
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
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Patient reported outcome measures of quality of end-of-life care: A systematic review. Maturitas 2016; 96:16-25. [PMID: 28041590 DOI: 10.1016/j.maturitas.2016.11.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 11/04/2016] [Indexed: 11/23/2022]
Abstract
End-of-life (EoL) care1 is increasingly used as a generic term in preference to palliative care or terminal care, particularly with reference to individuals with chronic disease, who are resident in community and long-term care (LTC) settings. This review evaluates studies based on patient reported outcome measures (PROMS) of quality of EoL care across all health-care settings. From 1041 citations, 12 studies were extracted by searches conducted in EBSCO, Scopus, Web of Science, PubMed, Cochrane, Open Grey and Google Scholar databases. At present, the evidence base for EoL care is founded on cancer care. This review highlights the paucity of studies that evaluate quality of EoL care for patients with chronic disease outside the established cancer-acute care paradigm, particularly in LTC. This review highlights the absence of any PROMs for the estimated 60% of patients in LTC with cognitive impairment. Patient-reported outcomes (PROs) are critical to understanding how EoL care services and practices affect patients' health and EoL experience. PROMs describe the quality of care from the patient's perspective and add balance to existing clinical or proxy-derived knowledge on the quality of care and services provided.
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Halpern MT, Urato MP, Kent EE. The health care experience of patients with cancer during the last year of life: Analysis of the SEER-CAHPS data set. Cancer 2016; 123:336-344. [PMID: 27654842 DOI: 10.1002/cncr.30319] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 07/02/2016] [Accepted: 08/05/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Providing high-quality medical care for individuals with cancer during their last year of life involves a range of challenges. An important component of high-quality care during this critical period is ensuring optimal patient satisfaction. The objective of the current study was to assess factors influencing health care ratings among individuals with cancer within 1 year before death. METHODS The current study used the Surveillance, Epidemiology, and End Results (SEER)-Consumer Assessment of Healthcare Providers and Systems (CAHPS) data set, a new data resource linking patient-reported information from the CAHPS Medicare Survey with clinical information from the National Cancer Institute's SEER program. The study included 5102 Medicare beneficiaries diagnosed with cancer who completed CAHPS between 1998 and 2011 within 1 year before their death. Multivariable logistic regression analyses examined associations between patient demographic and insurance characteristics with 9 measures of health care experience. RESULTS Patients with higher general or mental health status were significantly more likely to indicate excellent experience with nearly all measures examined. Sex, race/ethnicity, and education also were found to be significant predictors for certain ratings. Greater time before death predicted an increased likelihood of higher ratings for health plan and specialist physician. Clinical characteristics were found to have few significant associations with experience of care. Individuals in fee-for-service Medicare plans (vs Medicare Advantage) had a greater likelihood of excellent experience with health plans, getting care quickly, and getting needed care. CONCLUSIONS Among patients with cancer within 1 year before death, experience with health plans, physicians, and medical care were found to be associated with sociodemographic, insurance, and clinical characteristics. These findings provide guidance for the development of programs to improve the experience of care among individuals with cancer. Cancer 2017;123:336-344. © 2016 American Cancer Society.
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Affiliation(s)
- Michael T Halpern
- RTI International, Research Triangle Park, North Carolina.,Department of Health Services Administration and Policy, Temple University College of Public Health, Philadelphia, Pennsylvania
| | | | - Erin E Kent
- Outcomes Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
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Abstract
Hospices are required to provide pharmaceuticals under the Medicare Hospice Benefit. Since there are no data describing these costs for hospice programs, this study analyzes data from a cross-sectional survey of 34 hospices concerning their pharmaceutical cost trends. Most respondents reported higher pharmaceutical-related costs between 1998 and 2002, but a significant minority reported that their costs had decreased. Pharmaceutical costs varied by patient setting, but long-acting opioids and continuous-infusion delivery systems were the two most significant contributors. A variety of mechanisms were employed to control drug costs.
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Affiliation(s)
- David Nowels
- Department of Family Medicine, University of Colorado Health Sciences Center, Aurora, Colorado, USA
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Rocker G, Downar J, Morrison RS. Palliative care for chronic illness: driving change. CMAJ 2016; 188:E493-E498. [PMID: 27551031 DOI: 10.1503/cmaj.151454] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Graeme Rocker
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
| | - James Downar
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
| | - R Sean Morrison
- Department of Medicine (Rocker), Dalhousie University, Halifax, NS; Division of Respirology (Rocker), QEII Health Sciences Centre, Halifax, NS; Palliative Care and Critical Care (Downar), University Health Network, Toronto, Ont.; Divisions of Critical Care and Palliative Care (Downar), University of Toronto, Toronto, Ont.; National Palliative Care Research Center (Morrison), New York, NY; Hertzberg Palliative Care Institute (Morrison), Mt. Sinai School of Medicine, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine (Morrison), Icahn School of Medicine at Mount Sinai, New York, NY
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Jarosek SL, Shippee TP, Virnig BA. Place of Death of Individuals with Terminal Cancer: New Insights from Medicare Hospice Place-of-Service Codes. J Am Geriatr Soc 2016; 64:1815-22. [PMID: 27534517 DOI: 10.1111/jgs.14269] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To use place-of-service (POS) codes in the Medicare hospice claims files to document where elderly hospice users with cancer die. DESIGN Retrospective cohort study. SETTING Surveillance, Epidemiology, and End Results (SEER) cancer registry areas. PARTICIPANTS Elderly Medicare beneficiaries who died of lung, breast, colorectal, or pancreatic cancer in 2007 and 2008 (N = 46,037). MEASUREMENT Use of hospice, place of service at death (home, nursing home, hospital, inpatient hospice, other), length of stay in hospice. RESULTS Two-thirds of the beneficiaries used hospice. Younger, male, black, Asian, and unmarried beneficiaries and those enrolled in fee-for-service Medicare or from areas with lower income were less likely to use hospice. Hospice enrollment also varied significantly according to SEER registry. Thirty percent of the hospice users were not receiving home-based care at the time of death, and 17% were enrolled for less than 3 days. Factors associated with hospice death in the home mirrored those associated with hospice use. Individuals dying in hospitals (odds ratio (OR) = 5.13, 95% confidence interval (CI) = 4.63-5.69), inpatient hospice (OR = 1.86, 95% CI = 1.70-2.02), and nursing homes (OR = 1.19, 95% CI = 1.10-1.28) had greater odds of a short hospice stay (≤7 days) than those dying at home, after controlling for all other measured factors, whereas those dying in nursing homes had greater odds of long stays (>180 days) (OR = 1.46, 95% CI = 1.28-1.67). CONCLUSION New hospice POS codes are useful for understanding place of death for hospice users. Hospice deaths cannot be assumed to happen at home.
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Affiliation(s)
- Stephanie L Jarosek
- Department of Urology, Medical School, University of Minnesota, Minneapolis, Minnesota.
| | - Tetyana P Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Beth A Virnig
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
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Waldrop DP, Meeker MA, Kutner JS. Is It the Difference a Day Makes? Bereaved Caregivers' Perceptions of Short Hospice Enrollment. J Pain Symptom Manage 2016; 52:187-195.e1. [PMID: 27233144 PMCID: PMC4996677 DOI: 10.1016/j.jpainsymman.2016.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/17/2016] [Accepted: 04/06/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Hospice enrollment for less than one month has been considered too late by some caregivers and at the right time for others. Perceptions of the appropriate time for hospice enrollment in cancer are not well understood. OBJECTIVES The objectives of the study were to identify contributing factors of hospice utilization in cancer for ≤7 days, to describe and compare caregivers' perceptions of this as "too late" or at the "right time." METHODS Semistructured, in-depth, in-person interviews were conducted with a sample subgroup of 45 bereaved caregivers of people who died from cancer within seven days of hospice enrollment. Interviews were transcribed and entered into Atlas.ti for coding. Data were grouped by participants' perceptions of the enrollment as "right time" or "too late." RESULTS Overall, the mean length of enrollment was MLOE = 3.77 (SD = 1.8) days and ranged from three hours to seven days. The "right time" group (N = 25 [56%]) had a MLOE = 4.28 (SD = 1.7) days. The "too late" group (N = 20 [44%]) had a MLOE = 3.06 (SD = 1.03) days. The difference was statistically significant (P = 0.029). Precipitating factors included: late-stage diagnosis, continuing treatment, avoidance, inadequate preparation, and systems barriers. The "right time" experience was characterized by: perceived comfort, family needs were met, preparedness for death. The "too late" experience was characterized by perceived suffering, unprepared for death, and death was abrupt. CONCLUSION The findings suggest that one more day of hospice care may increase perceived comfort, symptom management, and decreased suffering and signal the need for rapid response protocols.
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Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work, Buffalo, New York, USA.
| | - Mary Ann Meeker
- University at Buffalo School of Nursing, Buffalo, New York, USA
| | - Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Kwok AO, Yuen SK, Yong DS, Tse DM. The Symptoms Prevalence, Medical Interventions, and Health Care Service Needs for Patients With End-Stage Renal Disease in a Renal Palliative Care Program. Am J Hosp Palliat Care 2016; 33:952-958. [DOI: 10.1177/1049909115598930] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A retrospective study was conducted to evaluate the symptoms prevalence and interventions initiated in the last 2 weeks of life, health care service utilization, and causes of death of patients with end-stage renal disease (ESRD under a renal palliative care (RPC) program. A total of 335 RPC patients were included, of which 226 patients died during the study period. The 5 most prevalent symptoms were dyspnea (63.7%), fatigue (51.8%), edema (48.2%), pain (44.2%), and anorexia (38.1%); and the 5 most prevalent interventions initiated were oxygen (69.5%), parenteral infusion (67.3%), antibiotics (53.5%), bladder catheterization (44.7%), and analgesic (39.8%) in the last 2 weeks of life. Each patient received 3.5 ± 4.4 outpatient clinic visit, 3.4 ± 10.3 home care visits, and 3.1 ± 2.7 hospital admissions. Besides ESRD (51.8%), the most common causes of death were cardiovascular events (18.6%) and infection (17.2%).
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Affiliation(s)
- Annie O. Kwok
- Department of Medicine & Geriatrics, Caritas Medical Centre, Kowloon, Hong Kong SAR
| | - Sze-kit Yuen
- Department of Medicine & Geriatrics, Caritas Medical Centre, Kowloon, Hong Kong SAR
| | - David S. Yong
- Department of Medicine & Geriatrics, Caritas Medical Centre, Kowloon, Hong Kong SAR
| | - Doris M. Tse
- Department of Medicine & Geriatrics, Caritas Medical Centre, Kowloon, Hong Kong SAR
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El-Jawahri A, Paasche-Orlow MK, Matlock D, Stevenson LW, Lewis EF, Stewart G, Semigran M, Chang Y, Parks K, Walker-Corkery ES, Temel JS, Bohossian H, Ooi H, Mann E, Volandes AE. Randomized, Controlled Trial of an Advance Care Planning Video Decision Support Tool for Patients With Advanced Heart Failure. Circulation 2016; 134:52-60. [PMID: 27358437 PMCID: PMC4933326 DOI: 10.1161/circulationaha.116.021937] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/13/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Conversations about goals of care and cardiopulmonary resuscitation (CPR)/intubation for patients with advanced heart failure can be difficult. This study examined the impact of a video decision support tool and patient checklist on advance care planning for patients with heart failure. METHODS This was a multisite, randomized, controlled trial of a video-assisted intervention and advance care planning checklist versus a verbal description in 246 patients ≥64 years of age with heart failure and an estimated likelihood of death of >50% within 2 years. Intervention participants received a verbal description for goals of care (life-prolonging care, limited care, and comfort care) and CPR/intubation plus a 6-minute video depicting the 3 levels of care, CPR/intubation, and an advance care planning checklist. Control subjects received only the verbal description. The primary analysis compared the proportion of patients preferring comfort care between study arms immediately after the intervention. Secondary outcomes were CPR/intubation preferences and knowledge (6-item test; range, 0-6) after intervention. RESULTS In the intervention group, 27 (22%) chose life-prolonging care, 31 (25%) chose limited care, 63 (51%) selected comfort care, and 2 (2%) were uncertain. In the control group, 50 (41%) chose life-prolonging care, 27 (22%) selected limited care, 37 (30%) chose comfort care, and 8 (7%) were uncertain (P<0.001). Intervention participants (compared with control subjects) were more likely to forgo CPR (68% versus 35%; P<0.001) and intubation (77% versus 48%; P<0.001) and had higher mean knowledge scores (4.1 versus 3.0; P<0.001). CONCLUSIONS Patients with heart failure who viewed a video were more informed, more likely to select a focus on comfort, and less likely to desire CPR/intubation compared with patients receiving verbal information only. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01589120.
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Affiliation(s)
- Areej El-Jawahri
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.).
| | - Michael K Paasche-Orlow
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Dan Matlock
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Lynne Warner Stevenson
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Eldrin F Lewis
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Garrick Stewart
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Marc Semigran
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Yuchiao Chang
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Kimberly Parks
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Elizabeth S Walker-Corkery
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Jennifer S Temel
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Hacho Bohossian
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Henry Ooi
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Eileen Mann
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
| | - Angelo E Volandes
- From Massachusetts General Hospital, Boston (A.E.-J., M.S., Y.C., K.P., E.S.W.-C., J.S.T., E.M., A.E.V.); Harvard Medical School, Boston, MA (A.E.-J., L.S., E.F.L., G.S., M.S., Y.C., K.P., E.S.W.-C., J.S.T., A.E.V.); Boston University School of Medicine, MA (M.K.P.-O.); University of Colorado School of Medicine, Aurora (D.M.); Brigham and Women's Hospital, Boston, MA (L.S., E.F.L., G.S.); Newton-Wellesley Hospital, Newton, MA (H.B.); Tufts University School of Medicine, Boston, MA (H.B.); Vanderbilt University Medical Center, Nashville, TN (H.O.); and Nashville Veterans Administration Medical Center, TN (H.O.)
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Davis MA, Nallamothu BK, Banerjee M, Bynum JPW. Identification Of Four Unique Spending Patterns Among Older Adults In The Last Year Of Life Challenges Standard Assumptions. Health Aff (Millwood) 2016; 35:1316-23. [PMID: 27307350 PMCID: PMC5046841 DOI: 10.1377/hlthaff.2015.1419] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The assumption that health care spending skyrockets at the end of life might suggest that policy makers should target the last few months of life to control costs. However, spending patterns leading up to death have not been fully examined. We applied a new methodology to administrative claims data for older Medicare beneficiaries who died in 2012 to characterize trajectories of health care spending in the last year of life. After adjustment, we identified four unique spending trajectories among decedents: 48.7 percent had high persistent spending, 29.0 percent had moderate persistent spending, 10.2 percent had progressive spending, and 12.1 percent had late rise spending. High spending throughout the full year before death (approximately half of all decedents) was associated with having multiple chronic conditions but not any specific diseases. These findings suggest that spending at the end of life is a marker of general spending patterns often set in motion long before death.
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Affiliation(s)
- Matthew Allen Davis
- Matthew Allen Davis is an assistant professor in the Department of Systems, Populations, and Leadership at the University of Michigan School of Nursing, in Ann Arbor; a faculty affiliate of the University of Michigan Institute for Social Research; and an adjunct assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, in Lebanon, New Hampshire
| | - Brahmajee K Nallamothu
- Brahmajee K. Nallamothu is an associate professor in the Department of Internal Medicine in the Division of Cardiovascular Medicine at the University of Michigan Medical School, an investigator at the Center for Clinical Management Research at the Ann Arbor VA Medical Center, and director of the Michigan Center for Health Analytics and Medical Prediction
| | - Mousumi Banerjee
- Mousumi Banerjee is a research professor of biostatistics at the University of Michigan School of Public Health
| | - Julie P W Bynum
- Julie P. W. Bynum is an associate professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
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Abstract
Objective: To profile communication and recommendations reported by adults with terminal illness and explore differences by patient and physician characteristics. Method: This pilot was a cross-sectional study sample of 90 patients (39 Caucasian, 51 African American) with advanced heart failure or cancer. Participants completed an in-person, race-matched interview. Results: Participation was high (94%). Discussion about end-of-life topics was low. For example, only 30% reported discussion of advance directives, and 22% reported their physician inquired about spiritual support. Participants with cancer were significantly more likely to be receiving pain and/or symptom management at home, aware of prognosis, and participating in hospice. African American participants who were under the care of African American physicians were less likely to report pain and/or symptom management than other racial matches. Discussion: Although additional research on factors related to communication is important, initiation of patient-centered counseling by all physicians with seriously ill patients is essential.
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Cholankeril G, Hu M, Tanner E, Cholankeril R, Reha J, Somasundar P. Skilled nursing facility placement in hospitalized elderly patients with colon cancer. Eur J Surg Oncol 2016; 42:1660-1666. [PMID: 27387271 DOI: 10.1016/j.ejso.2016.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/10/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND The current study sought to determine predictive risk factors and inpatient resource utilization associated with discharge to skilled nursing facility (SNF) in hospitalized elderly patients with colon cancer. MATERIALS AND METHODS Inpatient data from U.S. community hospital discharges from 2003 to 2011 was analyzed in a retrospective cohort study using the Healthcare Cost and Utilization Project, National Inpatient Sample (HCUP-NIS). Subjects included hospitalized postoperative colon cancer patients over age of 65 (N = 98,797). RESULTS The proportion of elderly colon cancer patients discharged to a SNF increased by 16.67% from 2003 to 2011 (18-21%). Elderly patients discharged to a SNF had increased hospitalization costs (+$10,293.70, p < 0.01) compared to elderly colon cancer patients discharged home. Hospitalization predictive risk factors associated with SNF placement include age above 75 (OR, 4.07; 95% CI, 3.90, 4.25; p < 0.01), paralysis (OR, 3.60; 95% CI, 3.06-4.23; p < 0.01), length of stay (LOS) 10 days or more (OR, 3.00; 95% CI, 2.88-3.13; p < 0.01), psychoses (OR, 2.91; 95% CI, 2.56-3.32; p < 0.01), and neurological disorders (OR, 2.34; 95% CI, 2.17-2.52; p < 0.01). CONCLUSIONS Despite increased costs and worse clinical outcomes associated with SNF placement, over 40% increase of hospital discharge to SNF should be anticipated from this population over the next 20 years. Neurologic and psychiatric comorbidities have significantly negative clinical impacts and increase the likelihood of colon cancer patients' discharge to a SNF.
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Affiliation(s)
- G Cholankeril
- Department of Internal Medicine, 825 Chalkstone Avenue, Roger Williams Medical Center, Providence, RI, 02908, United States; Department of Medicine, 72 East Concord Street, Boston University School of Medicine, Boston, MA, 02118, United States.
| | - M Hu
- Department of Biostatistics, 121 South Main Street, Brown University School of Public Health, Providence, RI, 02903, United States
| | - E Tanner
- Department of Internal Medicine, 825 Chalkstone Avenue, Roger Williams Medical Center, Providence, RI, 02908, United States; Department of Medicine, 72 East Concord Street, Boston University School of Medicine, Boston, MA, 02118, United States
| | - R Cholankeril
- Department of Internal Medicine, 825 Chalkstone Avenue, Roger Williams Medical Center, Providence, RI, 02908, United States
| | - J Reha
- Department of Surgical Oncology, 825 Chalkstone Avenue, Roger Williams Medical Center, Providence, RI, 02908, United States
| | - P Somasundar
- Department of Surgical Oncology, 825 Chalkstone Avenue, Roger Williams Medical Center, Providence, RI, 02908, United States
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Pak E, Wald J, Kirkpatrick JN. Multimorbidity and End of Life Care in Patients with Cardiovascular Disease. Clin Geriatr Med 2016; 32:385-97. [DOI: 10.1016/j.cger.2016.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Narang AK, Wright AA, Nicholas LH. Trends in Advance Care Planning in Patients With Cancer: Results From a National Longitudinal Survey. JAMA Oncol 2016; 1:601-8. [PMID: 26181909 DOI: 10.1001/jamaoncol.2015.1976] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Advance care planning (ACP) may prevent end-of-life (EOL) care that is nonbeneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether participation in ACP by patients with cancer has increased over time. OBJECTIVES To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences and to explore associations between ACP subtypes and EOL treatment intensity as reflected in EOL care decisions and terminal hospitalizations. DESIGN, SETTING, AND PARTICIPANTS We analyzed prospectively collected survey data from 1985 next-of-kin surrogates of Health and Retirement Study (HRS) participants with cancer who died between 2000 and 2012, including data from in-depth "exit" interviews conducted with the surrogates after the participant's death. The HRS is a nationally representative, biennial, longitudinal panel study of US residents older than 50 years. Trends in ACP subtypes were tested, and multivariable logistic regression models examined for associations between ACP subtypes and measures of treatment intensity. MAIN OUTCOMES AND MEASURES Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences; associations between ACP subtypes and both surrogate-reported EOL care decisions and terminal hospitalizations. RESULTS From 2000 to 2012, there was an increase in DPOA assignment (52% to 74%, P = .03), without significant change in use of living wills (49% to 40%, P = .63) or EOL discussions (68% to 60%, P = .62). Surrogate reports that patients received "all care possible" at EOL increased during the period (7% to 58%, P = .004), and rates of terminal hospitalizations were unchanged (29% to 27%, P = .70). Limiting or withholding treatment was associated with living wills (adjusted odds ratio [AOR], 2.51; 95% CI, 1.53-4.11; P < .001) and EOL discussions (AOR, 1.93; 95% CI, 1.53-3.14; P = .002) but not with DPOA assignment. CONCLUSIONS AND RELEVANCE Use of DPOA increased significantly between 2000 and 2012 but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision makers are critically needed to ensure receipt of goal-concordant care.
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Affiliation(s)
- Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexi A Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts3Harvard Medical School, Boston, Massachusetts
| | - Lauren H Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland5Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Affiliation(s)
- YongJoo Rhee
- Department of Health Sciences, Dongduk Women’s University, Seoul, Korea
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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da Silva AA, de Mello RGB, Schaan CW, Fuchs FD, Redline S, Fuchs SC. Sleep duration and mortality in the elderly: a systematic review with meta-analysis. BMJ Open 2016; 6:e008119. [PMID: 26888725 PMCID: PMC4762152 DOI: 10.1136/bmjopen-2015-008119] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE The purpose of our study was to evaluate the association between short and long sleep duration and all-cause and cardiovascular mortality among elderly individuals. DESIGN Systematic review and meta-analysis of population-based cohort studies. SETTING Articles were retrieved from international and national electronic databases. STUDY SELECTION Studies were identified in PubMed, EMBASE, LILACS (Latin American and Caribbean Health Sciences Literature), IBECS (Bibliographic Index on Health Sciences from Spain) and CAPES (PhD thesis repository) between 1980 and 2015. Studies which met all criteria were eligible: participants aged 60 years or over, assessment of sleep duration as 24 h, nighttime or daytime sleep, evaluation of all-cause or cause-specific mortality, population-based cohort studies conducted on representative samples. There was no language restriction and studies published as abstracts were excluded. DATA EXTRACTION Data were analysed using the Comprehensive Meta-Analysis software (V.3.3.070), and summary estimates (relative risk (RR), 95% CI) were calculated using a random effects model. Heterogeneity and consistency were evaluated through Cochran's Q and the I(2) statistics, respectively, and sensitivity analyses were conducted. PRIMARY AND SECONDARY OUTCOME MEASURES All-cause and cardiovascular mortality. RESULTS Overall, 27 cohort studies were selected, comprising >70,000 elderly individuals, and followed up from 3.4 to 35 years. In the pooled analysis, long and short sleep duration were associated with increased all-cause mortality (RR 1.33; 95% CI 1.24 to 1.43 and RR 1.07; 95% CI 1.03 to 1.11, respectively), compared with the reference category. For cardiovascular mortality, the pooled relative risks were 1.43 (95% CI 1.15 to 1.78) for long sleep, and 1.18 (95% CI 0.76 to 1.84) for short sleep. Daytime napping ≥ 30 min was associated with risk of all-cause mortality (RR 1.27; 95% CI 1.08 to 1.49), compared with no daytime sleep, but longer sleep duration (≥ 2.0 h) was not (RR 1.34; 95% CI 1.95 to 1.90). CONCLUSIONS Among elderly individuals, long and short sleep duration are associated with increased risk for all-cause mortality. Long sleep duration is associated with cardiovascular mortality.
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Affiliation(s)
- Andressa Alves da Silva
- Postgraduate Studies Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Renato Gorga Bandeira de Mello
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Camila Wohlgemuth Schaan
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Flávio D Fuchs
- Division of Cardiology, National Institute for Health Technology Assessment (IATS/CNPq), Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Susan Redline
- Department of Medicine, Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sandra C Fuchs
- Postgraduate Studies Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Calanzani N, Higginson IJ, Koffman J, Gomes B. Factors Associated with Participation, Active Refusals and Reasons for Not Taking Part in a Mortality Followback Survey Evaluating End-of-Life Care. PLoS One 2016; 11:e0146134. [PMID: 26745379 PMCID: PMC4706352 DOI: 10.1371/journal.pone.0146134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 12/14/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Examination of factors independently associated with participation in mortality followback surveys is rare, even though these surveys are frequently used to evaluate end-of-life care. We aimed to identify factors associated with 1) participation versus non-participation and 2) provision of an active refusal versus a silent refusal; and systematically examine reasons for refusal in a population-based mortality followback survey. METHODS Postal survey about the end-of-life care received by 1516 people who died from cancer (aged ≥18), identified through death registrations in London, England (response rate 39.3%). The informant of death (a relative in 95.3% of cases) was contacted 4-10 months after the patient died. We used multivariate logistic regression to identify factors associated with participation/active refusals and content analysis to examine refusal reasons provided by 205 nonparticipants. FINDINGS The odds of partaking were higher for patients aged 90+ (AOR 3.48, 95%CI: 1.52-8.00, ref: 20-49yrs) and female informants (AOR 1.70, 95%CI: 1.33-2.16). Odds were lower for hospital deaths (AOR 0.62, 95%CI: 0.46-0.84, ref: home) and proxies other than spouses/partners (AORs 0.28 to 0.57). Proxies of patients born overseas were less likely to provide an active refusal (AOR 0.49; 95% CI: 0.32-0.77). Refusal reasons were often multidimensional, most commonly study-related (36.0%), proxy-related and grief-related (25.1% each). One limitation of this analysis is the large number of nonparticipants who did not provide reasons for refusal (715/920). CONCLUSIONS Our survey better reached proxies of older patients while those dying in hospitals were underrepresented. Proxy characteristics played a role, with higher participation from women and spouses/partners. More information is needed about the care received by underrepresented groups. Study design improvements may guide future questionnaire development and help develop strategies to increase response rates.
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Affiliation(s)
- Natalia Calanzani
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
- University of Edinburgh, The Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, Medical School, Edinburgh, United Kingdom
- * E-mail:
| | - Irene J Higginson
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
| | - Jonathan Koffman
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
| | - Barbara Gomes
- King’s College London, Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, London, United Kingdom
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85
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Adorno G. Between Two Worlds: Liminality and Late-Stage Cancer-Directed Therapy. OMEGA-JOURNAL OF DEATH AND DYING 2015; 71:99-125. [PMID: 26625508 DOI: 10.1177/0030222815570589] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Disease-directed therapy near death is a growing trend among persons living with late-stage cancer. As a sociocultural phenomenon, cancer-directed therapy (e.g., chemotherapy) when given for very advanced disease is a process that offers questionable benefits and portends further suffering, but also suggests potential for growth and transcendence. Theories and concepts drawn from cultural anthropology, sociology, and existentialism illustrate how contextual factors contribute to the creation of a "liminal space"; the latter part of the cancer trajectory where living and dying can overlap. When applied to clinical practice, this theoretical framework gives the patient, family, and health care provider a way of "unmasking" a period of transition during terminal illness when aggressive disease-directed care continues to be provided. The liminal space may function as an existential plane; a gateway or threshold with inherent potential for psychospiritual development during the final stage of life.
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Blackhall LJ, Read P, Stukenborg G, Dillon P, Barclay J, Romano A, Harrison J. CARE Track for Advanced Cancer: Impact and Timing of an Outpatient Palliative Care Clinic. J Palliat Med 2015; 19:57-63. [PMID: 26624851 DOI: 10.1089/jpm.2015.0272] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Studies suggest that outpatient palliative care can reduce hospitalization and increase hospice utilization for patients with cancer, however there are insufficient resources to provide palliative care to all patients from time of diagnosis. It is also unclear whether inpatient consultation alone provides similar benefits. A better understanding of the timing, setting, and impact of palliative care for patients with cancer is needed. OBJECTIVES The purpose of this study was to measure timing of referral to outpatient palliative care and impact on end-of-life (EOL) care. DESIGN The Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track) program is a phased intervention integrating outpatient palliative care into cancer care. In Year 1 patients were referred at the discretion of their oncologist. SETTING Academic medical center. MEASUREMENTS We compared EOL hospitalization, hospice utilization, and costs of care for CARE Track patients compared to those never seen by palliative care or seen only in hospital. RESULTS Patients were referred a median of 72.5 days prior to death. CARE Track patients had few hospitalizations at end of life, were less likely to die in hospital, had increased hospice utilization, and decreased costs of care; these results were significant even after controlling for differences between groups. Inpatient consultation alone did not impact these variables. However, only approximately half of patients with incurable cancers were referred to this program. CONCLUSION Referral outpatient palliative care within 3 months of death improved EOL care and reduced costs, benefits not seen with inpatient care only. However, many patients were never referred, and methods of systematically identifying appropriate patients are needed.
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Affiliation(s)
- Leslie J Blackhall
- 1 Department of Palliative Care, University of Virginia , Charlottesville, Virginia.,2 Department of Internal Medicine, University of Virginia , Charlottesville, Virginia
| | - Paul Read
- 3 Department of Public Health Sciences, University of Virginia , Charlottesville, Virginia
| | - George Stukenborg
- 4 Department of Health Services Research, University of Virginia , Charlottesville, Virginia
| | - Patrick Dillon
- 5 Department of Medical Oncology, University of Virginia , Charlottesville, Virginia
| | - Joshua Barclay
- 2 Department of Internal Medicine, University of Virginia , Charlottesville, Virginia
| | - Andrew Romano
- 5 Department of Medical Oncology, University of Virginia , Charlottesville, Virginia
| | - James Harrison
- 3 Department of Public Health Sciences, University of Virginia , Charlottesville, Virginia
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Miyashita M, Morita T, Sato K, Tsuneto S, Shima Y. A Nationwide Survey of Quality of End-of-Life Cancer Care in Designated Cancer Centers, Inpatient Palliative Care Units, and Home Hospices in Japan: The J-HOPE Study. J Pain Symptom Manage 2015; 50:38-47.e3. [PMID: 25656327 DOI: 10.1016/j.jpainsymman.2015.01.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/28/2014] [Accepted: 01/07/2015] [Indexed: 11/28/2022]
Abstract
CONTEXT End-of-life (EOL) cancer care in general hospitals and home care has not previously been evaluated in Japan. OBJECTIVES This study aimed to evaluate EOL cancer care from the perspective of bereaved family members in nationwide designated cancer centers, inpatient palliative care units (PCUs), and home hospices in Japan. METHODS We conducted a cross-sectional, anonymous, self-report questionnaire survey for bereaved family members of cancer patients in March 2008 for 56 designated cancer centers and in June 2007 for 100 PCUs and 14 home hospices. Outcomes were overall care satisfaction, structure and process of care (Care Evaluation Scale), and achievement of a good death (Good Death Inventory). RESULTS In designated cancer centers, PCUs, and home hospices, 2794 (response rate 59%), 5312 (response rate 69%), and 292 (response rate 67%) bereaved family members participated, respectively. Mean scores for overall care satisfaction were high for all places of death, at 4.3 ± 1.2 for designated cancer centers, 5.0 ± 1.2 for PCUs, and 5.0 ± 1.0 for home hospices. Designated cancer centers showed significantly lower ratings than PCUs and home hospices for structure and process of care and achievement of a good death (P = 0.0001 each). Home hospices were rated significantly higher than PCUs for achievement of a good death (P = 0.0001). CONCLUSION The main findings of this study were: (1) overall, bereaved family members were satisfied with end-of-life care in all three places of death; (2) designated cancer centers were inferior to PCUs and home hospices and had more room for improvement; and 3) home hospices were rated higher than PCUs for achieving a good death, although home hospices remain uncommon in Japan.
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Affiliation(s)
- Mitsunori Miyashita
- Department of Adult Nursing/Palliative Care Nursing, School of Health Sciences and Nursing Sciences, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan; Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team and Seirei Hospice, Seirei Mikatahara Hospital, Hamamatsu, Japan
| | - Kazuki Sato
- Department of Adult Nursing/Palliative Care Nursing, School of Health Sciences and Nursing Sciences, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan; Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
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Bainbridge D, Seow H, Sussman J, Pond G, Barbera L. Factors associated with not receiving homecare, end-of-life homecare, or early homecare referral among cancer decedents: A population-based cohort study. Health Policy 2015; 119:831-9. [DOI: 10.1016/j.healthpol.2014.11.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 10/27/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
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Wolf DA, Freedman VA, Ondrich JI, Seplaki CL, Spillman BC. Disability Trajectories at the End of Life: A "Countdown" Model. J Gerontol B Psychol Sci Soc Sci 2015; 70:745-52. [PMID: 25740918 DOI: 10.1093/geronb/gbu182] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Studies of late-life disablement typically address the role of advancing age as a factor in developing disability, and in some cases have pointed out the importance of time to death (TTD) in understanding changes in functioning. However, few studies have addressed both factors simultaneously, and none have dealt satisfactorily with the problem of missing data on TTD in panel studies. METHODS We fit latent-class trajectory models of disablement using data from the Health and Retirement Study. Among survivors (~20% of the sample), TTD is unknown, producing a missing-data problem. We use an auxiliary regression equation to impute TTD and employ multiple imputation techniques to obtain final parameter estimates and standard errors. RESULTS Our best-fitting model has 3 latent classes. In all 3 classes, the probability of having a disability increases with nearness to death; however, in only 2 of the 3 classes is age associated with disability. We find gender, race, and educational differences in class-membership probabilities. DISCUSSION The model reveals a complex pattern of age- and time-dependent heterogeneity in late-life disablement. The techniques developed here could be applied to other phenomena known to depend on TTD, such as cognitive change, weight loss, and health care spending.
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Affiliation(s)
| | - Vicki A Freedman
- Institute for Social Research, University of Michigan, Ann Arbor
| | - Jan I Ondrich
- Center for Policy Research, Syracuse University, New York
| | - Christopher L Seplaki
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, New York
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90
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Washington KT, Pike KC, Demiris G, Oliver DP. Unique characteristics of informal hospice cancer caregiving. Support Care Cancer 2014; 23:2121-8. [PMID: 25547480 DOI: 10.1007/s00520-014-2570-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 12/15/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to describe the unique characteristics of informal hospice cancer caregiving. METHODS Researchers conducted a secondary analysis of data drawn from a randomized clinical trial of an informal hospice caregiving intervention (N = 348). Demographic characteristics and measures of the informal caregiving experience of hospice patients and their informal caregivers were compared based on the patient's diagnosis using chi-square tests for association of categorical variables and t tests for continuous variables. RESULTS Informal caregivers of cancer patients differed from their non-cancer counterparts in a number of respects including patient age, caregiver age, patient residence, relationship between patient and caregiver, amount and duration of care provided, likelihood to incur out-of-pocket expenses related to patient care, caregiver problem-solving style, and impact on caregiver daily schedule. There were no statistically significant differences between cancer and non-cancer caregivers in terms of gender, race, employment status, anxiety, and quality of life. CONCLUSIONS While cancer and non-cancer caregivers are similar in many respects, a number of unique features characterize the informal hospice cancer caregiving experience. Attention to these unique features will allow hospice providers to tailor supportive care interventions to better address cancer caregivers' needs.
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Affiliation(s)
- Karla T Washington
- Department of Family and Community Medicine, School of Medicine, University of Missouri, MA306 Medical Sciences Building, DC032.00, Columbia, MO, 65212, USA,
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91
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Palliative care among heart failure patients in primary care: a comparison to cancer patients using English family practice data. PLoS One 2014. [PMID: 25423169 DOI: 10.1371/journal.pone.0113188.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Patients with heart failure have a significant symptom burden and other palliative care needs often over a longer period than patients with cancer. It is acknowledged that this need may be unmet but by how much has not been quantified in primary care data at the population level. METHODS This was the first use of Clinical Practice Research Datalink, the world's largest primary care database to explore recognition of the need for palliative care. Heart failure and cancer patients who had died in 2009 aged 18 or over and had at least one year of primary care records were identified. A palliative approach to care among patients with heart failure was compared to that among patients with cancer using entry onto a palliative care register as a marker for a palliative approach to care. RESULTS Among patients with heart failure, 7% (234/3 122) were entered on the palliative care register compared to 48% (3 669/7 608) of cancer patients. Of heart failure patients on the palliative care register, 29% (69/234) were entered onto the register within a week of their death. CONCLUSIONS This confirms that the stark inequity in recognition of palliative care needs for people with heart failure in a large primary care dataset. We recommend a move away from prognosis based criteria for palliative care towards a patient centred approach, with assessment of and attention to palliative needs including advance care planning throughout the disease trajectory.
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92
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Gadoud A, Kane E, Macleod U, Ansell P, Oliver S, Johnson M. Palliative care among heart failure patients in primary care: a comparison to cancer patients using English family practice data. PLoS One 2014; 9:e113188. [PMID: 25423169 PMCID: PMC4244094 DOI: 10.1371/journal.pone.0113188] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 10/27/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Patients with heart failure have a significant symptom burden and other palliative care needs often over a longer period than patients with cancer. It is acknowledged that this need may be unmet but by how much has not been quantified in primary care data at the population level. METHODS This was the first use of Clinical Practice Research Datalink, the world's largest primary care database to explore recognition of the need for palliative care. Heart failure and cancer patients who had died in 2009 aged 18 or over and had at least one year of primary care records were identified. A palliative approach to care among patients with heart failure was compared to that among patients with cancer using entry onto a palliative care register as a marker for a palliative approach to care. RESULTS Among patients with heart failure, 7% (234/3 122) were entered on the palliative care register compared to 48% (3 669/7 608) of cancer patients. Of heart failure patients on the palliative care register, 29% (69/234) were entered onto the register within a week of their death. CONCLUSIONS This confirms that the stark inequity in recognition of palliative care needs for people with heart failure in a large primary care dataset. We recommend a move away from prognosis based criteria for palliative care towards a patient centred approach, with assessment of and attention to palliative needs including advance care planning throughout the disease trajectory.
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Affiliation(s)
- Amy Gadoud
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, East Yorkshire, United Kingdom
| | - Eleanor Kane
- Department of Health Sciences, University of York, York, North Yorkshire, United Kingdom
| | - Una Macleod
- Primary Care Medicine, Hull York Medical School, University of Hull, Hull, East Yorkshire, United Kingdom
| | - Pat Ansell
- Department of Health Sciences, University of York, York, North Yorkshire, United Kingdom
| | - Steven Oliver
- Population Health, Department of Health Sciences and Hull York Medical School, University of York, York, North Yorkshire, United Kingdom
| | - Miriam Johnson
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, East Yorkshire, United Kingdom
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93
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Tang ST, Liu LN, Lin KC, Chung JH, Hsieh CH, Chou WC, Su PJ. Trajectories of the multidimensional dying experience for terminally ill cancer patients. J Pain Symptom Manage 2014; 48:863-74. [PMID: 24742788 DOI: 10.1016/j.jpainsymman.2014.01.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 12/24/2013] [Accepted: 01/08/2014] [Indexed: 11/18/2022]
Abstract
CONTEXT Studies exploring the trajectories of physical-psychological-social-spiritual dying experiences frequently treat changes in these experiences as consistent across different domains and over time. OBJECTIVE This prospective, longitudinal investigation was designed to characterize trajectories of the multidimensional dying experience for cancer patients in their last year of life. METHODS Trajectories of physical-psychological-social-spiritual/existential dimensions and overall quality of life (QOL) were identified among 313 cancer patients using mixed-effects models to test for linear, quadratic, or cubic changes. Changes in each variable were evaluated for clinical significance using minimal important difference. RESULTS When patients transitioned to their end of life, symptom distress, functional dependence, anxiety, and depressive symptoms slightly increased, followed by a stable status for approximately four to six months, and accelerated dramatically to the first clinically significant changes at three to four months before death. Perceived social support and post-traumatic growth declined gradually to clinically significant changes at one and four months before death, respectively. Perceived sense of burden to others increased steadily in the last year of life, with no clinically significant changes identified. Overall QOL deteriorated gradually in the last year but did not reach a clinically significant change until 2.5 months before death. CONCLUSION All dimensions deteriorated in the last year of life but with distinctive physical-psychological-social-spiritual/existential and overall QOL trajectories. Recognizing trajectory patterns and tipping points of accelerating deterioration in each dimension can help clinicians anticipate times of increased distress, initiate timely, effective interventions to relieve patient suffering, and facilitate high-quality end-of-life care tailored to patients' needs and preferences.
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Affiliation(s)
- Siew T Tang
- School of Nursing, Chang Gung University, Tao-Yuan, Taiwan, Republic of China.
| | - Li N Liu
- Department of Nursing, Fu Jen Catholic University, Taipei, Taiwan, Republic of China
| | - Kuan-Chia Lin
- Department of Health Care and Management, National Taipei University of Nursing and Health Science, Taipei, Taiwan, Republic of China
| | - Jui-Hung Chung
- Department of Health Care and Management, National Taipei University of Nursing and Health Science, Taipei, Taiwan, Republic of China
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taipei, Taiwan, Republic of China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taipei, Taiwan, Republic of China
| | - Po-Jung Su
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taipei, Taiwan, Republic of China
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First in line: prioritizing receipt of Social Security disability benefits based on likelihood of death during adjudication. Med Care 2014; 52:944-50. [PMID: 25310524 DOI: 10.1097/mlr.0000000000000204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given the complexity of the adjudication process and volume of applications to Social Security Administration's (SSA) disability programs, many individuals with serious medical conditions die while awaiting an application decision. Limitations of traditional survival methods called for a new empirical approach to identify conditions resulting in rapid mortality. OBJECTIVE To identify health conditions associated with significantly higher mortality than a key reference group among applicants for SSA disability programs. RESEARCH DESIGN We identified mortality patterns and generated a survival surface for a reference group using conditions already designated for expedited processing. We identified conditions associated with significantly higher mortality than the reference group and prioritized them by the expected likelihood of death during the adjudication process. SUBJECTS Administrative records of 29 million Social Security disability applicants, who applied for benefits from 1996 to 2007, were analyzed. MEASURES We computed survival spells from time of onset of disability to death, and from date of application to death. Survival data were organized by entry cohort. RESULTS In our sample, we observed that approximately 42,000 applicants died before a decision was made on their disability claims. We identified 24 conditions with survival profiles comparable with the reference group. Applicants with these conditions were not likely to survive adjudication. CONCLUSIONS Our approach facilitates ongoing revision of the conditions SSA designates for expedited awards and has applicability to other programs where survival profiles are a consideration.
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95
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Boersma I, Miyasaki J, Kutner J, Kluger B. Palliative care and neurology: time for a paradigm shift. Neurology 2014; 83:561-7. [PMID: 24991027 DOI: 10.1212/wnl.0000000000000674] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Palliative care is an approach to the care of patients and families facing progressive and chronic illnesses that focuses on the relief of suffering due to physical symptoms, psychosocial issues, and spiritual distress. As neurologists care for patients with chronic, progressive, life-limiting, and disabling conditions, it is important that they understand and learn to apply the principles of palliative medicine. In this article, we aim to provide a practical starting point in palliative medicine for neurologists by answering the following questions: (1) What is palliative care and what is hospice care? (2) What are the palliative care needs of neurology patients? (3) Do neurology patients have unique palliative care needs? and (4) How can palliative care be integrated into neurology practice? We cover several fundamental palliative care skills relevant to neurologists, including communication of bad news, symptom assessment and management, advance care planning, caregiver assessment, and appropriate referral to hospice and other palliative care services. We conclude by suggesting areas for future educational efforts and research.
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Affiliation(s)
- Isabel Boersma
- From the Departments of Neurology and Psychiatry (I.B., B.K.) and Internal Medicine (J.K.), University of Colorado Anschutz Medical Campus, Aurora; and Department of Neurology (J.M.), University of Alberta, Edmonton, Canada
| | - Janis Miyasaki
- From the Departments of Neurology and Psychiatry (I.B., B.K.) and Internal Medicine (J.K.), University of Colorado Anschutz Medical Campus, Aurora; and Department of Neurology (J.M.), University of Alberta, Edmonton, Canada
| | - Jean Kutner
- From the Departments of Neurology and Psychiatry (I.B., B.K.) and Internal Medicine (J.K.), University of Colorado Anschutz Medical Campus, Aurora; and Department of Neurology (J.M.), University of Alberta, Edmonton, Canada
| | - Benzi Kluger
- From the Departments of Neurology and Psychiatry (I.B., B.K.) and Internal Medicine (J.K.), University of Colorado Anschutz Medical Campus, Aurora; and Department of Neurology (J.M.), University of Alberta, Edmonton, Canada.
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Evans N, Pasman HRW, Donker GA, Deliens L, Van den Block L, Onwuteaka-Philipsen B, De Groote Z, Brearley S, Caraceni A, Cohen J, Francke A, Harding R, Higginson IJ, Kaasa S, Linden K, Miccinesi G, Onwuteaka-Philipsen B, Pardon K, Pasman R, Pautex S, Payne S, Luc D. End-of-life care in general practice: A cross-sectional, retrospective survey of 'cancer', 'organ failure' and 'old-age/dementia' patients. Palliat Med 2014; 28:965-975. [PMID: 24642671 DOI: 10.1177/0269216314526271] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND End-of-life care is often provided in primary care settings. AIM To describe and compare general-practitioner end-of-life care for Dutch patients who died from 'cancer', 'organ failure' and 'old-age or dementia'. DESIGN A cross-sectional, retrospective survey was conducted within a sentinel network of general practitioners. General practitioners recorded the end-of-life care of all patients who died (1 January 2009 to 31 December 2011). Differences in care between patient groups were analysed using multivariate logistic regressions performed with generalised linear mixed models. SETTING/PARTICIPANTS Up to 63 general practitioners, covering 0.8% of the population, recorded the care of 1491 patients. RESULTS General practitioners personally provided palliative care for 75% of cancer, 38% of organ failure and 64% of old-age/dementia patients (adjusted odds ratio (confidence interval): cancer (reference category); organ failure: 0.28 (0.17, 0.47); old-age/dementia: 0.31 (0.15, 0.63)). In the week before death, 89% of cancer, 77% of organ failure and 86% of old-age/dementia patients received palliative treatments: (adjusted odds ratio (confidence interval): cancer (reference category); old-age/dementia: 0.54 (0.29, 1.00); organ failure: 0.38 (0.16, 0.92)). Options for palliative care were discussed with 81% of cancer, 44% of organ failure and 39% of old-age/dementia patients (adjusted odds ratio (confidence interval): cancer (reference category); old-age/dementia: 0.34 (0.21, 0.57); organ failure: 0.17 (0.08, 0.36)). CONCLUSION The results highlight the need to integrate palliative care with optimal disease management in primary practice and to initiate advance care planning early in the chronic disease trajectory to enable all patients to live as well as possible with progressive illness and die with dignity and comfort.
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Affiliation(s)
- Natalie Evans
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - H Roeline W Pasman
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Gé A Donker
- NIVEL (Netherlands Institute for Health Services Research) Primary Care Database, Sentinel Practices, Utrecht, The Netherlands
| | - Luc Deliens
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium
| | - Bregje Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Temporal disease trajectories condensed from population-wide registry data covering 6.2 million patients. Nat Commun 2014; 5:4022. [PMID: 24959948 PMCID: PMC4090719 DOI: 10.1038/ncomms5022] [Citation(s) in RCA: 215] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 05/01/2014] [Indexed: 11/08/2022] Open
Abstract
A key prerequisite for precision medicine is the estimation of disease progression from the current patient state. Disease correlations and temporal disease progression (trajectories) have mainly been analysed with focus on a small number of diseases or using large-scale approaches without time consideration, exceeding a few years. So far, no large-scale studies have focused on defining a comprehensive set of disease trajectories. Here we present a discovery-driven analysis of temporal disease progression patterns using data from an electronic health registry covering the whole population of Denmark. We use the entire spectrum of diseases and convert 14.9 years of registry data on 6.2 million patients into 1,171 significant trajectories. We group these into patterns centred on a small number of key diagnoses such as chronic obstructive pulmonary disease (COPD) and gout, which are central to disease progression and hence important to diagnose early to mitigate the risk of adverse outcomes. We suggest such trajectory analyses may be useful for predicting and preventing future diseases of individual patients.
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Rothenberg LR, Doberman D, Simon LE, Gryczynski J, Cordts G. Patients surviving six months in hospice care: who are they? J Palliat Med 2014; 17:899-905. [PMID: 24933676 DOI: 10.1089/jpm.2013.0512] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND On January 1, 2011, the Centers for Medicare and Medicaid Services (CMS) began requiring U.S. hospices to conduct a "face-to-face" (F2F) assessment of eligibility for continued hospice care with patients entering their third certification period (180 days after initial enrollment). Understanding which patient populations require F2F assessment is important for evaluating the impact of the CMS regulation and gauging the appropriateness of the 6-month prognosis criteria for different patient groups. METHODS Retrospective program records were obtained for patients enrolled in a large hospice 6 months prior to implementation of the CMS regulation (N=375). Patients who remained in hospice and received a F2F (n=140) were compared to patients who were no longer in hospice (n=235) on demographics, terminal condition (categorized as debility/dementia, cancer, or other), presence of serious comorbidity, length of stay, setting of care prior to admission, and hospice outcome using bivariate statistics. Predictors of F2F recertification were examined using a multivariable logistic regression model controlling for demographics, setting of care prior to admission, comorbidity, and primary terminal diagnosis. RESULTS At the bivariate level, patients who received an F2F were older (p<0.001), and more likely to have lived in a facility care setting prior to hospice admission (p<0.001) than their non-F2F counterparts. Findings from the logistic regression analysis indicate that initial setting of care (odds ratio [OR] for inpatient versus home=0.20; p=0.01), presence of serious comorbidity (OR=2.84; p<0.001), and primary diagnosis (OR for debility/dementia versus cancer=3.35; p<0.001) were significant predictors of F2F recertification. CONCLUSIONS Unlike hospice patients with cancer, patients with a primary diagnosis of dementia or debility are more likely to remain in hospice care beyond 6 months and require F2F recertification. Still, these patients need the services provided by hospice care and may be limited by the 6-month recertification criteria.
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Gadoud AC, Johnson MJ. Response: what tools are available to identify patients with palliative care needs in primary care: a systematic literature review and survey of European practice? BMJ Support Palliat Care 2014; 4:130. [PMID: 28949925 DOI: 10.1136/bmjspcare-2014-000706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2014] [Indexed: 11/04/2022]
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Kinley J, Hockley J, Stone L, Dewey M, Hansford P, Stewart R, McCrone P, Begum A, Sykes N. The provision of care for residents dying in U.K. nursing care homes. Age Ageing 2014; 43:375-9. [PMID: 24132855 DOI: 10.1093/ageing/aft158] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES to identify the care currently provided to residents dying in U.K. nursing care homes. METHOD study participants were residents who had died within 38 nursing care homes in southeast England over a 3-year period. The nursing care homes had been recruited to take part in a cluster randomised controlled trial looking at different models of facilitation while implementing the Gold Standards Framework in Care Homes (GSFCH) programme. Two researchers examined the notes and daily records of all residents who died in each of these homes between the 1 June 2008 and the 31 May 2011. RESULTS a total of 2,444 residents died during the 3-year period. Fifty-six percent of these residents died within a year of admission. The support from specialist healthcare services to residents during their last 6 months of life was variable. CONCLUSIONS nursing care homes have established links with some external healthcare providers. These links included the GP, palliative care nurses and physiotherapy. As dependency of resident increase with 56% residents dying within a year of admission these links need to be expanded. The provision of health care that meets the needs of future nursing care home residents needs to be 'proactively' obtained rather than left to chance.
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Affiliation(s)
- Julie Kinley
- Care Home Project Team, St Christophers Hospice, 51-59 Lawrie Park Road Sydenham, London SE26 6DZ, UK
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