Continuity of care and intensive care unit use at the end of life

Using Design Thinking to Promote Goals of Care Conversations With Seriously Ill Patients

BACKGROUND

Goals of care (GOC) conversations can improve serious illness outcomes such as pain and symptom management and patient satisfaction.

PROBLEM

However, we recognized that very few Duke Health patients who died had a GOC conversation documented in the designated electronic health record (EHR) tab. Therefore, in 2020, we set a target that all Duke Health patients who died should have had a GOC conversation documented in a designated EHR tab in the last 6 months of life.

INTERVENTION

In developing a strategy to promote GOC conversations, we used two interwoven approaches. The first was RE-AIM, a model for designing, reporting and evaluating health behavior research. The second was less of a model than a way of approaching problems, known as "design thinking."

OUTCOMES

We employed both of these approaches in a system-wide effort that achieved a 50% prevalence of GOC conversations in the last 6 months of life.

KEY MESSAGE

In combination, simple interventions can have a significant impact on behavior change in an academic health system.

LESSONS LEARNED

We found that design thinking techniques offered a useful bridge between RE-AIM strategy and clinical.

Primary care physician continuity, survival, and end-of-life care intensity

OBJECTIVE

To examine the associations of primary care physician (PCP) care continuity with cancer-specific survival and end-of-life care intensity.

DATA SOURCES

Surveillance, epidemiology, and end results linked to Medicare claims data from 2001 to 2015.

STUDY DESIGN

Cox proportional hazards models with mixed effects and hierarchical generalized logistic models were used to examine the associations of PCP care continuity with cancer-specific survival and end-of-life care intensity, respectively. PCP care continuity, defined as having visited the predominant PCP (who saw the patient most frequently before diagnosis) within 6 months of diagnosis.

DATA EXTRACTION METHODS

We identified Medicare patients diagnosed at age 66.5-94 years with stage-III or IV poor-prognosis cancer during 2001-2012 and followed them up until 2015. Patients who died within 6 months after diagnosis were excluded.

PRINCIPAL FINDINGS

Primary study cohort consisted of 85,467 patients (median survival 22 months), 71.7% of whom had PCP care continuity. Patients with PCP care continuity tended to be older, married, nonblack, non-Hispanic, and to have fewer comorbid conditions (p < 0.001 for all). Patients with PCP care continuity had lower cancer-specific mortality (adjusted hazard ratio: 0.93; 95% confidence interval [CI]: 0.91 to 0.95; p = 0.001) than did those without PCP care continuity. Findings of the 2001-2003 cohorts (nearly all of whom died by 2015) show no associations of overall end-of-life care intensity measures with PCP care continuity (adjusted marginal effects: 0.005; 95% CI: -0.016 to 0.026; p = 0.264).

CONCLUSIONS

Among Medicare beneficiaries with advanced poor-prognosis cancer, PCP continuity was associated with modestly improved survival without raising overall aggressive end-of-life care.

Health Care Expenditures Attributable to Primary Care Physician Overall and Burnout-Related Turnover: A Cross-sectional Analysis

OBJECTIVE

To estimate the excess health care expenditures due to US primary care physician (PCP) turnover, both overall and specific to burnout.

METHODS

We estimated the excess health care expenditures attributable to PCP turnover using published data for Medicare patients, calculated estimates for non-Medicare patients, and the American Medical Association Masterfile. We used published data from a cross-sectional survey of US physicians conducted between October 12, 2017, and March 15, 2018, of burnout and intention to leave one's current practice within 2 years by primary care specialty to estimate excess expenditures attributable to PCP turnover due to burnout. A conservative estimate from the literature was used for actual turnover based on intention to leave. Additional publicly available data were used to estimate the average PCP panel size and the composition of Medicare and non-Medicare patients within a PCP's panel.

RESULTS

Turnover of PCPs results in approximately $979 million in excess health care expenditures for public and private payers annually, with $260 million attributable to PCP burnout-related turnover.

CONCLUSION

Turnover of PCPs, including that due to burnout, is costly to public and private payers. Efforts to reduce physician burnout may be considered as one approach to decrease US health care expenditures.

Variation among hospitals in the continuity of care for older hospitalized patients: a cross-sectional cohort study

BACKGROUND

Little is known about how continuity of care for hospitalized patients varies among hospitals. We describe the number of different general internal medicine physicians seeing hospitalized patients during a medical admission and how that varies by hospital.

METHODS

We conducted a retrospective study of a national 20% sample of Medicare inpatients from 01/01/16 to 12/31/18. In patients with routine medical admissions (length of stay of 3-6 days, no Intensive Care Unit stay, and seen by only one generalist per day), we assessed odds of receiving all generalist care from one generalist. We calculated rates for each hospital, adjusting for patient and hospital characteristics in a multi-level logistic regression model.

RESULTS

Among routine medical admissions with 3- to 6-day stays, only 43.1% received all their generalist care from the same physician. In those with a 3-day stay, 50.1% had one generalist providing care vs. 30.8% in those with a 6-day stay. In a two-level (admission and hospital) logistic regression model controlling for patient characteristics and length of stay, the odds of seeing just one generalist did not vary greatly by patient characteristics such as age, race/ethnicity, comorbidity or reason for admission. There were large variations in continuity of care among different hospitals and geographic areas. In the highest decile of hospitals, the adjusted mean percentage of patients receiving all generalist care from one physician was > 84.1%, vs. < 24.1% in the lowest decile. This large degree of variation persisted when hospitals were stratified by size, ownership, location or teaching status.

CONCLUSIONS

Continuity of care provided by generalist physicians to medical inpatients varies widely among hospitals. The impact of this variation on quality of care is unknown.

Continuity of care and receipt of aggressive end of life care among women dying of ovarian cancer

OBJECTIVE

To evaluate the association between post-diagnosis continuity of care and receipt of aggressive end of life care among women dying of ovarian cancer.

METHODS

This retrospective claims analysis included 6680 Medicare beneficiaries over age 66 with ovarian cancer who survived at least one year after diagnosis, had at least 4 outpatient evaluation and management visits and died between 2000 and 2016. We calculated the Bice-Boxerman Continuity of Care Index (COC) for each woman, and split COC into tertiles (high, medium, low). We compared late or no hospice use, >1 emergency department (ED) visit, intensive care unit (ICU) admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive and/or life extending procedures among women with high or medium vs. low COC using multivariable adjusted logistic regression.

RESULTS

In this sample, 49.8% of women received aggressive care in the last month of life. Compared to women with low COC, women with high COC had 66% higher odds of chemotherapy (adjusted OR 1.66 CI 1.23-2.24) in the last two weeks of life. Women with high COC also had 16% greater odds of not enrolling in hospice compared to women with low COC (adjusted OR 1.16 CI 1.01-1.33). COC was not associated with late enrollment in hospice, hospital utilization, or aggressive procedures.

CONCLUSIONS

COC at the end of life is complicated and may pose unique challenges in providing quality end of life care. Future work exploring the specific facets of continuity associated with quality end of life care is needed.

Better continuity of care improves the quality of end-of-life care among elderly patients with end-stage renal disease

Continuity of care (COC) has been emphasized in research on terminal cancer patients to increase the quality of end-of-life care; however, limited research has been conducted on end-stage renal disease patients. We applied a retrospective cohort design on 29,095 elderly patients with end-stage renal disease who died between 2005 and 2013. These patients were identified from the National Health Insurance Research Database of Taiwan. The provider Continuity of Care Index (COCI) and site COCI were calculated on the basis of outpatient visits during the 6–12 months before death. We discovered that increases in the provider COCI were significantly associated with reductions in health expenditures after adjusting for confounders, especially in inpatient and emergency departments, where the treatment intensity is high. Higher provider and site COC were also associated with lower utilization of acute care and invasive treatments in the last month before death. Provider COC had a greater effect on end-of-life care expenditures than site COC did, which indicated significant care coordination gaps within the same facility. Our findings support the recommendation of prioritizing the continuity of end-of-life care, especially provider continuity, for patients with end-stage renal disease.

Association of the Work Schedules of Hospitalists With Patient Outcomes of Hospitalization

IMPORTANCE

The working schedules of hospitalists vary widely. Discontinuous schedules, such as 24 hours on and 48 hours off, result in several hospitalists providing care during a patient's hospital stay. Poor continuity of care during hospitalization may be associated with poor patient outcomes.

OBJECTIVE

To determine whether admitted patients receiving care from hospitalists with more discontinuous schedules experience worse outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used conditional models to assess Medicare claims data for 114 777 medical admissions of patients with a 3-day to 6-day length of stay from January 1, 2014, through November 30, 2016, who received all general medical care from hospitalists in 229 hospitals in Texas. Data were analyzed from November 2018 to June 2019.

EXPOSURES

For each admission, the weighted mean of schedule continuity for the treating hospitalists, assessed as the percentage of all their working days in that year that were part of a block of 7 or more consecutive working days, was calculated.

MAIN OUTCOMES AND MEASURES

The primary outcome was patient mortality in the 30 days after discharge. Secondary outcomes were readmission rates and Medicare costs in the 30 days after discharge, and discharge destination.

RESULTS

Of the 114 777 patient admissions, the mean (SD) age was 79.9 (8.3) years, and 70 047 (61.0%) were women. For admissions in the lowest quartile for continuity of hospitalist schedules, the hospitalists providing care worked 0% to 30% of their total working days as part of a block of 7 or more consecutive days vs 67% to 100% for hospitalists providing care for patients in the highest quartile for continuity. Patient characteristics were not associated with the continuity of working schedules for the hospitalist(s) providing care. In conditional logistic regression models, admitted patients cared for by hospitalists in the highest quartile of schedule continuity (vs the lowest quartile) had lower 30-day mortality after discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.81-0.95), lower readmission rates (aOR, 0.94; 95% CI, 0.90-0.99), higher rates of discharge to the home (aOR, 1.08; 95% CI, 1.03-1.13), and lower 30-day postdischarge costs (-$223; 95% CI, -$441 to -$7). The results were similar across a range of different methods for defining continuity of hospitalist schedules and selecting the cohort.

CONCLUSIONS AND RELEVANCE

Hospitalist schedules vary widely. Admitted patients receiving care from hospitalists with schedules that promote inpatient continuity of care may experience better outcomes of hospitalization.

Quality Indicators of End-of-Life Care Among Privately Insured People With Cancer in Brazil

PURPOSE

To examine quality indicators of end-of-life (EOL) care among privately insured people with cancer in Brazil.

METHODS

We evaluated medical records linked to health insurance databank to study consecutive patients who died of cancer. We collected information about demographics, cancer type, and quality indicators of EOL care including emergency department (ED) visits, intensive care unit (ICU) admissions, chemotherapy use, medical imaging utilization, blood transfusions, home care support, days of inpatient care, and hospital deaths.

RESULTS

We included 865 patients in the study. In the last 30 days of life, 62% visited the ED, 33% were admitted to the ICU, 24% received blood transfusions, and 51% underwent medical imaging. Only 1% had home care support in the last 60 days of life, and 29% used chemotherapy in the last 14 days of life. Patients had an average of 8 days of inpatient care and 52% died in the hospital. Patients with advanced cancer who used chemotherapy were more likely to visit the ED (78% vs 59%; P < .001), undergo medical imaging (67% vs 51%; P < .001), and die in the hospital (73% vs 50%; P = .03) than patients who did not use chemotherapy. In the multivariate analysis, chemotherapy use near death and advanced cancer were associated with ED visits and ICU admissions, respectively (odds ratio >1).

CONCLUSION

Our study suggests that privately insured people with cancer receive poor quality EOL care in Brazil. Further research is needed to assess the impact of improvements in palliative care provision in this population.

End-of-Life Place of Care, Health Care Settings, and Health Care Transitions Among Cancer Patients: Impact of an Integrated Cancer Palliative Care Plan

CONTEXT

Frequent end-of-life health care setting transitions can lead to an increased risk of fragmented care and exposure to unnecessary treatments.

OBJECTIVES

We assessed the relationship between the presence and the intensity of an Integrated Cancer Palliative Care (ICPC) plan and the occurrence of multiple transitions during the last month of life.

METHODS

Decedents of cancer aged 18-85 years residents in two regions of Italy were investigated accessing their integrated administrative data (death certificates, hospital discharges, hospice, and home care records). The principal outcome was defined as having 3+ health care setting transitions during the last month of life. The ICPC plans instituted 90-31 days before death represented the main exposure of interest.

RESULTS

Of the 17,604 patients, 6698 included in an ICPC, although spending in hospital a median number of only two days (interquartile range 1-2), experienced 1+ (59.8%), 2+ (21.1%), or 3+ (5.9%) health care transitions. Among the latter group, the most common trajectory of care is home-hospital-home-hospital (36.0%). The intensity of the ICPC plan showed a marked protective effect toward the event of 3+ health care setting transitions; the effect is already evident from an intensity of at least one home visit/week (odds ratio 0.73; 95% confidence interval 0.62-0.87).

CONCLUSION

A well-integrated palliative care approach can be effective in further reducing the percentage of patients who spent many days in hospital and/or undergo frequent and inopportune changes of their care setting during their last month of life.

Association of Physician Specialty with Hospice Referral for Hospitalized Nursing Home Patients with Advanced Dementia

OBJECTIVES

Hospitalists hospice referral patterns have been unstudied. This study aims to examine hospice referral rates by attending type for hospitalized nursing home (NH) residents with advanced cognitive impairment (ACI) at the time of discharge between 2000 and 2010.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Hospitalized NH residents age ≥66 drawn from the 20% sample of Medicare beneficiaries with ACI, 4 or more activities of daily living (ADL) impairments on last minimum data set (MDS) assessment completed within 120 days of admission (n = 128,989).

MEASUREMENTS

Hospice referral was defined as referral to hospice within 1 day after hospital discharge. Attending physician type was determined by Part B physician billing for 100% of the billings during that admission. Continuity of care was defined as the hospital physician also billing for an outpatient visit within 120 days of that hospital admission. Number of ADL impairments, cognitive measures, pre-admission illnesses and illness severity were derived from the MDS.

RESULTS

Of the 105,329 hospitalized patients with ACI that survived to discharge (72.3% white, 30.6% male), the hospice referral rate at the time of hospital discharge increased from 2.8% in 2000 to 11.2% in 2010. Using a multivariate, hospital fixed effects model examining changes in the distribution of inpatient attending physicians, hospitalists compared to generalist physicians were more likely to refer these patients to hospice at discharge (AOR 1.17, 95% CI 1.09-1.26). Continuity of physician care from the outpatient setting to the hospital was associated with lower hospice referral (AOR 0.78, 95% CI 0.73-0.85).

CONCLUSION

Hospice referrals for NH-dwelling persons with ACI admitted to the hospital increased between 2000 and 2011 and disproportionately so when the attending physician was a hospitalist.

Regional Variation in Primary Care Involvement at the End of Life

PURPOSE

Variation in end-of-life care in the United States is frequently driven by the health care system. We assessed the association of primary care physician involvement at the end of life with end-of-life care patterns.

METHODS

We analyzed 2010 Medicare Part B claims data for US hospital referral regions (HRRs). The independent variable was the ratio of primary care physicians to specialist visits in the last 6 months of life. Dependent variables included the rate of hospital deaths, hospital and intensive care use in the last 6 months of life, percentage of patients seen by more than 10 physicians, and Medicare spending in the last 2 years of life. Robust linear regression analysis was used to measure the association of primary care physician involvement at the end of life with the outcome variables, adjusting for regional characteristics.

RESULTS

We assessed 306 HRRs, capturing 1,107,702 Medicare Part B beneficiaries with chronic disease who died. The interquartile range of the HRR ratio of primary care to specialist end-of-life visits was 0.77 to 1.21. HRRs with high vs low primary care physician involvement at the end of life had significantly different patient, population, and health system characteristics. Adjusting for these differences, HRRs with the greatest primary care physician involvement had lower Medicare spending in the last 2 years of life ($65,160 vs $69,030; P = .003) and fewer intensive care unit days in the last 6 months of life (2.90 vs 4.29; P <.001), but also less hospice enrollment (44.5% of decedents vs 50.4%; P = .004).

CONCLUSIONS

Regions with greater primary care physician involvement in end-of-life care have overall less intensive end-of-life care.

Trends in the Aggressiveness of End-of-Life Cancer Care in the State of Qatar

Purpose

Quality of end-of-life (EOL) care is a key component of excellence in cancer care, and monitoring indicators for quality of EOL cancer care is crucial to providing excellent care. The aim of the current study is to describe the relative aggressiveness of EOL cancer care in the state of Qatar and to compare it with international figures.

Methods

We analyzed all deaths from cancer in Qatar between January 1, 2009 and December 31, 2013. A total of 784 eligible patients were studied to assess aggressiveness of cancer care at EOL.

Results

The average number of intensive care unit admissions per person decreased from 0.44 to 0.22 (P < .001) over the period of study. In addition, patients spent fewer days in the intensive care unit (2.79 to 1.82 days; P = .006) and made fewer visits to the emergency department (1.00 to 0.52 visits; P < .001) in the last 30 days of life. Fewer patients had at least one aggressive treatment measure at EOL during the 5-year period (82.3% to 71.0%; P = .038). The mean composite score for aggressiveness of EOL care decreased from 2.24 to 1.92 (P < .01).

Conclusion

The aggressiveness of EOL cancer care has significantly decreased over time in Qatar; however, despite this decrease, the rate is still higher than that reported internationally. The integration of community palliative care services in Qatar may further decrease the aggressiveness of cancer care at EOL.

Redesigning care for patients at increased hospitalization risk: the Comprehensive Care Physician model

Patients who have been hospitalized often experience care coordination problems that worsen outcomes and increase costs. One reason is that hospital care and ambulatory care are often provided by different physicians. However, interventions to improve care coordination for hospitalized patients have not consistently improved outcomes and generally have not reduced costs. We describe the rationale for the Comprehensive Care Physician model, in which physicians focus their practice on patients at increased risk of hospitalization so that they can provide both inpatient and outpatient care to their patients. We also describe the design and implementation of a study supported by the Center for Medicare and Medicaid Innovation to assess the model's effects on costs and outcomes. Evidence concerning the effectiveness of the program is expected by 2016. If the program is found to be effective, the next steps will be to assess the durability of its benefits and the model's potential for dissemination; evidence to the contrary will provide insights into how to alter the program to address sources of failure.

Resource use, costs and quality of end-of-life care: observations in a cohort of elderly Australian cancer decedents

Background

The last year of life is one of the most resource-intensive periods for people with cancer. Very little population-based research has been conducted on end-of-life cancer care in the Australian health care setting. The objective of this program is to undertake a series of observational studies examining resource use, costs and quality of end-of-life care in a cohort of elderly cancer decedents using linked, routinely collected data.

Methods/Design

This study forms part of an ongoing cancer health services research program. The cohorts for the end-of-life research program comprise Australian Government Department of Veterans’ Affairs decedents with full health care entitlements, residing in NSW for the last 18 months of life and dying between 2005 and 2009. We used cancer and death registry data to identify our decedent cohorts and their causes of death. The study population includes 9,862 decedents with a cancer history and 15,483 decedents without a cancer history. The median age at death is 86 and 87 years in the cancer and non-cancer cohorts, respectively. We will examine resource use and associated costs in the last 6 months of life using linked claims data to report on health service use, hospitalizations, emergency department visits and medicines use. We will use best practice methods to examine the nature and extent of resource use, costs and quality of care based on previously published indicators. We will also examine factors associated with these outcomes.

Discussion

This will be the first Australian research program and among the first internationally to combine routinely collected data from primary care and hospital-based care to examine comprehensively end-of-life care in the elderly. The research program has high translational value, as there is limited evidence about the nature and quality of care in the Australian end-of-life setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0148-2) contains supplementary material, which is available to authorized users.

Long-term outcomes after in-hospital CPR in older adults with chronic illness

BACKGROUND

Outcomes after in-hospital CPR in older adults with chronic illness are unclear.

METHODS

We examined inpatient Medicare data from 1994 through 2005 to identify CPR recipients. We grouped beneficiaries aged ≥ 67 years by severity of six chronic diseases-COPD, congestive heart failure (CHF), chronic kidney disease (CKD), malignancy, diabetes, and cirrhosis-and investigated survival to discharge, discharge destination, rehospitalizations, and long-term survival.

RESULTS

We identified 358,682 CPR recipients. Most patients with chronic disease were less likely to survive to discharge (eg, 14.8% in the advanced COPD group [P < .001] and 11.3% in the advanced malignancy group [P < .001]) than patients without chronic illness (17.3%). Among discharge survivors, the median long-term survival was shorter in patients with chronic illness (eg, 5.0, 3.5, and 2.8 months in the advanced COPD, malignancy, and cirrhosis groups, respectively; P < .001 for all) than without (26.7 months). Although 7.2% of CPR recipients without chronic disease were discharged home and survived at least 6 months without readmission, ≤ 2.0% of recipients with advanced COPD, CHF, malignancy, and cirrhosis (P < .001 for all) met these criteria. Adjusted analyses confirmed that most subgroups with chronic illness had lower hospital discharge survival, and among discharge survivors, most were discharged home less often, experienced more hospital readmissions, and had worse long-term survival.

CONCLUSIONS

Older CPR recipients with any of the six underlying chronic diseases investigated generally have much worse outcomes than CPR recipients without chronic disease. These findings may substantially affect decisions about CPR in patients with chronic illness.

Escalation of oncologic services at the end of life among patients with gynecologic cancer at an urban, public hospital

PURPOSE

Use of oncology-related services is increasingly scrutinized, yet precisely which services are actually rendered to patients, particularly at the end of life, is unknown. This study characterizes the end-of-life use of medical services by patients with gynecologic cancer at a safety-net hospital.

METHODS

Oncologic history and metrics of medical use (eg, hospitalizations, chemotherapy infusions, procedures) for patients with gynecologic oncology who died between December 2006 and February 2012 were evaluated. Mixed-effect regression models were used to test time effects and construct usage summaries.

RESULTS

Among 116 subjects, cervical cancer accounted for the most deaths (42%). The median age at diagnosis was 55 years; 63% were Hispanic, and 65% had advanced disease. Only 34% died in hospice care. The median times from do not resuscitate/do not intubate documentation and from last therapeutic intervention to death were 9 days and 55 days, respectively. Significant time effects for all services (eg, hospitalizations, diagnostics, procedures, treatments, clinic appointments) were detected during the patient's final year (P < .001), with the most dramatic changes occurring during the last 2 months. Patients with longer duration of continuity of care used significantly fewer resources toward the end of life.

CONCLUSION

To our knowledge, this is the first report enumerating medical services obtained by patients with gynecologic cancer in a large, public hospital during the end of life. Marked changes in interventions in the patient's final 2 months highlight the need for cost-effective, evidence-based metrics for delivering cancer care. Our data emphasize continuity of care as a significant determinant of oncologic resource use during this critical period.

Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review

BACKGROUND

There has been an increase in observational studies using health administrative data to examine the nature, quality, and costs of care at life's end, particularly in cancer care.

AIM

To synthesize retrospective observational studies on resource utilization and/or costs at the end of life in cancer patients. We also examine the methods and outcomes of studies assessing the quality of end-of-life care.

DESIGN

A systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) methodology.

DATA SOURCES

We searched MEDLINE, Embase, CINAHL, and York Centre for Research and Dissemination (1990-2011). Independent reviewers screened abstracts of 14,424 articles, and 835 full-text manuscripts were further reviewed. Inclusion criteria were English-language; at least one resource utilization or cost outcome in adult cancer decedents with solid tumors; outcomes derived from health administrative data; and an exclusive end-of-life focus.

RESULTS

We reviewed 78 studies examining end-of-life care in over 3.7 million cancer decedents; 33 were published since 2008. We observed exponential increases in service use and costs as death approached; hospital services being the main cost driver. Palliative services were relatively underutilized and associated with lower expenditures than hospital-based care. The 15 studies using quality indicators demonstrated that up to 38% of patients receive chemotherapy or life-sustaining treatments in the last month of life and up to 66% do not receive hospice/palliative services.

CONCLUSION

Observational studies using health administrative data have the potential to drive evidence-based palliative care practice and policy. Further development of quality care markers will enhance benchmarking activities across health care jurisdictions, providers, and patient populations.

High burden of palliative needs among older intensive care unit survivors transferred to post-acute care facilities. a single-center study

RATIONALE

Adults with chronic critical illness (tracheostomy after ≥ 10 d of mechanical ventilation) have a high burden of palliative needs, but little is known about the actual use and potential need of palliative care services for the larger population of older intensive care unit (ICU) survivors discharged to post-acute care facilities.

OBJECTIVES

To determine whether older ICU survivors discharged to post-acute care facilities have potentially unmet palliative care needs.

METHODS

We examined electronic records from a 1-year cohort of 228 consecutive adults ≥ 65 years of age who had their first medical-ICU admission in 2009 at a single tertiary-care medical center and survived to discharge to a post-acute care facility (excluding hospice). Use of palliative care services was defined as having received a palliative care consultation. Potential palliative care needs were defined as patient characteristics suggestive of physical or psychological symptom distress or anticipated poor prognosis. We examined the prevalence of potential palliative needs and 6-month mortality.

MEASUREMENTS AND MAIN RESULTS

The median age was 78 years (interquartile range, 71-84 yr), and 54% received mechanical ventilation for a median of 7 days (interquartile range, 3-16 d). Six subjects (2.6%) received a palliative care consultation during the hospitalization. However, 88% had at least one potential palliative care need; 22% had chronic wounds, 37% were discharged on supplemental oxygen, 17% received chaplaincy services, 23% preferred to not be resuscitated, and 8% were designated "comfort care." The 6-month mortality was 40%.

CONCLUSIONS

Older ICU survivors from a single center who required postacute facility care had a high burden of palliative care needs and a high 6-month mortality. The in-hospital postcritical acute care period should be targeted for palliative care assessment and intervention.

Cardiopulmonary resuscitation among mechanically ventilated patients

PURPOSE

To evaluate the outcomes, including long-term survival, after cardiopulmonary resuscitation (CPR) in mechanically ventilated patients.

METHODS

We analyzed Medicare data from 1994 to 2005 to identify beneficiaries who underwent in-hospital CPR. We then identified a subgroup receiving CPR one or more days after mechanical ventilation was initiated [defined by ICD-9 procedure code for intubation (96.04) or mechanical ventilation (96.7x) one or more days prior to procedure code for CPR (99.60 or 99.63)].

RESULTS

We identified 471,962 patients who received in-hospital CPR with an overall survival to hospital discharge of 18.4 % [95 % confidence interval (CI) 18.3-18.5 %]. Of those, 42,163 received CPR one or more days after mechanical ventilation initiation. Survival to hospital discharge after CPR in ventilated patients was 10.1 % (95 % CI 9.8-10.4 %), compared to 19.2 % (95 % CI 19.1-19.3 %) in non-ventilated patients (p < 0.001). Among this group, older age, race other than white, higher burden of chronic illness, and admission from a nursing facility were associated with decreased survival in multivariable analyses. Among all CPR recipients, those who were ventilated had 52 % lower odds of survival (OR 0.48, 95 % CI 0.46-0.49, p < 0.001). Median long-term survival in ventilated patients receiving CPR who survived to hospital discharge was 6.0 months (95 % CI 5.3-6.8 months), compared to 19.0 months (95 % CI 18.6-19.5 months) among the non-ventilated survivors (p < 0.001 by logrank test). Of all patients receiving CPR while ventilated, only 4.1 % were alive at 1 year.

CONCLUSIONS

Survival after in-hospital CPR is decreased among ventilated patients compared to those who are not ventilated. This information is important for clinicians, patients, and family members when discussing CPR in critically ill patients.

Defining hospitalist physicians using clinical practice data: a systems-level pilot study of Ontario physicians

BACKGROUND

Hospitalists have become dominant providers of inpatient care in many North American hospitals. Despite the global growth of hospital medicine, no objective method has been proposed for defining the hospitalist discipline and delineating among inpatient practices on the basis of physicians' clinical volumes. We propose a functional method of identifying hospital-based physicians using aggregated measures of inpatient volume and apply this method to a retrospective, population-based cohort to describe the growth of the hospitalist movement, as well as the prevalence and practice characteristics of hospital-based generalists in one Canadian province.

METHODS

We used human resource databases and financial insurance claims to identify all active fee-for-service physicians working in Ontario, Canada, between fiscal year 1996/1997 and fiscal year 2010/2011. We constructed 3 measures of inpatient volume from the insurance claims to reflect the time that physicians spent delivering inpatient care in each fiscal year. We then examined how inpatient volumes have changed for Ontario physicians over time and described the prevalence of full-time and part-time hospital-based generalists working in acute care hospitals in fiscal year 2010/2011.

RESULTS

Our analyses showed a significant increase since fiscal year 2000/2001 in the number of high-volume hospital-based family physicians practising in Ontario (p < 0.001) and associated decreases in the numbers of high-volume internists and specialists (p = 0.03), where high volume was defined as ≥ 2000 inpatient services/ year. We estimated that 620 full-time and 520 part-time hospital-based physicians were working in Ontario hospitals in 2010/2011, accounting for 4.5% of the active physician workforce (n = 25 434). Hospital-based generalists, consisting of 207 family physicians and 130 general internists, were prevalent in all geographic regions and hospital types and collectively delivered 10% of all inpatient evaluation and care coordination for Ontario residents who had been admitted to hospital.

INTERPRETATION

These analyses confirmed a substantial increase in the prevalence of general hospitalists in Ontario from 1996 to 2011. Systems-level analyses of clinical practice data represent a practical and valid method for defining and identifying hospital-based physicians.

Provider continuity prior to the diagnosis of advanced lung cancer and end-of-life care

Background

Little is known about the effect of provider continuity prior to the diagnosis of advanced lung cancer and end-of-life care.

Methods

Retrospective analysis of 69,247 Medicare beneficiaries aged 67 years or older diagnosed with Stage IIIB or IV lung cancer between January 1, 1993 and December 31, 2005 who died within two years of diagnosis. We examined visit patterns to a primary care physician (PCP) and/or any provider one year prior to the diagnosis of advanced lung cancer as measures of continuity of care. Outcome measures were hospitalization, ICU use and chemotherapy use during the last month of life, and hospice use during the last week of life.

Results

Seeing a PCP or any provider in the year prior to the diagnosis of advanced lung cancer increased the likelihood of hospitalization, ICU care, chemotherapy and hospice use during the end of life. Patients with 1–3, 4–7 or >7 visits to their PCP in the year prior to the diagnosis of lung cancer had 1.0 (reference), 1.08 (95% CI; 1.04–1.13), and 1.14 (95% CI; 1.08–1.19) odds of hospitalization during the last month of life, respectively. Odds of hospice use during the last week of life were higher in patients with visits to multiple PCPs (OR 1.10: 95% CI; 1.06–1.15) compared to those whose visits were all to the same PCP.

Conclusion

Provider continuity in the year prior to the diagnosis of advanced lung cancer was not associated with lower use of aggressive care during end of life. Our study did not have information on patient preferences and result should be interpreted accordingly.

Provider connectedness and communication patterns: extending continuity of care in the context of the circle of care

BACKGROUND

Continuity is an important aspect of quality of care, especially for complex patients in the community. We explored provider perceptions of continuity through a system's lens. The circle of care was used as the system.

METHODS

Soft systems methodology was used to understand and improve continuity for end of life patients in two communities.

PARTICIPANTS

Physicians, nurses, pharmacists in two communities in British Columbia, involved in end of life care. Two debates/discussion groups were completed after the interviews and initial analysis to confirm findings. Interview recordings were qualitatively analyzed to extract components and enablers of continuity.

RESULTS

32 provider interviews were completed. Findings from this study support the three types of continuity described by Haggerty and Reid (information, management, and relationship continuity). This work extends their model by adding features of the circle of care that influence and enable continuity: Provider Connectedness the sense of knowing and trust between providers who share care of a patient; a set of ten communication patterns that are used to support continuity across the circle of care; and environmental factors outside the circle that can indirectly influence continuity.

CONCLUSIONS

We present an extended model of continuity of care. The components in the model can support health planners consider how health care is organized to promote continuity and by researchers when considering future continuity research.

Measuring fragmentation of ambulatory care in a tripartite healthcare system

BACKGROUND

Hong Kong has a tripartite healthcare system, where western medicine provided in both public and private sectors coexist with Chinese medicine practice. The purpose of this study is to measure fragmentation of ambulatory care experienced by the non-institutionalized population aged 15 and over in such a tripartite system, thus shed light on the ongoing primary care reform.

METHODS

This is a cross-sectional secondary data analysis using the Thematic Household Survey, which was conducted by the Hong Kong Census and Statistics Department during November 2009 to February 2010 to collect territory-wide health-related information. Among 18,226 individuals with two or more ambulatory visits during the past 12 months before interview, we grouped each visit into one of the three care segments-public western, private western and Chinese medicine. Two individual-level measures were used to quantify longitudinal fragmentation of care across segments over the one-year period: Most Frequent Provider Continuity Index (MFPC) and Fragmentation of Care Index (FCI). Both are analyzed for distribution and subgroup comparison. A Tobit model was used to further examine the determinants of fragmentation.

RESULTS

More than a quarter of individuals sought care in two or all three segments, with an average MFPC of 65% and FCI of 0.528. Being older, female, married, unemployed, uninsured, or born in mainland China, with lower education, lower income, higher number of chronic conditions or poorer health were found to have experienced higher fragmentation of care. We also found that, fragmentation of care increased with the total number of ambulatory care visits and it varied significantly depending on what segment the individual chose to visit most frequently-those chose private western clinics had lower FCI, compared with those chose public western or Chinese medicine as the most frequently visited segment.

CONCLUSIONS

Even measured at healthcare segment level, people in Hong Kong experienced modest fragmentation of care. Individuals' health beliefs-as a result of the persistent habitual tendency and latitude incentivized by the system-may be behind the fragmented care we saw. Efforts are needed to alter health beliefs, targeting subgroups of vulnerable population, and create environments that promote better coordinated primary care.

Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists

BACKGROUND

There have been no prior population-based studies of variation in performance of hospitalists.

OBJECTIVE

To measure the variation in performance of hospitalists.

DESIGN

Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models.

SUBJECTS

131,710 hospitalized patients cared for by 1,099 hospitalists in 268 hospitals from 2006-2009.

MAIN MEASURES

We calculated, for each hospitalist, adjusted for patient and disease factors (case mix), their patients' average length of stay, rate of discharge home or to skilled nursing facility (SNF) and rate of 30-day mortality, readmissions and emergency room (ER) visits.

KEY RESULTS

In two-level models (admission and hospitalist), there was significant variation in average length of stay and discharge location among hospitalists, but very little variation in 30-day mortality, readmission or emergency room visit rates. There was stability over time (2008-2009 vs. 2006-2007) in hospitalist performance. In three-level models including admissions, hospitalists and hospitals, the variation among hospitalists was substantially reduced. For example, hospitals, hospitalists and case mix contributed 1.02 %, 0.75 % and 42.15 % of the total variance in 30-day mortality rates, respectively.

CONCLUSIONS

There is significant variation among hospitalists in length of stay and discharge destination of their patients, but much of the variation is attributable to the hospitals where they practice. The very low variation among hospitalists in 30-day readmission rates suggests that hospitalists are not important contributors to variations in those rates among hospitals.

Prescription drug request and denial

Purpose

Prescription drug requests and physician denial are important aspects of medical decision making, but little research has been done to identify factors linked to prescription drug request and physician denial. This paper aims to explore factors in relation to patient prescription drug request and provider denial.

Design/methodology/approach

The paper is based on a cross‐sectional study in a nationally representative database of 2,988 individuals. Descriptive and multivariate stepwise conditional logistic regression analyses were conducted.

Findings

Results of multivariate regression models reveal, after adjusting for personal factors, that heart disease, allergy, anxiety, minor chronic conditions, medical seeking behaviors and direct‐to‐consumer advertising (DTCA) were found to be related to prescription drug request. The denied were individuals with arthritis, less prevalent chronic conditions, the uninsured, and African Americans. It was also found that 27.4 percent of the sample requested a prescription drug and about 24 percent of those who segmented for prescriptions were physicians.

Research limitations/implications

DTCA is positively associated with prescription drug requests but the analysis did not support any effect of DTCA on the refusal status. Patients' requests and physician decision making to refuse are somewhat complicated and vary with different medical conditions.

Originality/value

The paper, using nationally representative data, investigates the factors associated with prescription drug request and denial.

End-of-life hospital referrals by out-of-hours general practitioners: a retrospective chart study

Background

Many patients are transferred from home to hospital during the final phase of life and the majority die in hospital. The aim of the study is to explore hospital referrals of palliative care patients for whom an out-of-hours general practitioner was called.

Methods

A retrospective descriptive chart study was conducted covering a one-year period (1/Nov/2005 to 1/Nov/2006) in all eight out-of-hours GP co-operatives in the Amsterdam region (Netherlands). All symptoms, sociodemographic and medical characteristics were recorded in 529 charts for palliative care patients. Multivariate logistic regression analysis was performed to identify the variables associated with hospital referrals at the end of life.

Results

In all, 13% of all palliative care patients for whom an out-of-hours general practitioner was called were referred to hospital. Palliative care patients with cancer (OR 5,1), cardiovascular problems (OR 8,3), digestive problems (OR 2,5) and endocrine, metabolic and nutritional (EMN) problems (OR 2,5) had a significantly higher chance of being referred. Patients receiving professional nursing care (OR 0,2) and patients for whom their own general practitioner had transferred information to the out-of-hours cooperative (OR 0,4) had a significantly lower chance of hospital referral. The most frequent reasons for hospital referral, as noted by the out-of-hours general practitioner, were digestive (30%), EMN (19%) and respiratory (17%) problems.

Conclusion

Whilst acknowledging that an out-of-hours hospital referral can be the most desirable option in some situations, this study provides suggestions for avoiding undesirable hospital referrals by out-of-hours general practitioners at the end of life. These include anticipating digestive, EMN, respiratory and cardiovascular symptoms in palliative care patients.

Risk of continued institutionalization after hospitalization in older adults

BACKGROUND

Little is known about the role of hospitalization as a risk factor for placement into long-term care. We therefore sought to estimate the percentage of long-term care nursing home stays precipitated by a hospitalization and factors associated with risk of nursing home placement after hospitalization.

METHODS

We studied a retrospective cohort of a 5% sample of Medicare enrollees aged ≥ 66 years. The study included 762,243 patients admitted 1,149,568 times in January-April of 1996-2008, with 3,880,292 nonhospitalized controls. We measured residence in a nursing home 6 months after hospitalization.

RESULTS

From 1996 through 2008, 5.55% of hospitalized patients resided in a nursing home 6 months later compared with 0.54% of nonhospitalized control patients. Three quarters of new nursing home placements were precipitated by a hospitalization. Independent risk factors for long-term care placement after hospitalization included advanced age (odds ratio [OR] = 3.56 for age 85-94 vs. 66-74 years), female gender (OR = 1.41), dementia (OR = 6.15), and discharge from the hospital to a skilled nursing facility (SNF; OR = 10.83). Having a primary care physician was associated with reduced odds (OR = 0.75). In the adjusted analyses, risk of institutionalization after hospitalization decreased 4% per year from 1996 to 2008. There were very large geographic variations in rates of long-term care after hospitalization, from < 2% in some hospital referral regions to > 13% in others for patients > 75 years in 2007-2008.

CONCLUSIONS

Most placements in nursing homes are preceded by a hospitalization followed by discharge to a SNF. Discharge to a SNF is associated with a high risk of subsequent long-term care.

Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke

OBJECTIVES

The use of hospitalists is increasing. Hospitalists have been associated with reductions in length of stay and associated costs while not negatively impacting outcomes. We examine care for stroke patients because it requires complex care in the hospital and has high post discharge complications. We assessed the association of care provided by a hospitalist with length of stay, discharge destination, 30-day mortality, 30-day readmission, and 30-day emergency department visits.

METHODS

This study used the 5% Medicare sample from 2002 to 2006. Models included demographic variables, prior health status, type of admission and hospital, and region. Multinomial logit models, generalized estimating equations, Cox proportional hazard models, and propensity score analyses were explored in the analysis.

RESULTS

After adjusting models for covariates, hospitalists were associated with increased odds of discharge to inpatient rehabilitation or other facilities compared with discharge home (Odds Ratio, 1.24; 95% CI, 1.07-1.43 and Odds Ratio, 1.34; 95% CI 1.05-1.69, respectively). Mean length of stay was 0.37 days lower for patients in hospitalist care compared to nonhospitalist care. This reduction in length of stay was not appreciably changed after adjusting for discharge destination. Hospitalist care was not associated with differences in 30-day emergency department use or mortality. Readmission rates were higher for patients in hospitalist care (Hazard, 1.30; 95% CI, 1.11-1.52).

CONCLUSIONS

Hospitalists are associated with reduced length of stay and higher rates of discharge to inpatient rehabilitation. The higher readmission rates should be further explored.

Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study

BACKGROUND

Hospitalist care has grown rapidly, in part because it is associated with decreased length of stay and hospital costs. No national studies examining the effect of hospitalist care on hospital costs or on medical utilization and costs after discharge have been done.

OBJECTIVE

To assess the relationship of hospitalist care with hospital length of stay, hospital charges, and medical utilization and Medicare costs after discharge.

DESIGN

Population-based national cohort study.

SETTING

Hospital care of Medicare patients.

PATIENTS

A 5% national sample of enrollees in Medicare parts A and B with a primary care physician who were cared for by their primary care physician or a hospitalist during medical hospitalizations from 2001 to 2006.

MEASUREMENTS

Length of stay, hospital charges, discharge location and physician visits, emergency department visits, rehospitalization, and Medicare spending within 30 days after discharge.

RESULTS

In propensity score analysis, hospital length of stay was 0.64 day less among patients receiving hospitalist care. Hospital charges were $282 lower, whereas Medicare costs in the 30 days after discharge were $332 higher (P < 0.001 for both). Patients cared for by hospitalists were less likely to be discharged to home (odds ratio, 0.82 [95% CI, 0.78 to 0.86]) and were more likely to have emergency department visits (odds ratio, 1.18 [CI, 1.12 to 1.24]) and readmissions (odds ratio, 1.08 [CI, 1.02 to 1.14]) after discharge. They also had fewer visits with their primary care physician and more nursing facility visits after discharge.

LIMITATION

Observational studies are subject to selection bias.

CONCLUSION

Decreased length of stay and hospital costs associated with hospitalist care are offset by higher medical utilization and costs after discharge.

PRIMARY FUNDING SOURCE

National Institute on Aging and National Cancer Institute.

Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures

BACKGROUND

Despite more than a decade of research on hospitalists and their performance, disagreement still exists regarding whether and how hospital-based physicians improve the quality of inpatient care delivery. This systematic review summarizes the findings from 65 comparative evaluations to determine whether hospitalists provide a higher quality of inpatient care relative to traditional inpatient physicians who maintain hospital privileges with concurrent outpatient practices.

METHODS

Articles on hospitalist performance published between January 1996 and December 2010 were identified through MEDLINE, Embase, Science Citation Index, CINAHL, NHS Economic Evaluation Database and a hand-search of reference lists, key journals and editorials. Comparative evaluations presenting original, quantitative data on processes, efficiency or clinical outcome measures of care between hospitalists, community-based physicians and traditional academic attending physicians were included (n = 65). After proposing a conceptual framework for evaluating inpatient physician performance, major findings on quality are summarized according to their percentage change, direction and statistical significance.

RESULTS

The majority of reviewed articles demonstrated that hospitalists are efficient providers of inpatient care on the basis of reductions in their patients' average length of stay (69%) and total hospital costs (70%); however, the clinical quality of hospitalist care appears to be comparable to that provided by their colleagues. The methodological quality of hospitalist evaluations remains a concern and has not improved over time. Persistent issues include insufficient reporting of source or sample populations (n = 30), patients lost to follow-up (n = 42) and estimates of effect or random variability (n = 35); inappropriate use of statistical tests (n = 55); and failure to adjust for established confounders (n = 37).

CONCLUSIONS

Future research should include an expanded focus on the specific structures of care that differentiate hospitalists from other inpatient physician groups as well as the development of better conceptual and statistical models that identify and measure underlying mechanisms driving provider-outcome associations in quality.

Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada

PURPOSE

To describe trends in the aggressiveness of end-of-life (EOL) cancer care in a universal health care system in Ontario, Canada, between 1993 and 2004, and to compare with findings reported in the United States.

METHODS

A population-based, retrospective, cohort study that used administrative data linked to registry data. Aggressiveness of EOL care was defined as the occurrence of at least one of the following indicators: last dose of chemotherapy received within 14 days of death; more than one emergency department (ED) visit within 30 days of death; more than one hospitalization within 30 days of death; or at least one intensive care unit (ICU) admission within 30 days of death.

RESULTS

Among 227,161 patients, 22.4% experienced at least one incident of potentially aggressive EOL cancer care. Multivariable analyses showed that with each successive year, patients were significantly more likely to encounter some aggressive intervention (odds ratio, 1.01; 95% CI, 1.01 to 1.02). Multiple emergency department (ED) visits, ICU admissions, and chemotherapy use increased significantly over time, whereas multiple hospital admissions declined (P < .05). Patients were more likely to receive aggressive EOL care if they were men, were younger, lived in rural regions, had a higher level of comorbidity, or had breast, lung, or hematologic malignancies. Chemotherapy and ICU utilization were lower in Ontario than in the United States.

CONCLUSION

Aggressiveness of cancer care near the EOL is increasing over time in Ontario, Canada, although overall rates were lower than in the United States. Health system characteristics and patient or physician cultural factors may play a role in the observed differences.

Bringing generalists into the hospital: outcomes of a family medicine hospitalist model in Singapore

PURPOSE

The aim of this study was to assess a newly introduced hospitalist care model in a Singapore hospital. Clinical outcomes of the family medicine hospitalists program were compared with the traditional specialists-based model using the hospital's administrative database.

METHODS

Retrospective cohort study of hospital discharge database for patients cared for by family medicine hospitalists and specialists in 2008. Multivariate analysis models were used to compare the clinical outcomes and resource utilization between patients cared for by family medicine hospitalists and specialist with adjustment for demographics, and comorbidities.

RESULTS

Of 3493 hospitalized patients in 2008 who met the criteria of the study, 601 patients were under the care of family medicine hospitalists. As compared with patients cared for by specialists, patients cared for by family medicine hospitalists had a shorter hospital length of stay (adjusted LOS, geometric mean, GM, 4.4 vs. 5.3 days; P < 0.001) and lower hospitalization costs (adjusted cost, GM, $2250.7 vs. $2500.0; P= 0.003), but a similar in-patient mortality rate (4.2% vs. 5.3%, P= 0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P= 0.231) after adjustment for age, ethnicity, gender, intensive care unit (ICU) admission, numbers of organ failures, and comorbidities.

CONCLUSION

The family medicine hospitalist model was associated with reductions in hospital LOS and cost of care without adversely affecting mortality or 30-day all-cause readmission rate. These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings.

The association between night or weekend admission and hospitalization-relevant patient outcomes

INTRODUCTION

Nights and weekends represent a potentially high-risk time for hospitalized patients. Data regarding night or weekend admission and its impact on outcomes is limited. We studied the association between night or weekend admission and outcomes.

METHODS

We reviewed 857 admissions to the general medicine services from the emergency department (ED) at our tertiary care hospital for demographic information, time and day of admission, and hospitalization-relevant outcomes (length of stay [LOS], hospital charges, intensive care unit [ICU] transfer during hospitalization, repeat ED visit within 30 days, readmission within 30 days, and poor outcome [ICU transfer, cardiac arrest, or death] within the first 24 hours of admission). Outcomes were compared between groups using univariate and multivariate modeling.

RESULTS

Complete data for analysis were available for 824 patients. A total of 58% of patients were admitted at night and 22% were admitted during the weekend. Patients admitted at night as compared to those admitted during the day had similar a LOS (4.1 vs. 4.3, P = 0.38), hospital charges (25,200 vs. 27,500, P = 0.17), ICU transfer during hospitalization (3% vs. 6%, P = 0.06), 30 day repeat ED visit (22% vs. 20%, P = 0.42), 30 day readmission (20% vs. 17%, P = 0.23), and poor outcomes within 24 hours of admission (1% vs. 2%, P = 0.15). Patients admitted during the weekend as compared to those admitted during the week had lower hospital charges and lower likelihood of an ICU transfer but were otherwise similar.

CONCLUSION

Night or weekend admission was not associated with worse hospitalization-relevant outcomes at our tertiary care hospital.

Influence of patients' preferences and treatment site on cancer patients' end-of-life care

BACKGROUND

Research suggests that patients' end-of-life (EOL) care is determined primarily by the medical resources available, and not by patient preferences. The authors examined whether patients' desire for life-extending therapy was associated with their EOL care.

METHODS

Coping with Cancer is a multisite, prospective, longitudinal study of patients with advanced cancer. Three hundred one patients were interviewed at baseline and followed until death, a median of 4.5 months later. Multivariate analyses examined the influence of patients' preferences and treatment site on whether patients received intensive care or hospice services in the final week of life.

RESULTS

Eighty-three of 301 patients (27.6%) with advanced cancer wanted life-extending therapy at baseline. Patients who understood that their disease was terminal or who reported having EOL discussions with their physicians were less likely to want life-extending care compared with others (23.4% vs 42.6% and 20.7% vs 44.4%, respectively; P≤.003). Patients who were treated at Yale Cancer Center received more intensive care (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.16-8.47) and less hospice services (OR, 0.52; 95% CI, 0.29-0.92) compared with patients who were treated at Parkland Hospital. However, in multivariate analyses that controlled for confounding influences, patients who preferred life-extending care were more likely to receive intensive care (adjusted OR [AOR], 2.91; 95% CI, 1.09-7.72) and were less likely to receive hospice services (AOR, 0.45; 95% CI, 0.26-0.78). Treatment site was not identified as a significant predictor of EOL care.

CONCLUSIONS

The treatment preferences of patients with advanced cancer may play a more important role in determining the intensity of medical care received at the EOL than previously recognized. Future research is needed to determine the mechanisms by which patients' preferences for care and treatment site interact to influence EOL care.

The coordination of primary and oncology specialty care at the end of life

The end of life is a time in which both the intensity of cancer patients' needs and the complexity of care increase, heightening the need for effective care coordination between oncology and primary care physicians. However, little is known about the extent to which such coordination occurs or the ways in which it is achieved. We review existing evidence on current practice patterns, patient and physician preferences regarding involvement of oncology and primary care physicians in end-of-life care, and the potential impact of care coordination on the quality of care and health outcomes. Data are lacking on the extent to which end-of-life care is coordinated between oncology and primary care physicians. Patients appear to prefer the continued involvement of both types of physicians, and preliminary evidence suggests that coordinated care improves health outcomes. However, more work needs to be done to corroborate these findings, and many unanswered questions remain.

End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences

PURPOSE

Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences.

METHODS

This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians.

RESULTS

Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences.

CONCLUSION

Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.

Prior hospitalization and the risk of heart attack in older adults: a 12-year prospective study of Medicare beneficiaries

BACKGROUND

We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old.

METHODS

Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect.

RESULTS

The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.

Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults

CONTEXT

Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization.

OBJECTIVES

To describe continuity of care in older hospitalized patients, change in continuity over time, and factors associated with discontinuity.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of 3,020,770 hospital admissions between 1996 and 2006 using enrollment and claims data for a 5% national sample of Medicare beneficiaries older than 66 years. Data files were constructed to include the patients' demographic and enrollment information (denominator file) and claims for hospital stays (MEDPAR file) and physician services (carrier claims file). Characteristics of the hospitals were included in annual provider of services files. Being seen by a physician was defined as when a physician had submitted a bill for evaluation and management services for that patient.

MAIN OUTCOME MEASURES

Percentage of patients who during hospitalization were seen by any outpatient physician they had visited in the year before hospitalization (continuity with any outpatient physician) or by their primary care physician (PCP) (continuity with a PCP).

RESULTS

In 1996, 50.5% (95% confidence interval [CI], 50.3%-50.7%) of hospitalized patients were seen by at least 1 physician that they had visited in an outpatient setting in the prior year, and 44.3% (95% CI, 44.1%-44.6%) of patients with an identifiable PCP were seen by that physician while hospitalized. These percentages decreased to 39.8% (95% CI, 39.6%-40.0%) and 31.9% (95% CI, 31.6%-32.1%), respectively, in 2006. Greater absolute decreases in continuity with any outpatient physician between 1996 and 2006 occurred in patients admitted on weekends (13.9%; 95% CI, 12.9%-14.7%) and those living in large metropolitan areas (11.7%; 95% CI, 11.1%-12.3%) and in New England (16.2%; 95% CI, 14.4%-18.0%). In multivariable multilevel models, increasing involvement of hospitalists was associated with approximately one-third of the decrease in continuity of care between 1996 and 2006.

CONCLUSION

Between 1996 and 2006, physician continuity from outpatient to inpatient settings decreased in the Medicare population.