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Roux A, Vu DL, Niquille A, Truchard ER, Bizzozzero T, Tahar A, Morlan T, Colin J, Akpokavie D, Grandin M, Merkly A, Cassini A, Glampedakis E, Brahier T, Suttels V, Prendki V, Boillat-Blanco N. Factors associated with antibiotics for respiratory infections in Swiss long-term care facilities. J Hosp Infect 2024:S0195-6701(24)00318-9. [PMID: 39357543 DOI: 10.1016/j.jhin.2024.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 09/02/2024] [Accepted: 09/16/2024] [Indexed: 10/04/2024]
Abstract
OBJECTIVES To identify factors contributing to general and inappropriate antibiotic prescription among long-term care facility (LTCF) residents with lower respiratory tract infections (LRTI). METHODS Prospective multicentric observational study. Residents with LRTI were recruited among 32 LTCFs in Western Switzerland during winter 2022-2023. Residents underwent lung ultrasound (LUS) within three days of LRTI onset, serving as the pneumonia diagnosis reference standard. To identify factors among demographics, vital signs, diagnostic tests, and LTCF characteristics associated with (i) antibiotic prescription and (ii) inappropriate prescription, we used multivariable logistic regression and backward selection with a p-value cutoff of <0.1. RESULTS We included 114 residents, 63% female, median age of 87 years. Overall, 59 (52%) residents had diagnostic tests performed: 50 (44%) had a PCR for respiratory viruses and 16 (14%) had a blood test with CRP and/or blood count. A total of 63 (55%) residents received antibiotics. Factors associated with antibiotic prescriptions were CFS ≥ 7 (aOR 6.8, 95% CI 1.5-24.4), oxygen saturation < 92% (3.5, 1.4-8.8), performing a blood test (0.1, 0.0-0.6), rural LTCFs (0.3, 0.1-0.7), and female physician (0.3, 0.1-0.8). Among residents receiving antibiotics, 48 (74%) had inappropriate prescriptions, with as only protective factor performing a respiratory virus PCR test (0.1, 0.0-0.4). CONCLUSIONS AND IMPLICATIONS While half of LRTI residents received antibiotics, falling within lower ranges of European LTCFs prescription rates (53-80%), most antibiotic prescriptions were inappropriate. Utilization of diagnostic tests correlates with lower overall and inappropriate prescription, advocating for their use to optimize prescription practices in LTCFs.
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Affiliation(s)
- Alexia Roux
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Faculty of Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Diem-Lan Vu
- Communicable Disease Unit, Division of General Cantonal Physician, Geneva Directorate of Health, Geneva, Switzerland; Paediatric Infectious Diseases Unit, Department of Woman, Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
| | - Anne Niquille
- Center for Primary Care and Public Health (Unisanté), Pharmacy, University of Lausanne, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Switzerland
| | - Eve Rubli Truchard
- Geriatric Medicine and Geriatric Rehabilitation Division, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Tosca Bizzozzero
- Department of Internal Medicine and Geriatrics, Morges Hospital, Morges, Switzerland
| | - Aurélie Tahar
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Switzerland; Division of Primary Care Medicine, Department of primary Care Medicine, Geneva University Hospitals, Switzerland
| | - Thibaud Morlan
- Division of Primary Care Medicine, Department of primary Care Medicine, Geneva University Hospitals, Switzerland
| | - Julien Colin
- Internal Medicine Department, Trois-Chêne Hospital, Geneva, Switzerland
| | - Dela Akpokavie
- Internal Medicine Department, Trois-Chêne Hospital, Geneva, Switzerland
| | - Margaux Grandin
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Axel Merkly
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alessandro Cassini
- Cantonal Doctor Office, Public Health Department, Canton of Vaud, Lausanne, Switzerland; Infection Prevention and Control Unit, Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emmanouil Glampedakis
- Cantonal Infection Prevention and Control Unit, Cantonal Doctor Office, Public Health Department, Canton of Vaud, Lausanne, Switzerland
| | - Thomas Brahier
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Véronique Suttels
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Virginie Prendki
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Switzerland; Internal Medicine Department, Trois-Chêne Hospital, Geneva, Switzerland; Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Crowley PD, Whalen FX, Siegel LR, Challener DW. Antibiotics at End of Life: Where Are We Now and Where Are We Going? A Narrative Review. Am J Hosp Palliat Care 2024:10499091241282627. [PMID: 39250304 DOI: 10.1177/10499091241282627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Antibiotics are frequently prescribed at the end of life, though the benefits and harms are not well understood. METHODS We abstracted relevant findings from articles published in English in the past 25 years to answer questions generated by discussion among the authors and with stakeholders in Palliative Care and Infectious Diseases. FINDINGS Prescribing practices vary based on individual situation and geographic location. Patients with cancer and those hospitalized receive more antibiotics than those enrolled in outpatient hospice. Urinary tract infections and pulmonary infections are the most common conditions treated with antibiotics at the end of life -most often with penicillin derivatives and vancomycin in the hospital, fluoroquinolones in outpatient, and cephalosporins in both settings. When asked, patients most often prefer limiting antibiotics to symptom management at the end of life. Physicians' over-estimation of patient preference for antibiotics and the increased probability of misdiagnosis increases antibiotic prescription rates. Antibiotics can improve symptoms when used for specific diseases at the cost of drug reactions, resistant organisms, and delayed discharge. Antibiotic use has variable results on survival duration. Antimicrobial stewardship exists in hospital and long-term care facilities, but not outpatient hospice groups. Stewardship interventions could increase proper use of antibiotics, but more information is needed to apply these interventions to hospice groups. CONCLUSIONS Antibiotics at the end of life are impactful and efforts to educate patients and providers will be invaluable in optimizing care.
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Affiliation(s)
- Patrick D Crowley
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francis X Whalen
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
- Department of Palliative and Supportive Care, Mayo Clinic, Rochester, MN, USA
| | - Leslie R Siegel
- Department of Palliative and Supportive Care, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
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Takazono T, Namie H, Nagayoshi Y, Imamura Y, Ito Y, Sumiyoshi M, Ashizawa N, Yoshida M, Takeda K, Iwanaga N, Ide S, Harada Y, Hosogaya N, Takemoto S, Fukuda Y, Yamamoto K, Miyazaki T, Sakamoto N, Obase Y, Sawai T, Higashiyama Y, Hashiguchi K, Funakoshi S, Suyama N, Tanaka H, Yanagihara K, Izumikawa K, Mukae H. Development of a score model to predict long-term prognosis after community-onset pneumonia in older patients. Respirology 2024; 29:722-730. [PMID: 38769707 DOI: 10.1111/resp.14752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/09/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND AND OBJECTIVE The identification of factors associated with long-term prognosis after community-onset pneumonia in elderly patients should be considered when initiating advance care planning (ACP). We aimed to identify these factors and develop a prediction score model. METHODS Patients aged 65 years and older, who were hospitalized for pneumonia at nine collaborating institutions, were included. The prognosis of patients 180 days after the completion of antimicrobial treatment for pneumonia was prospectively collected. RESULTS The total number of analysable cases was 399, excluding 7 outliers and 42 cases with missing data or unknown prognosis. These cases were randomly divided in an 8:2 ratio for score development and testing. The median age was 82 years, and there were 68 (17%) deaths. A multivariate analysis showed that significant factors were performance status (PS) ≥2 (Odds ratio [OR], 11.78), hypoalbuminemia ≤2.5 g/dL (OR, 5.28) and dementia (OR, 3.15), while age and detection of antimicrobial-resistant bacteria were not associated with prognosis. A scoring model was then developed with PS ≥2, Alb ≤2.5, and dementia providing scores of 2, 1 and 1 each, respectively, for a total of 4. The area under the curve was 0.8504, and the sensitivity and specificity were 94.6% and 61.7% at the cutoff of 2, respectively. In the test cases, the sensitivity and specificity were 91.7% and 63.1%, respectively, at a cutoff value of 2. CONCLUSION Patients meeting this score should be considered near the end of life, and the initiation of ACP practices should be considered.
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Affiliation(s)
- Takahiro Takazono
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Hotaka Namie
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yohsuke Nagayoshi
- Department of Respiratory Medicine, Japanese Red Cross Nagasaki Genbaku Isahaya Hospital, Isahaya, Japan
| | - Yoshifumi Imamura
- Medical Education Development Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuya Ito
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Makoto Sumiyoshi
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, University of Miyazaki, Miyazaki, Japan
| | - Nobuyuki Ashizawa
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Masataka Yoshida
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Kazuaki Takeda
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Naoki Iwanaga
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Shotaro Ide
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yosuke Harada
- Department of Internal Medicine, Saiseikai Nagasaki Hospital, Nagasaki, Japan
| | - Naoki Hosogaya
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinnosuke Takemoto
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuichi Fukuda
- Department of Respiratory Medicine, Sasebo City General Hospital, Sasebo, Japan
| | - Kazuko Yamamoto
- First Department of Internal Medicine, Division of Infectious, Respiratory, and Digestive Medicine, University of the Ryukyus Graduate School of Medicine Okinawa, Okinawa, Japan
| | - Taiga Miyazaki
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, University of Miyazaki, Miyazaki, Japan
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Toyomitsu Sawai
- Department of Respiratory Medicine, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | | | | | | | - Naofumi Suyama
- Department of Internal Medicine, Izumikawa Hospital, Minamishimabara, Japan
| | - Hikaru Tanaka
- Department of Internal Medicine, Senju Hospital, Sasebo, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Kang M, Wang WS, Chang Z. Antibiotic Use at the End of Life: Current Practice and Ways to Optimize. Am J Hosp Palliat Care 2024:10499091241266986. [PMID: 39030663 DOI: 10.1177/10499091241266986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
Infections are common complications in end of life (EOL). However, clinicians have minimal guidance regarding antibiotic decision-making in EOL care, leading to the overuse of antibiotics. While symptom relief is frequently cited as a major reason for antibiotic use in EOL, antibiotics have not been shown to provide significant improvement in symptoms outside of urinary tract infections. In addition, when prognosis is expected to be in the range of days to weeks, antibiotics have not been shown to provide significant survival benefit. Antibiotics can be beneficial in EOL care in appropriate scenarios, but the current widespread use of antibiotics in EOL requires reevaluation. There needs to be broader efforts to think about antibiotics like other invasive medical procedures in which benefits and risks are weighed, recognizing that not all patients in EOL who receive antibiotics will benefit. In addition, during care planning process, discussing and documenting antibiotic preferences will be beneficial. Non-antibiotic symptom management should be incorporated to plan of care when infection is suspected. Ultimately, the use of antibiotics at EOL should be for the clear benefit for the recipient and should be guided by the type of infection and its clinical course, patients' primary disease and its prognosis, and the preferences of patients or surrogate decision makers.
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Affiliation(s)
- Minji Kang
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Winnie S Wang
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Zieanna Chang
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Alves J, Prendki V, Chedid M, Yahav D, Bosetti D, Rello J. Challenges of antimicrobial stewardship among older adults. Eur J Intern Med 2024; 124:5-13. [PMID: 38360513 DOI: 10.1016/j.ejim.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 02/17/2024]
Abstract
Older adults hospitalized in internal medicine wards or long-term care facilities (LTCF) are progressively increasing. Older adults with multimorbidity are more susceptible to infections, as well as to more vulnerable to adverse effects (and interactions) of antibiotics, resulting in a need for effective and safer strategies for antimicrobial stewardship (ASM), both in hospitalization wards and long-term care facilities. Studies on antimicrobial stewardship in older patients are scarce and guidelines are required. Given the peculiarities of the optimization of antimicrobial prescription in individual older adults for common infections, tactics to overcome barriers need an update. The use of rapid diagnosis tests, biomarkers, de-escalation and switching from intravenous to oral/subcutaneous therapy strategies are examples of successful AMS interventions. AMS interventions are associated with reduced side effects, lower mortality, shorter hospital stays, and reduced costs. The proposed AMS framework in LTCF should focus on five domains: strategic vision, team, interventions, patient-centred care and awareness. Internists can partner with geriatrists, pharmacists and infectious disease specialists to address barriers and to improve patient care.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Specialist, Head of Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance, Hospital de Braga, Portugal.
| | - Virginie Prendki
- Department of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland; Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Marie Chedid
- Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - Davide Bosetti
- Department of Infectious Disease, Geneva University Hospital, Switzerland; Infection Control Programme and WHO Collaborating Centre for Infection Prevention and Control and Antimicrobial Resistance, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jordi Rello
- Medicine Department, Universitat Internacional de Catalunya, Spain; Clinical Research Pneumonia and Sepsis (CRIPS) Research Group-Vall d'Hebrón Institute Research (VHIR), Barcelona, Spain; Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
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6
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Karlin D, Pham C, Furukawa D, Kaur I, Martin E, Kates O, Vijayan T. State-of-the-Art Review: Use of Antimicrobials at the End of Life. Clin Infect Dis 2024; 78:e27-e36. [PMID: 38301076 DOI: 10.1093/cid/ciad735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Indexed: 02/03/2024] Open
Abstract
Navigating antibiotics at the end of life is a challenge for infectious disease (ID) physicians who remain deeply committed to providing patient-centered care and engaging in shared decision making. ID physicians, who often see patients in both inpatient and outpatient settings and maintain continuity of care for patients with refractory or recurrent infections, are ideally situated to provide guidance that aligns with patients' goals and values. Complex communication skills, including navigating difficult emotions around end-of-life care, can be used to better direct shared decision making and assist with antibiotic stewardship.
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Affiliation(s)
- Daniel Karlin
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California, USA
| | - Christine Pham
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, USA
- Department of Pharmaceutical Services, University of California, Los Angeles, California, USA
| | - Daisuke Furukawa
- Division of Infectious Diseases, Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Ishminder Kaur
- Division of Infectious Diseases, Department of Pediatrics, University of California, Los Angeles, California, USA
| | - Emily Martin
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California, USA
| | - Olivia Kates
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tara Vijayan
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, USA
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Lee S, Datta R. Frontiers in antimicrobial stewardship: antimicrobial use during end-of-life care. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e164. [PMID: 38028928 PMCID: PMC10644156 DOI: 10.1017/ash.2023.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Seohyuk Lee
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rupak Datta
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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Wi YM, Kwon KT, Hwang S, Bae S, Kim Y, Chang HH, Kim SW, Cheong HS, Lee S, Jung DS, Sohn KM, Moon C, Heo ST, Kim B, Lee MS, Hur J, Kim J, Yoon YK. Use of Antibiotics Within the Last 14 Days of Life in Korean Patients: A Nationwide Study. J Korean Med Sci 2023; 38:e66. [PMID: 36880107 PMCID: PMC9988432 DOI: 10.3346/jkms.2023.38.e66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/06/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Antimicrobial prescriptions for serious chronic or acute illness nearing its end stages raise concerns about the potential for futile use, adverse events, increased multidrug-resistant organisms, and significant patient and social cost burdens. This study investigated the nationwide situation of how antibiotics are prescribed to patients during the last 14 days of life to guide future actions. METHODS This nationwide multicenter retrospective cohort study was conducted at 13 hospitals in South Korea from November 1 to December 31, 2018. All decedents were included in the study. Antibiotic use during the last two weeks of their lives was investigated. RESULTS A total of 1,201 (88.9%) patients received a median of two antimicrobial agents during the last two weeks of their lives. Carbapenems were prescribed to approximately half of the patients (44.4%) in the highest amount (301.2 days of therapy per 1,000 patient-days). Among the patients receiving antimicrobial agents, 63.6% were inappropriate and only 327 patients (27.2%) were referred by infectious disease specialists. The use of carbapenem (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.13-2.03; P = 0.006), underlying cancer (OR, 1.56; 95% CI, 1.20-2.01, P = 0.047), underlying cerebrovascular disease (OR, 1.88; 95% CI, 1.23-2.89, P = 0.004), and no microbiological testing (OR, 1.79; 95% CI, 1.15-2.73; P = 0.010) were independent predictors for inappropriate antibiotic prescribing. CONCLUSION A considerable number of antimicrobial agents are administered to patients with chronic or acute illnesses nearing their end-of-life, a high proportion of which are prescribed inappropriately. Consultation with an infectious disease specialist, in addition to an antimicrobial stewardship program, may be necessary to induce the optimal use of antibiotics.
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Affiliation(s)
- Yu Mi Wi
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dong Sik Jung
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Kyung Mok Sohn
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Sang Taek Heo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Jeju National University, Jeju, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Larnard J, Stead W, Branch-Elliman W. Considering Patient, Family, and Provider Goals and Expectations in a Rapidly Changing Clinical Context: A Framework for Antimicrobial Stewardship at the End of Life. Infect Dis Clin North Am 2023; 37:139-151. [PMID: 36805010 DOI: 10.1016/j.idc.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Antibiotic administration is often a part of end-of-life (EOL) care, including among patients who are not critically ill. Guideline-issuing bodies recommend that antimicrobial stewardship providers (ASPs) provide support to prescribers making decisions about whether or not to treat infections in this population. Relatively little is known about the rationale for antimicrobial prescribing during the EOL period in noncritical care settings, although patient and family preferences are often an influencing factor. The effectiveness of antimicrobials in improving quantity or quality of life in this population is unclear and likely context-specific.
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Affiliation(s)
- Jeffrey Larnard
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Suite GB, Boston, MA 02215, USA.
| | - Wendy Stead
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Suite GB, Boston, MA 02215, USA
| | - Westyn Branch-Elliman
- Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA; Department of Medicine, Harvard Medical School
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10
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Malhotra C, Chaudhry I, Shafiq M, Malhotra R. Three distinct symptom profiles among older adults with severe dementia: A latent class analysis. Palliat Support Care 2023:1-8. [PMID: 36785870 DOI: 10.1017/s1478951523000068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
OBJECTIVES Older adults with severe dementia experience multiple symptoms at the end of life. This study aimed to delineate distinct symptom profiles of older adults with severe dementia and to assess their association with older adults' and caregiver characteristics and 1-year mortality among older adults. METHODS We used baseline data from a cohort of 215 primary informal caregivers of older adults with severe dementia in Singapore. We identified 10 indicators representing physical, emotional, and functional symptoms, and responsive behaviors, and conducted latent class analysis. We assessed the association between delineated older adults' symptom profiles and their use of potentially burdensome health-care interventions in the past 4 months; older adults' 1-year mortality; and caregiver outcomes. RESULTS We delineated 3 profiles of older adults - primarily responsive behaviors (Class 1; 33%); physical and emotional symptoms with responsive behaviors (Class 2; 20%); and high functional deficits with loss of speech and eye contact (Class 3; 47%). Classes 2 and 3 older adults were more likely to have received a potentially burdensome intervention for symptoms in the past 4 months and have a greater hazard for 1-year mortality. Compared to Class 1, caregivers of Class 2 older adults were more likely to experience adverse caregiver outcomes, that is, higher distress, impact on schedule and health, anticipatory grief, and coping and lower satisfaction with care received (p<0.01 for all). SIGNIFICANCE OF RESULTS The 3 delineated profiles of older adults can be used to plan or optimize care plans to effectively manage symptoms of older adults and improve their caregivers' outcomes.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
- Health Services and System Research, Duke-NUS Medical School, Singapore, Singapore
| | - Isha Chaudhry
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore
| | - Rahul Malhotra
- Health Services and System Research, Duke-NUS Medical School, Singapore, Singapore
- Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore, Singapore
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Henri B, Sirvain S, de Wazieres B, Bernard L, Gavazzi G, Forestier E, Fraisse T. [Survey on antibiotic prescription practices for palliative care terminally ill patients of 75 years old and more]. Rev Med Interne 2022; 43:589-595. [PMID: 36064626 DOI: 10.1016/j.revmed.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/25/2022] [Accepted: 08/24/2022] [Indexed: 11/20/2022]
Abstract
Infections commonly occur terminally ill oldest patients in palliative care and questioned about antimicrobial use. The aim of this study was to describe practitioners' habits. METHOD ancillary study on antibiotic modalities according to the setting of care from a national practices survey based on self administered questionnaire sent by e-mail in 2017. RESULTS 220 practitioners/327 used antibiotic, 136 worked in hospital department (52 geriatricians), 20 nursing home and 64 general practitioners (GP). GP declared less palliative care patients (6/year). The antibiotic goal was symptomatic relief for 181 (82.3%) without statistically significant difference between groups. GP (25%) were the group that most collected patient opinion for antibiotic prescription. Nursing home (23%) and GP (18%) reported more urinary tract symptoms than others (11.7%) (P=0.003). Geriatricians (59.6%) declared significantly less urinary analysis than GP (90%) (P=0.0009). 212 doctor (96.4%) faced side effect (SI): more allergic reaction and less administration difficulties than the other groups. The stop decision was collegially took (156, 70,9%) significantly more in hospital (121, 89%) than in community (25, 39.1%) (P<0.001). Patient wishes were noted by 30 (46.96%) only GP. CONCLUSION Even if practice and number of patients follow up differ from each place of care, doctors' intention in antibiotic use respect palliative care goal to relieve discomfort. It is hard to diagnose infection and complementary exam are scarce. A repeated individualized evaluation with patient, his surrounding and his medical referent participation, is mandatory to give a constant adapted level of care in every place of care.
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Affiliation(s)
- B Henri
- Post-urgences gériatriques, CHU Purpan, 31000 Toulouse, France
| | - S Sirvain
- Court séjour gériatrique, CH Alès-Cevennes, 811 avenue du Dr J goubert, 30100 Ales, France
| | - B de Wazieres
- Service de gériatrie, CHU Caremeau, 30000 Nimes, France
| | - L Bernard
- Service de Maladies Infectieuses, CHU Hôpitaux de Tours, 37000 Tours, France
| | - G Gavazzi
- Service Universitaire de Gériatrie Clinique, CHU de Grenoble, 38000 Grenoble, France
| | - E Forestier
- Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, 73000 Chambéry, France
| | - T Fraisse
- Court séjour gériatrique, CH Alès-Cevennes, 811 avenue du Dr J goubert, 30100 Ales, France.
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12
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Göl M, Hoşoğlu Y, Türkbeyler İH. Management of the infectious diseases during palliative care. Rev Assoc Med Bras (1992) 2022; 68:1127-1129. [PMID: 36228243 PMCID: PMC9575015 DOI: 10.1590/1806-9282.20220768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mehmet Göl
- Gaziantep Islam Science and Technology University, Faculty of Medicine, Department of Physiology – Gaziantep, Turkey.,Corresponding author: ,
| | - Yusuf Hoşoğlu
- Ersin Arslan Education and Research Hospital, Department of Cardiology – Gaziantep, Turkey
| | - İbrahim Halil Türkbeyler
- Gaziantep Islam Science and Technology University, Faculty of Medicine, Ersin Arslan Education and Research Hospital, Department of Internal Medicine, Division of Geriatric Medicine – Gaziantep, Turkey
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13
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Erel M, Marcus EL, Heyman SN, DeKeyser Ganz F. Do Perceptions about Palliative Care Affect Emergency Decisions of Health Personnel for Patients with Advanced Dementia? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10236. [PMID: 36011871 PMCID: PMC9408797 DOI: 10.3390/ijerph191610236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 06/15/2023]
Abstract
Decision analysis regarding emergency medical treatment in patients with advanced dementia has seldom been investigated. We aimed to examine the preferred medical treatment in emergency situations for patients with advanced dementia and its association with perceptions of palliative care. We conducted a survey of 159 physicians and 156 nurses from medical and surgical wards in two tertiary hospitals. The questionnaire included two case scenarios of patients with advanced dementia presenting gastrointestinal bleeding (scenario I) or pneumonia (scenario II) with a list of possible interventions and 11 items probing perceptions towards palliative care. Low burden interventions such as laboratory tests and intravenous administration of antibiotics/blood were preferred. Palliative measures such as analgesia/sedation were chosen by about half of the participants and invasive intervention by 41.6% (gastroscopy in scenario I) and 37.1% (intubation/mechanical ventilation in scenario II). Medical ward staff had a more palliative approach than surgical ward staff in scenario I, and senior staff had a more palliative approach than junior staff in scenario II. Most participants (90.4%) agreed that palliative care was appropriate for patients with advanced dementia. Stress in caring for patients with advanced dementia was reported by 24.5% of participants; 33.1% admitted fear of lawsuit, 33.8% were concerned about senior-level responses, and 69.7% were apprehensive of family members' reaction to palliative care. Perceptions of health care workers towards palliative care were associated with preferred treatment choice for patients with advanced dementia, mainly in scenario II. Attitudes and apprehensions regarding palliative care in these situations may explain the gap between positive attitudes towards palliative care and the chosen treatment approach. Acquainting emergency care practitioners with the benefits of palliative care may impact their decisions when treating this population.
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Affiliation(s)
- Meira Erel
- Henrietta Szold School of Nursing, Hadassah Hebrew University, Jerusalem 9112102, Israel
| | - Esther-Lee Marcus
- Henrietta Szold School of Nursing, Hadassah Hebrew University, Jerusalem 9112102, Israel
- Herzog-Medical Center, Department of Geriatrics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9103702, Israel
| | - Samuel N. Heyman
- Herzog-Medical Center, Department of Geriatrics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9103702, Israel
- Department of Medicine, Hadassah Hebrew University Hospital, Mt. Scopus, Jerusalem 9765422, Israel
| | - Freda DeKeyser Ganz
- Henrietta Szold School of Nursing, Hadassah Hebrew University, Jerusalem 9112102, Israel
- Faculty of Health and Life Sciences, Jerusalem College of Technology, Jerusalem 9372115, Israel
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14
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Hendricksen M, Mitchell SL, Lopez RP, Mazor KM, McCarthy EP. Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions. J Am Med Dir Assoc 2022; 23:1367-1374. [PMID: 34826394 PMCID: PMC9124728 DOI: 10.1016/j.jamda.2021.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/20/2021] [Accepted: 10/23/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Intensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs). DESIGN Cross-sectional analysis. SETTING AND PARTICIPANTS 1449 NHs. METHODS Nationwide 2016-2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR. RESULTS In high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH. CONCLUSIONS AND IMPLICATIONS These findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.
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Affiliation(s)
- Meghan Hendricksen
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, MA, USA; Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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15
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Kim D, Kim S, Lee KH, Han SH. Use of antimicrobial agents in actively dying inpatients after suspension of life-sustaining treatments: Suggestion for antimicrobial stewardship. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:651-661. [PMID: 35365408 DOI: 10.1016/j.jmii.2022.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/11/2022] [Accepted: 03/04/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The role of antimicrobial treatment in end-of-life care has been controversial, whether antibiotics have beneficial effects on comfort and prolonged survival or long-term harmful effects on increasing antimicrobial resistance. We assessed the use of antimicrobial agents and factors associated with de-escalation in inpatients who suspended life-sustaining treatments (SLST) and immediately died. METHODS We included 1296 (74.7%) inpatients who died within 7 days after SLST out of 1734 patients who consented to SLST on their own or family's initiative following a decision by two physicians, observing the "Life-sustaining Treatment Decision Act" between January 2020 and December 2020 at two teaching hospitals. De-escalation was defined as changing to narrower spectrum anti-bacterial drugs or stopping ≥ one antibiotic of combined treatment. RESULTS 90.6% of total patients received anti-bacterial agents, particularly a combination treatment in 60.1% and use of ≥ three drugs in 18.2% of them. Antifungal and antiviral drugs were administered to 12.6% and 3.3% of the patients on SLST, respectively. Antibacterial and antifungal agents were withdrawn in only 8.3% and 1.3% of the patients after SLST, respectively. Anti-bacterial de-escalation was performed in 17.0% of patients, but 43.6% of them received more or broad-spectrum antibiotics after SLST. In multivariate regression, longer hospital stays before SLST, initiation of SLST in the intensive care unit, and cardiovascular diseases were independently associated with anti-bacterial de-escalation after SLST. CONCLUSIONS The intervention for substantial antibiotic use in patients on SLST should be carefully considered as antimicrobial stewardship after decision by the will of the patient and proxy.
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Affiliation(s)
- Dayeong Kim
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Subin Kim
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyoung Hwa Lee
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Han
- Division of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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16
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Chiang JK, Kao YH. Factors associated with death places among elderly patients receiving home-based care. Medicine (Baltimore) 2022; 101:e29630. [PMID: 35905239 PMCID: PMC9333526 DOI: 10.1097/md.0000000000029630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The quality of end-of-life (EOL) care for patients receiving home-based care is a critical issue for health care providers. Dying in a preferred place is recognized as a key EOL care quality indicator. We explore the factors associated with death at home or nursing facilities among elderly patients receiving home-based care. This retrospective study was based on a medical chart review between January 2018 and December 2019 of elderly patients. Multivariate analysis was conducted by fitting multiple logistic regression models with the stepwise variable selection procedure to explore the associated factors. The 205 elderly patients receiving home-based care were enrolled for analysis. The mean participant age was 84.2 ± 7.8 years. Multiple logistic regression indicated that significant factors for elderly home-based patients who died at home or nursing facilities were receiving palliative service (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.37-7.51; P = .007), symptoms of nausea or vomiting (OR, 5.38; 95% CI, 1.12-25.84; P = .036), fewer emergency department visits (OR, 0.07; 95% CI, 0.03-0.16; P < .001), and less intravenous third-generation cephalosporin use (OR, 0.15; 95% CI, 0.03-0.75; P = .021) in the last month of life. Patients with dementia had a lower probability of dying at home or nursing facilities than patients with other diagnosis (OR, 0.34, 95% CI, 0.13-0.90; P = .030). Among elderly home-based patients, receiving palliative service, with nausea or vomiting, and fewer emergency department visits in the last month of life favored home or nursing facilities deaths. Practitioners should be aware of the factors with higher probabilities of dying at home and in nursing facilities. We suggested that palliative services need to be further developed and extended to ensure that patients with dementia can receive adequate EOL care at home and in nursing facilities.
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Affiliation(s)
- Jui-Kun Chiang
- Department of Family Medicine, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan
| | - Yee-Hsin Kao
- Department of Family Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
- *Correspondence: Yee-Hsin Kao, Department of Family Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), 670 Chung Te Road, Tainan 70173, Taiwan (e-mail: )
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17
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Palan Lopez R, Hendricksen M, McCarthy EP, Mazor KM, Roach A, Hendrix Rogers A, Epps F, Johnson KS, Akunor H, Mitchell SL. Association of Nursing Home Organizational Culture and Staff Perspectives With Variability in Advanced Dementia Care: The ADVANCE Study. JAMA Intern Med 2022; 182:313-323. [PMID: 35072703 PMCID: PMC8787681 DOI: 10.1001/jamainternmed.2021.7921] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Regional, facility, and racial and ethnic variability in intensity of care provided to nursing home residents with advanced dementia is well documented but poorly understood. OBJECTIVE To assess the factors associated with facility and regional variation in the intensity of care for nursing home residents with advanced dementia. DESIGN, SETTING, AND PARTICIPANTS In the ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life) qualitative study, conducted from June 1, 2018, to July 31, 2021, nationwide 2016-2017 Medicare Minimum Data Set information identified 4 hospital referral regions (HRRs) with high (n = 2) and low (n = 2) intensity of care for patients with advanced dementia based on hospital transfer and tube-feeding rates. Within those HRRs, 14 facilities providing relatively high-intensity and low-intensity care were recruited. A total of 169 nursing home staff members were interviewed, including administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians, and chaplains. MAIN OUTCOMES AND MEASURES Data included 275 hours of observation, 169 staff interviews, and abstraction of public nursing home material (eg, websites). Framework analyses explored organizational factors and staff perceptions across HRRs and nursing homes in the following 4 domains: physical environment, care processes, decision-making processes, and implicit and explicit values. RESULTS Among 169 staff members interviewed, 153 (90.5%) were women, the mean (SD) age was 47.6 (4.7) years, and 54 (32.0%) were Black. Tube-feeding rates ranged from 0% in 5 low-intensity facilities to 44.3% in 1 high-intensity facility, and hospital transfer rates ranged from 0 transfers per resident-year in 2 low-intensity facilities to 1.6 transfers per resident-year in 1 high-intensity facility. The proportion of Black residents in facilities ranged from 2.9% in 1 low-intensity facility to 71.6% in 1 high-intensity facility, and the proportion of Medicaid recipients ranged from 45.3% in 1 low-intensity facility to 81.3% in 1 high-intensity facility. Factors distinguishing facilities providing the lowest-intensity care from those providing the highest-intensity care facilities included more pleasant physical environment (eg, good repair and nonmalodorous), standardized advance care planning, greater staff engagement in shared decision-making, and staff implicit values unfavorable to tube feeding. Many staff perceptions were ubiquitous (eg, adequate staffing needs), with no distinct pattern across nursing homes or HRRs. Staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care. Except in nursing homes providing the lowest-intensity care, many staff believed that feeding tubes prolonged life and had other clinical benefits. CONCLUSIONS AND RELEVANCE This study found that variability in the care of patients with advanced dementia may be reduced by addressing modifiable nursing home factors, including enhancing support for low-resource facilities, standardizing advance care planning, and educating staff about evidence-based care and shared decision-making. Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care.
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Affiliation(s)
- Ruth Palan Lopez
- Massachusetts General Hospital Institute of Health Professions, School of Nursing, Boston
| | - Meghan Hendricksen
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, Massachusetts.,Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Ashley Roach
- Oregon Health & Science University, School of Nursing, Portland
| | | | - Fayron Epps
- Emory Center for Health in Aging, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Kimberly S Johnson
- Division of Geriatrics, Department of Medicine, Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina.,Geriatrics Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina
| | - Harriet Akunor
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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18
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Maciel MG, Fruitg M, Lawall RP, Maciel AT. Characterization of Antibiotic Use, Documented Infection and Prevalence of Multidrug-Resistant Organisms in Palliative Care Patients Admitted to a Private Hospital in Brazil: A Retrospective, Cohort Study. Indian J Palliat Care 2021; 27:530-537. [PMID: 34898948 PMCID: PMC8655641 DOI: 10.25259/ijpc_112_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/10/2021] [Indexed: 11/09/2022] Open
Abstract
Objectives: Antibiotic use in palliative care patients is a frequent dilemma. The benefits of their use in terms of quality of end-of-life care or survival improvement are not clear and the potential harm and futility of this practice not well established. Our aim was to characterise the prevalence of antibiotic use, documented infection and multidrug-resistant organisms (MDROs) colonisation among palliative care patients admitted to a private hospital in Brazil. Materials and Methods: Retrospective analysis of all palliative care patients admitted to our hospital during 1 year, including demographic characteristics, diagnosis of infectious disease at admission, antibiotic use during hospital stay, infectious agents isolated in cultures, documented MDRO colonisation and hospital mortality. Results: A total of 114 patients were included in the analysis. Forty-five (39%) were male and the median age was 83 years. About 78% of the patients had an infectious diagnosis at hospital admission and 80% of the patients not admitted with an infectious diagnosis used antibiotics during their stay, out of which a great proportion of large spectrum antibiotics. Previous MDRO colonisation and hospital mortality were similar between patients admitted with or without an infectious diagnosis. Conclusion: Infection is the leading cause of hospital admission in palliative care patients. However, antibiotics prescription is also very prevalent during hospital stay of patients not admitted with an infectious condition. Mortality is very high regardless of the initial reason for hospital admission. Therefore, the impact of multiple large spectrum antibiotics prescription and consequent significant cost burden should be urgently confronted with the real benefit to these patients.
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Affiliation(s)
- Mara Graziele Maciel
- Department of Geriatric and Palliative Care, Hospital São Camilo Ipiranga, São Paulo, Brazil
| | - Mayra Fruitg
- Department of Geriatric and Palliative Care, Hospital São Camilo Ipiranga, São Paulo, Brazil
| | - Rebeca Pissolati Lawall
- Department of Geriatric and Palliative Care, Hospital São Camilo Ipiranga, São Paulo, Brazil
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19
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Lantz TL, Noble BN, McPherson ML, Tjia J, Colangeli HN, Ferris RE, Bearden DT, Furuno JP. Frequency and Characteristics of Patients Prescribed Antibiotics on Admission to Hospice Care. J Palliat Med 2021; 25:584-590. [PMID: 34818067 DOI: 10.1089/jpm.2021.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Little is known about antibiotic prescribing on hospice admission despite known risks and limited evidence for potential benefits. Objective: To describe the frequency and characteristics of patients prescribed antibiotics on hospice admission. Design: Cross-sectional study. Subjects: Adult (age ≥18 years) decedents of a national, for-profit hospice chain across 19 U.S. states who died between January 1, 2017 and December 31, 2019. Measures: The primary outcome was having an antibiotic prescription on hospice admission. Patient characteristics of interest were demographics, hospice referral location, hospice care location, census region, primary diagnosis, and infectious diagnoses on admission. We used multivariable logistic regression to quantify associations between study variables. Results: Among 66,006 hospice decedents, 6080 (9.2%) had an antibiotic prescription on hospice admission. Fluoroquinolones (22%) were the most frequently prescribed antibiotic class. Patients more likely to have an antibiotic prescription on hospice admission included those referred to hospice care from the hospital (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.00-1.29) compared with an assisted living facility, those receiving hospice care in a private home (aOR 3.85, 95% CI 3.50-4.24), nursing home (aOR 3.65, 95% CI 3.24-4.11), assisted living facility (aOR 4.04, 95% CI 3.51-4.64), or hospital (aOR 2.43, 95% CI 2.18-2.71) compared with inpatient hospice, and those with a primary diagnosis of liver disease (aOR 2.23, 95% CI 1.82-2.74) or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (aOR 3.89, 95% CI 2.27-6.66) compared with those without these diagnoses. Conclusions: Approximately 9% of hospice patients had an antibiotic prescription on hospice admission. Patients referred to hospice from a hospital, those receiving care in a noninpatient hospice facility, and those with liver disease or HIV/AIDS were more likely to have an antibiotic prescription. These results may inform future antimicrobial stewardship interventions among patients transitioning to hospice care.
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Affiliation(s)
- Tyler L Lantz
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - Brie N Noble
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - Mary Lynn McPherson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worchester, Massachusetts, USA
| | - Hailey N Colangeli
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - Ryan E Ferris
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - David T Bearden
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.,Department of Pharmacy Services, Oregon Health and Science University Hospitals and Clinics, Portland, Oregon, USA
| | - Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
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20
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Walsh SC, Murphy E, Devane D, Sampson EL, Connolly S, Carney P, O'Shea E. Palliative care interventions in advanced dementia. Cochrane Database Syst Rev 2021; 9:CD011513. [PMID: 34582034 PMCID: PMC8478014 DOI: 10.1002/14651858.cd011513.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dementia is a chronic, progressive and ultimately fatal neurodegenerative disease. Advanced dementia is characterised by profound cognitive impairment, inability to communicate verbally and complete functional dependence. Usual care of people with advanced dementia is not underpinned universally by a palliative approach. Palliative care has focused traditionally on care of people with cancer, but for more than a decade, there have been calls worldwide to extend palliative care services to include all people with life-limiting illnesses in need of specialist care, including people with dementia. This review is an updated version of a review first published in 2016. OBJECTIVES To assess the effect of palliative care interventions in advanced dementia. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialised Register on 7 October 2020. ALOIS contains records of clinical trials identified from monthly searches of several major healthcare databases, trial registries and grey literature sources. We ran additional searches across MEDLINE (OvidSP), Embase (OvidSP), four other databases and two trial registries on 7 October 2020 to ensure that the searches were as comprehensive and as up-to-date as possible. SELECTION CRITERIA We searched for randomised (RCTs) and non-randomised controlled trials (nRCTs), controlled before-and-after studies and interrupted time series studies evaluating the impact of palliative care interventions for adults with advanced dementia of any type. Participants could be people with advanced dementia, their family members, clinicians or paid care staff. We included clinical interventions and non-clinical interventions. Comparators were usual care or another palliative care intervention. We did not exclude studies based on outcomes measured. DATA COLLECTION AND ANALYSIS At least two review authors (SW, EM, PC) independently assessed all potential studies identified in the search against the review inclusion criteria. Two authors independently extracted data from eligible studies. Where appropriate, we estimated pooled treatment effects in a fixed-effect meta-analysis. We assessed the risk of bias of included studies using the Cochrane Risk of Bias tool and the overall certainty of the evidence for each outcome using GRADE. MAIN RESULTS Nine studies (2122 participants) met the review inclusion criteria. Two studies were individually-randomised RCTs, six were cluster-randomised RCTs and one was a controlled before-and-after study. We conducted two separate comparisons: organisation and delivery of care interventions versus usual care (six studies, 1162 participants) and advance care planning interventions versus usual care (three studies, 960 participants). Two studies were carried out in acute hospitals and seven in nursing homes or long-term care facilities. For both comparisons, we found the included studies to be sufficiently similar to conduct meta-analyses. Changes to the organisation and delivery of care for people with advanced dementia may increase comfort in dying (MD 1.49, 95% CI 0.34 to 2.64; 5 studies, 335 participants; very low certainty evidence). However, the evidence is very uncertain and unlikely to be clinically significant. These changes may also increase the likelihood of having a palliative care plan in place (RR 5.84, 95% CI 1.37 to 25.02; 1 study, 99 participants; I2 = 0%; very low certainty evidence), but again the evidence is very uncertain. Such interventions probably have little effect on the use of non-palliative interventions (RR 1.11, 95% CI 0.71 to 1.72; 2 studies, 292 participants; I2 = 0%; moderate certainty evidence). They may also have little or no effect on documentation of advance directives (RR 1.46, 95% CI 0.50 to 4.25; 2 studies, 112 participants; I2 = 52%; very low certainty evidence), or whether discussions take place about advance care planning (RR 1.08, 95% CI 1.00 to 1.18; 1 study, 193 participants; I2 = 0%; very low certainty evidence) and goals of care (RR 2.36, 95% CI 1.00 to 5.54; 1 study, 13 participants; I2 = 0%; low certainty evidence). No included studies assessed adverse effects. Advance care planning interventions for people with advanced dementia probably increase the documentation of advance directives (RR 1.23, 95% CI 1.07 to 1.41; 2 studies, 384; moderate certainty evidence) and the number of discussions about goals of care (RR 1.33, 95% CI 1.11 to 1.59; 2 studies, 384 participants; moderate certainty evidence). They may also slightly increase concordance with goals of care (RR 1.39, 95% CI 1.08 to 1.79; 1 study, 63 participants; low certainty evidence). On the other hand, they may have little or no effect on perceived symptom management (MD -1.80, 95% CI -6.49 to 2.89; 1 study, 67 participants; very low certainty evidence) or whether advance care planning discussions occur (RR 1.04, 95% CI 0.87 to 1.24; 1 study, 67 participants; low certainty evidence). AUTHORS' CONCLUSIONS The evidence on palliative care interventions in advanced dementia is limited in quantity and certainty. When compared to usual care, changes to the organisation and delivery of care for people with advanced dementia may lead to improvements in comfort in dying, but the evidence for this was of very low certainty. Advance care planning interventions, compared to usual care, probably increase the documentation of advance directives and the occurrence of discussions about goals of care, and may also increase concordance with goals of care. We did not detect other effects. The uncertainty in the evidence across all outcomes in both comparisons is mainly driven by imprecision of effect estimates and risk of bias in the included studies.
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Affiliation(s)
- Sharon C Walsh
- Economics, National University of Ireland Galway, Galway, Ireland
| | - Edel Murphy
- PPI Ignite Programme, National University of Ireland Galway, Galway, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | - Patricia Carney
- Department of Public Health HSE Midlands, Health Service Executive, Tullamore, Ireland
| | - Eamon O'Shea
- School of Business and Economics, National University of Ireland Galway, Galway, Ireland
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21
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Bravo G, Van den Block L, Downie J, Arcand M, Trottier L. Attitudes toward withholding antibiotics from people with dementia lacking decisional capacity: findings from a survey of Canadian stakeholders. BMC Med Ethics 2021; 22:119. [PMID: 34488722 PMCID: PMC8420012 DOI: 10.1186/s12910-021-00689-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Healthcare professionals and surrogate decision-makers often face the difficult decision of whether to initiate or withhold antibiotics from people with dementia who have developed a life-threatening infection after losing decisional capacity. Methods We conducted a vignette-based survey among 1050 Quebec stakeholders (senior citizens, family caregivers, nurses and physicians; response rate 49.4%) to (1) assess their attitudes toward withholding antibiotics from people with dementia lacking decisional capacity; (2) compare attitudes between dementia stages and stakeholder groups; and (3) investigate other correlates of attitudes, including support for continuous deep sedation (CDS) and medical assistance in dying (MAID). The vignettes feature a woman moving along the dementia trajectory, who has refused in writing all life-prolonging interventions and explicitly requested that a doctor end her life when she no longer recognizes her loved ones. Two stages were considered after she had lost capacity: the advanced stage, where she likely has several more years to live, and the terminal stage, where she is close to death. Results Support for withholding antibiotics ranged from 75% among seniors and caregivers at the advanced stage, to 98% among physicians at the terminal stage. Using the generalized estimating equation approach, we found stakeholder group, religiosity, and support for CDS and MAID, to be associated with attitudes toward antibiotics. Conclusions Findings underscore the importance for healthcare professionals of discussing underlying values and treatment goals with people at an early stage of dementia and their relatives, to help them anticipate future care decisions and better prepare surrogates for their role. Findings also have implications for the scope of MAID laws, in particular in Canada where the extension of MAID to persons lacking decisional capacity is currently being considered. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00689-1.
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Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada. .,Research Centre On Aging, CIUSSS de l'Estrie - CHUS, 1036 South Belvedere Street, Sherbrooke, J1H 4C4, Canada.
| | - Lieve Van den Block
- VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jocelyn Downie
- Schulich School of Law and Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Marcel Arcand
- Research Centre On Aging, CIUSSS de l'Estrie - CHUS, 1036 South Belvedere Street, Sherbrooke, J1H 4C4, Canada.,Department of Family Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Lise Trottier
- Research Centre On Aging, CIUSSS de l'Estrie - CHUS, 1036 South Belvedere Street, Sherbrooke, J1H 4C4, Canada
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22
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Zhou S, Malani PN. Reducing Antimicrobial Use Among Nursing Home Residents With Advanced Dementia: The Need for Practical Tools. JAMA Intern Med 2021; 181:1183-1184. [PMID: 34251398 DOI: 10.1001/jamainternmed.2021.3243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Shiwei Zhou
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
| | - Preeti N Malani
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
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23
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Mitchell SL, D'Agata EMC, Hanson LC, Loizeau AJ, Habtemariam DA, Tsai T, Anderson RA, Shaffer ML. The Trial to Reduce Antimicrobial Use in Nursing Home Residents With Alzheimer Disease and Other Dementias (TRAIN-AD): A Cluster Randomized Clinical Trial. JAMA Intern Med 2021; 181:1174-1182. [PMID: 34251396 PMCID: PMC8276127 DOI: 10.1001/jamainternmed.2021.3098] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Antimicrobials are extensively prescribed to nursing home residents with advanced dementia, often without evidence of infection or consideration of the goals of care. OBJECTIVE To test the effectiveness of a multicomponent intervention to improve the management of suspected urinary tract infections (UTIs) and lower respiratory infections (LRIs) for nursing home residents with advanced dementia. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized clinical trial of 28 Boston-area nursing homes (14 per arm) and 426 residents with advanced dementia (intervention arm, 199 residents; control arm, 227 residents) was conducted from August 1, 2017, to April 30, 2020. INTERVENTIONS The intervention content integrated best practices from infectious diseases and palliative care for management of suspected UTIs and LRIs in residents with advanced dementia. Components targeting nursing home practitioners (physicians, physician assistants, nurse practitioners, and nurses) included an in-person seminar, an online course, management algorithms (posters, pocket cards), communication tips (pocket cards), and feedback reports on prescribing of antimicrobials. The residents' health care proxies received a booklet about infections in advanced dementia. Nursing homes in the control arm continued routine care. MAIN OUTCOMES AND MEASURES The primary outcome was antimicrobial treatment courses for suspected UTIs or LRIs per person-year. Outcomes were measured for as many as 12 months. Secondary outcomes were antimicrobial courses for suspected UTIs and LRIs when minimal criteria for treatment were absent per person-year and burdensome procedures used to manage these episodes (bladder catherization, chest radiography, venous blood sampling, or hospital transfer) per person-year. RESULTS The intervention arm had 199 residents (mean [SD] age, 87.7 [8.0] years; 163 [81.9%] women; 36 [18.1%] men), of which 163 (81.9%) were White and 27 (13.6%) were Black. The control arm had 227 residents (mean [SD] age, 85.3 [8.6] years; 190 [83.7%] women; 37 [16.3%] men), of which 200 (88.1%) were White and 22 (9.7%) were Black. There was a 33% (nonsignificant) reduction in antimicrobial treatment courses for suspected UTIs or LRIs per person-year in the intervention vs control arm (adjusted marginal rate difference, -0.27 [95% CI, -0.71 to 0.17]). This reduction was primarily attributable to reduced antimicrobial use for LRIs. The following secondary outcomes did not differ significantly between arms: antimicrobials initiated when minimal criteria were absent, bladder catheterizations, venous blood sampling, and hospital transfers. Chest radiography use was significantly lower in the intervention arm (adjusted marginal rate difference, -0.56 [95% CI, -1.10 to -0.03]). In-person or online training was completed by 88% of the targeted nursing home practitioners. CONCLUSIONS AND RELEVANCE This cluster randomized clinical trial found that despite high adherence to the training, a multicomponent intervention promoting goal-directed care for suspected UTIs and LRIs did not significantly reduce antimicrobial use among nursing home residents with advanced dementia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03244917.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erika M C D'Agata
- Division of Infectious Diseases, Brown University, Providence, Rhode Island
| | - Laura C Hanson
- Palliative Care Program, Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Andrea J Loizeau
- Division of Primary Care Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Daniel A Habtemariam
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
| | - Timothy Tsai
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
| | - Ruth A Anderson
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill
| | - Michele L Shaffer
- Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey.,Frank Statistical Consulting LLC, Vashon, Washington
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24
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Hung KC, Lee LW, Liew YX, Krishna L, Chlebicki MP, Chung SJ, Kwa ALH. Antibiotic stewardship program (ASP) in palliative care: antibiotics, to give or not to give. Eur J Clin Microbiol Infect Dis 2021; 41:29-36. [PMID: 34414518 DOI: 10.1007/s10096-021-04325-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/26/2021] [Indexed: 12/26/2022]
Abstract
Antimicrobial therapy in terminally ill patients remains controversial as goals of care tend to be focused on optimizing comfort. International guidelines recommend for antibiotic stewardship program (ASP) involvement in antibiotic decisions in palliative patients. The primary objective was to evaluate the clinical impact of ASP interventions made to stop broad-spectrum intravenous antibiotics in terminally ill patients. This was a retrospective chart review of 459 terminally ill patients in Singapore General Hospital audited by ASP between December 2010 and December 2018. Antibiotic duration, time-to-terminal discharge for end-of-life care, time-to-mortality, and mortality rates of patients with antibiotics ceased or continued upon ASP recommendations were compared. A total of 283 and 176 antibiotic courses were ceased and continued post-intervention, respectively. The intervention acceptance rate was 61.7%. The 7-day mortality rate (47.3% vs 61.9%, p = 0.003) was lower in the ceased group, while 30-day mortality rate (76.0% vs 81.2%, p = 0.203) and time-to-mortality post-intervention (3 [0-24] vs 2 [0-27] days, p = 0.066) did not differ between the ceased and continued groups. After excluding the 57 patients who had antibiotics continued until death within 48 h of intervention, only time-to-mortality post-intervention was statistically significantly shorter in the ceased group (3 [0-24] vs 4 [0-27], p < 0.001). Of the 131 terminally discharged patients, antibiotic duration (4 [0-17] vs 6.5 [1-14] days, p = 0.001) and time-to-terminal discharge post-intervention (6 [0-74] vs 10.5 [3-63] days, p = 0.001) were shorter in the ceased group. Antibiotic cessation in terminally ill patients was safe, and was associated with a significantly shorter time-to-terminal discharge.
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Affiliation(s)
- Kai Chee Hung
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Lai Wei Lee
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Yi Xin Liew
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Lalit Krishna
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Drive, Singapore, 169610, Singapore
| | - Maciej Piotr Chlebicki
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Shimin Jasmine Chung
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore. .,Emerging Infectious Diseases, Duke-National University of Singapore Medical School, 8 College Rd, Singapore, 169857, Singapore. .,Singhealth Duke-NUS Medicine Academic Clinical Programme, 8 College Road, Level 4, Singapore, 169857, Singapore.
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25
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Lopez RP, McCarthy EP, Mazor KM, Hendricksen M, McLennon S, Johnson KS, Mitchell SL. ADVANCE: Methodology of a qualitative study. J Am Geriatr Soc 2021; 69:2132-2142. [PMID: 33971029 PMCID: PMC8373706 DOI: 10.1111/jgs.17217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Quantitative studies have documented persistent regional, facility, and racial differences in the intensity of care provided to nursing home (NH) residents with advanced dementia including, greater intensity in the Southeastern United States, among black residents, and wide variation among NHs in the same hospital referral region (HRR). The reasons for these differences are poorly understood, and the appropriate way to study them is poorly described. DESIGN Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) is a large qualitative study to elucidate factors related to NH organizational culture and proxy perspectives contributing to differences in the intensity of advanced dementia care. Using nationwide 2016-2017 Minimum DataSet information, four HRRs were identified in which the relative intensity of advanced dementia care was high (N = 2 HRRs) and low (N = 2 HRRs) based on hospital transfer and tube-feeding rates among residents with this condition. Within those HRRs, we identified facilities providing high (N = 2 NHs) and low (N = 2 NHs) intensity care relative to all NHs in that HRR (N = 16 total facilities; 4 facilities/HRR). RESULTS/CONCLUSIONS To date, the research team conducted 275 h of observation in 13 NHs and interviewed 158 NH providers from varied disciplines to assess physical environment, care processes, decision-making processes, and values. We interviewed 44 proxies (black, N = 19; white, N = 25) about their perceptions of advance care planning, decision-making, values, communication, support, trust, literacy, beliefs about death, and spirituality. This report describes ADVANCE study design and the facilitators and challenges of its implementation, providing a template for the successful application of large qualitative studies focused on quality care in NHs.
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Affiliation(s)
| | - Ellen P. McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Kathleen M. Mazor
- Meyers Primary Care Institute, Worcester, MA
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Meghan Hendricksen
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston MA
| | | | - Kimberly S. Johnson
- Division of Geriatrics, Department of Medicine, Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC
- Geriatrics Research Education and Clinical Center, Veteran Affairs Medicine Center, Durham, NC
| | - Susan L. Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
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26
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Mahmoud E, Abanamy R, Binawad E, Alhatmi H, Alzammam A, Habib A, Alturaifi D, Alharbi A, Alqahtani H, Aldohayan M. Infections and patterns of antibiotic utilization in support and comfort care patients: A tertiary care center experience. J Infect Public Health 2021; 14:839-844. [PMID: 34118733 DOI: 10.1016/j.jiph.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/07/2021] [Accepted: 05/18/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Little is known regarding the burden of infections and clinical practice towards hospitalized patients with limits on life-sustaining measures. We aim to describe the infectious syndromes, clinical care, the emergence of multi-drug resistant organisms and outcomes in this population. PATIENTS AND METHODS Retrospective cohort of patients labeled as support or comfort care in a tertiary care center between 2016-2019. RESULTS A total of 347 patients were included with a mean age of 68.5 years, who were predominantly males (59.94%), bedbound (69.74%), on tube feeding (66.86%), and required indwelling urinary catheters (61.96%). The total number of admissions during the first year was 498, with the mean length of stay being 30 days. The number of infectious syndromes identified during that period was 821episodes, with a mean of 2 infectious syndromes per admission. The most common infection identified was pneumonia (41.66%) followed by urinary tract infections (27.16%). A total of 3891 microbiological cultures were taken with a mean of 5 cultures per infectious syndrome. The most commonly identified pathogens were Gram-negative bacteria (61.03%), with a high rate of multidrug-resistant organisms (MDROs) (48.53%). The one-year mortality was 86.4%. Using carbapenem antibiotic and pneumonia were the independent predictors used for the MDROs. CONCLUSION Our study reflects the high burden of infections, antimicrobial resistance, and hospital admissions among a population with limited life expectancy. A consensus regarding investigating and managing of infectious syndromes, and antimicrobial prescription is needed to reduce the harms associated with overuse of antimicrobials.
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Affiliation(s)
- Ebrahim Mahmoud
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.
| | - Reem Abanamy
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Eman Binawad
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hind Alhatmi
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ali Alzammam
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman Habib
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Dana Alturaifi
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Alharbi
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hajar Alqahtani
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Aldohayan
- Department of Health Informatics, CPHHI, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Data and Business Intelligence Management Department, ISID, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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27
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Janbek J, Frimodt-Møller N, Laursen TM, Waldemar G. Hospital readmissions following infections in dementia: a nationwide and registry-based cohort study. Eur J Neurol 2021; 28:3603-3614. [PMID: 33978303 DOI: 10.1111/ene.14911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We aimed to investigate readmission risks following infections in dementia, identify the types of infections behind the risks, and highlight the reasons for readmissions. METHODS Acute inpatient hospital admissions for infections in Danish residents were included from 1 January 2000, or age 65 years. Primary outcomes were 7-day readmissions risk ratios (RRs; risk following infection index admissions of people with dementia relative to those without dementia), risks by infection site, and reasons for readmission. Secondary outcomes were 30- and 90-day readmission risks. Competing risk of death was estimated. RESULTS Seven-day readmission RR was increased in all age groups and was highest in the youngest patients (women RR: 1.37, 95% confidence interval [CI] 1.22-1.53; men RR: 1.23, 95% CI 1.12-1.35). RRs decreased with increasing age and longer follow-up. The most notable common readmissions were for infections and dehydration in dementia. CONCLUSIONS We conclude that there is a substantially increased readmission risk in people with dementia than in those without dementia, particularly within 7 days, and for the youngest in the cohort. Readmission risks were higher for infection index admissions than for admissions for causes other than infection, and readmissions were mostly due to infections. Our findings highlight the burden of infections in people with dementia and call for in-depth investigations of determinants related to readmission risks, to inform public policy and identify avenues for interventions that can decrease or prevent potentially avoidable readmissions.
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Affiliation(s)
- Janet Janbek
- Department of Neurology, Danish Dementia Research Centre, Section 8007, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Niels Frimodt-Møller
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Munk Laursen
- Department of Economics and Business Economics, National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus V, Denmark
| | - Gunhild Waldemar
- Department of Neurology, Danish Dementia Research Centre, Section 8007, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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28
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Fairweather J, Cooper L, Sneddon J, Seaton RA. Antimicrobial use at the end of life: a scoping review. BMJ Support Palliat Care 2020:bmjspcare-2020-002558. [PMID: 33257407 DOI: 10.1136/bmjspcare-2020-002558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine antibiotic use in patients approaching end of life, in terms of frequency of prescription, aim of treatment, beneficial and adverse effects and contribution to the development of antimicrobial resistance. DESIGN Scoping review DATA SOURCES: An information scientist searched Ovid MEDLINE, Ovid EMBASE, The Cochrane library, PubMed Clinical Queries, NHS Evidence, Epistemonikos, SIGN, NICE, Google Scholar from inception to February 2019 for any study design including, but not limited to, randomised clinical trials, prospective interventional or observational studies, retrospective studies and qualitative studies. The search of Ovid MEDLINE was updated on the 10 June 2020. STUDY SELECTION Studies reporting antibiotic use in patients approaching end of life in any setting and clinicians' attitudes and behaviour in relation to antibiotic prescribing in this population DATA EXTRACTION: Two reviewers screened studies for eligibility; two reviewers extracted data from included studies. Data were analysed to describe antibiotic prescribing patterns across different patient populations, the benefits and adverse effects (for individual patients and wider society), the rationale for decision making and clinicians behaviours and attitudes to treatment with antibiotics in this patient group. RESULTS Eighty-eight studies were included. Definition of the end of life is highly variable as is use of antibiotics in patients approaching end of life. Prescribing decisions are influenced by patient age, primary diagnosis, care setting and therapy goals, although patients' preferences are not always documented or adhered to. Urinary and lower respiratory tract infections are the most commonly reported indications with outcomes in terms of symptom control and survival variably reported. Small numbers of studies reported on adverse events and antimicrobial resistance. Clinicians sometimes feel uncomfortable discussing antibiotic treatment at end of life and would benefit from guidelines to direct care. CONCLUSIONS Use of antibiotics in patients approaching the end of life is common although there is significant variation in practice. There are a myriad of intertwined biological, ethical, social, medicolegal and clinical issues associated with the topic.
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Affiliation(s)
| | - Lesley Cooper
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland Glasgow, Glasgow, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland Glasgow, Glasgow, UK
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Antibiotic use during end-of-life care: A systematic literature review and meta-analysis. Infect Control Hosp Epidemiol 2020; 42:523-529. [PMID: 33172507 DOI: 10.1017/ice.2020.1241] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND We performed a systematic literature review and meta-analysis measuring the burden of antibiotic use during end-of-life (EOL) care. METHODS We searched PubMed, CINAHL (EBSCO platform), and Embase (Elsevier platform), through July 2019 for studies with the following inclusion criteria in the initial analysis: antibiotic use in the EOL care patients (advanced dementia, cancer, organ failure, frailty or multi-morbidity). If the number of patients in palliative care consultation (PCC) was available, antibiotic use data were pooled to compare the proportion of patients who received antibiotics under PCC compared to those not receiving PCC. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 value. RESULTS Overall, 72 studies met the inclusion criteria and were included in the final review: 22 EOL studies included only patients with cancer; 17 studies included only patients with advanced dementia; and 33 studies included "mixed populations" of EOL patients. Although few studies reported antibiotic using standard metrics (eg, days of therapy), 48 of 72 studies (66.7%) reported antibiotic use in >50% of all patients. When the 3 studies that evaluated antibiotic use in PCC were pooled together, patients under PCC was more likely to receive antibiotics compared to patients not under PCC (pooled odds ratio, 1.73; 95% CI, 1.02-2.93). CONCLUSIONS Future studies are needed to evaluate the benefits and harms of using antibiotics for patients during EOL care in diverse patient populations.
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30
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Loomer L, Ogarek JA, Mitchell SL, Volandes AE, Gutman R, Gozalo PL, McCreedy EM, Mor V. Impact of an Advance Care Planning Video Intervention on Care of Short-Stay Nursing Home Patients. J Am Geriatr Soc 2020; 69:735-743. [PMID: 33159697 DOI: 10.1111/jgs.16918] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short-stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. PARTICIPANTS A total of 2,538 and 5,290 short-stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short-stay patients without advanced illness in the intervention and control arms, respectively. INTERVENTION Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. MEASUREMENTS Follow-up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person-days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube-feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. RESULTS There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6-13.1) vs 13.2 (12.5-13.7); rate difference: -0.8; 95% CI = -1.8-0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person-days alive in the intervention versus control among short-stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short-stay patients with and without advanced illness were shown videos, respectively. CONCLUSION An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short-stay NH patients; however, fidelity to the intervention was low.
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Affiliation(s)
- Lacey Loomer
- Department of Economics, Labovitz School of Business and Economics, Duluth, Minnesota, USA
| | - Jessica A Ogarek
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Angelo E Volandes
- General Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Pedro L Gozalo
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
| | - Ellen M McCreedy
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vincent Mor
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
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Durand M, Forestier E, Gras Aygon C, Sirvain S, de Wazières B, Bernard L, Paccalin M, Legout L, Roubaud Baudron C, Gavazzi G, Fraisse T. Determinants of doctors' antibiotic prescriptions for patients over 75 years old in the terminal stage of palliative care. Infect Dis Now 2020; 51:340-345. [PMID: 33075403 DOI: 10.1016/j.medmal.2020.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 03/31/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Notwithstanding high prevalence of presumably bacterial infections in elderly persons (EP) in palliative care (PC), there exists no recommendation on the role of antibiotic therapy (ABP) in this type of situation. OBJECTIVE To describe the determinants of antibiotic prescription by general practitioners (GP) and by doctors practicing in institutions (DPI) for patients>75 years, in end-of-life situations in PC. METHOD Descriptive investigation by anonymous self-administered questionnaire disseminated in France by e-mail. RESULTS A total of 301 questionnaires analyzed: 113 GP, 188 DPIs. The latter were mainly geriatricians (69, 36.6%) and infectologists/internists (41, 21.8%). Sixty-three (55,75%) GPs and 144 (78.7%) DPIs stated that they had prescribed antibiotics. Practice in "EHPAD" retirement homes or intensive care was often associated with non-prescription of antibiotics. Age, PC training and number of patients monitored bore no influence. Family involvement in decision-making was more frequent for GPs than for DPIs. The main purpose of antibiotic therapy was to relieve different symptoms (fever, respiratory congestion, functional urinary signs). Most of the doctors (81%) had previously encountered complications (allergy, adverse effect), which represented the main causes of treatment discontinuation. CONCLUSION Antibiotic use in end-of-life EPs in PC seems frequent. In accordance with the principle of beneficence, its goal of often symptom-related; that said, in the absence of scientific data, antibiotic prescription in end-of-life situations should be individualized in view of observing the other ethical caregiving principles (beneficence, non-maleficence, justice, patient autonomy) and re-evaluated daily.
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Affiliation(s)
- M Durand
- Court séjour gériatrique, CH Alès Cévennes, Avenue du Docteur Jean Goubert, 30100 Alès, France
| | - E Forestier
- Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, 73000 Chambéry, France
| | - C Gras Aygon
- Département de médecine générale, UFR médecine Montpellier-Nîmes, 34000 Montpellier, France
| | - S Sirvain
- Court séjour gériatrique, CH Alès Cévennes, Avenue du Docteur Jean Goubert, 30100 Alès, France
| | - B de Wazières
- Service de médecine gériatrique, CHU de Nîmes, Place du Pr R Debré, 30000 Nîmes, France
| | - L Bernard
- Service de Maladies Infectieuses, CHU Hôpitaux de Tours, 37000 Tours, France
| | - M Paccalin
- Pôle de Gériatrie, CHU La Milétrie, 86000 Poitiers, France
| | - L Legout
- Service des maladies infectieuses et tropicales, CH Alpes Léman, Contamine sur Arve, France
| | - C Roubaud Baudron
- Pôle de Gérontologie Clinique, Université de Bordeaux, CHU Hôpitaux de Bordeaux, 33000 Bordeaux, France
| | - G Gavazzi
- Service Universitaire de Gériatrie Clinique, CHU de Grenoble, 38000 Grenoble, France
| | - T Fraisse
- Court séjour gériatrique, CH Alès Cévennes, Avenue du Docteur Jean Goubert, 30100 Alès, France.
| | -
- Court séjour gériatrique, CH Alès Cévennes, Avenue du Docteur Jean Goubert, 30100 Alès, France; Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, 73000 Chambéry, France; Service de médecine gériatrique, CHU de Nîmes, Place du Pr R Debré, 30000 Nîmes, France; Service de Maladies Infectieuses, CHU Hôpitaux de Tours, 37000 Tours, France; Pôle de Gériatrie, CHU La Milétrie, 86000 Poitiers, France; Service des maladies infectieuses et tropicales, CH Alpes Léman, Contamine sur Arve, France; Pôle de Gérontologie Clinique, Université de Bordeaux, CHU Hôpitaux de Bordeaux, 33000 Bordeaux, France; Service Universitaire de Gériatrie Clinique, CHU de Grenoble, 38000 Grenoble, France
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Lopez S, Vyas P, Malhotra P, Finuf K, Magalee C, Nouryan C, Hirsch B. A Retrospective Study Analyzing the Lack of Symptom Benefit With Antimicrobials at the End of Life. Am J Hosp Palliat Care 2020; 38:391-395. [PMID: 32830525 DOI: 10.1177/1049909120951748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Infections are common in terminally ill patients (pts), and although antibiotics are frequently prescribed, their benefit for symptom relief is not clear. Antimicrobials at the end of life (EOL) may increase the risk of antimicrobial resistance and Clostrioides difficile infection. Our aim was to determine the frequency of symptom occurrence at the EOL when comparing pts who did or did not receive antibiotics (AB+ or AB-). METHODS We reviewed electronic medical records of pts admitted to a palliative care unit of a quarternary care hospital between 01/09/2017 and 07/16/2017 and assessed antimicrobial use in the last 14 days of life. Differences in demographics and symptom control between AB+ and AB- pts were analyzed using chi-square analyses; p-values were computed using Mann-Whitney tests. RESULTS Of a total of 133 pts included, 90 (68%) received antimicrobials (AB+). The indication for antibiotics was documented in only 12% of pts. The AB+ and AB- groups were similar with respect to demographics, including sex, and Charleston Comorbidity Index except for age (p = 0.01) and race (p = 0.03). Documented infections were similar between AB+ and AB- groups, except urinary tract infections. No statistically significant differences were noted in documented symptoms including pain, dyspnea, fever, lethargy, and alteration of mental state or length of stay. CONCLUSION Our study did not show differences in frequencies of documented symptoms with use of antimicrobials at EOL. Antimicrobial stewardship programs and further research can help with developing EOL care antimicrobial guidelines supporting patients and providers through shared decision-making.
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Affiliation(s)
- Santiago Lopez
- Department of Medicine, 24945Northwell Heath, New York, NY, USA
| | - Pooja Vyas
- Department of Medicine, 24945Northwell Heath, New York, NY, USA
| | | | - Kayla Finuf
- Department of Medicine, 24945Northwell Heath, New York, NY, USA
| | | | | | - Bruce Hirsch
- Department of Medicine, 24945Northwell Heath, New York, NY, USA
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Factors Associated With Antimicrobial Use in Nursing Home Residents With Advanced Dementia. J Am Med Dir Assoc 2020; 22:178-181. [PMID: 32839124 DOI: 10.1016/j.jamda.2020.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Widespread antimicrobial misuse among nursing home (NH) residents with advanced dementia raises concerns regarding the emergence of multidrug-resistant organisms and avoidable treatment burden in this vulnerable population. The objective of this report was to identify facility and resident level characteristics associated with receipt of antimicrobials in this population. DESIGN Cross-sectional analysis of baseline data from the Trial to Reduce Antimicrobial use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD). SETTING AND PARTICIPANTS Twenty-eight Boston area NHs, 430 long stay NH residents with advanced dementia. MEASURES The outcome was the proportion of residents who received any antimicrobials during the 2 months prior to the start of TRAIN-AD determined by chart review. Multivariable logistic regression was used to identify resident and facility characteristics associated with this outcome. RESULTS A total of 13.7% of NH residents with advanced dementia received antimicrobials in the 2 months prior to the start of TRAIN-AD. Residents in facilities with the following characteristics were significantly more likely to receive antimicrobials: having a full time nurse practitioner/physician assistant on staff [adjusted odds ratio (aOR) 3.02; 95% confidence interval (CI), 1.54, 5.94], fewer existing infectious disease practices (eg, antimicrobial stewardship programs, established algorithms for infection management) (aOR, 2.35; 95% CI 1.14, 4.84), and having fewer residents with severely cognitively impaired residents (aOR 1.96; 95% CI 1.12, 3.40). No resident characteristics were independently associated with receipt of antimicrobials. CONCLUSIONS AND IMPLICATIONS Facility-level characteristics are associated with the receipt of antimicrobials among residents with advanced dementia. Implementation of more intense infectious disease practices and targeting the prescribing practices of nurse practitioners/physician assistants may be critical targets for interventions aimed at reducing antimicrobial use in this population.
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Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, McCreedy EM, Zhai R, Mor V. Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents: A Pragmatic Cluster Randomized Clinical Trial. JAMA Intern Med 2020; 180:1070-1078. [PMID: 32628258 PMCID: PMC7399750 DOI: 10.1001/jamainternmed.2020.2366] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking. OBJECTIVE To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness. DESIGN, SETTING, AND PARTICIPANTS The Pragmatic Trial of Video Education in Nursing Homes was a pragmatic cluster randomized clinical trial conducted between February 1, 2016, and May 31, 2019, at 360 nursing homes (119 intervention and 241 control) in 32 states owned by 2 for-profit corporations. Participants included 4171 long-stay residents with advanced dementia or cardiopulmonary disease (hereafter referred to as advanced illness) in the intervention group and 8308 long-stay residents with advanced illness in the control group, 5764 long-stay residents without advanced illness in the intervention group, and 11 773 long-stay residents without advanced illness in the control group. Analyses followed the intention-to-treat principle. INTERVENTIONS Five 6- to 10-minute ACP videos were made available on tablet computers or online. Designated champions (mostly social workers) in intervention facilities were instructed to offer residents (or their proxies) the opportunity to view a video(s) on admission and every 6 months. Control facilities used usual ACP practices. MAIN OUTCOMES AND MEASURES Twelve-month outcomes were measured for each resident. The primary outcome was hospital transfers per 1000 person-days alive in the advanced illness cohort. Secondary outcomes included the proportion of residents with or without advanced illness experiencing 1 or more hospital transfer, 1 or more burdensome treatment, and hospice enrollment. To monitor fidelity, champions completed reports in the electronic record whenever they offered to show residents a video. RESULTS The study included 4171 long-stay residents with advanced illness in the intervention group (2970 women [71.2%]; mean [SD] age, 83.6 [9.1] years), and 8308 long-stay residents with advanced illness in the control group (5857 women [70.5%]; mean [SD] age, 83.6 [8.9] years), 5764 long-stay residents without advanced illness in the intervention group (3692 women [64.1%]; mean [SD] age, 81.5 [9.2] years), and 11 773 long-stay residents without advanced illness in the control group (7467 women [63.4%]; mean [SD] age, 81.3 [9.2] years). There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention vs control groups (rate [SE], 3.7 [0.2]; 95% CI, 3.4-4.0 vs 3.9 [0.3]; 95% CI, 3.6-4.1; rate difference [SE], -0.2 [0.3]; 95% CI, -0.5 to 0.2). Secondary outcomes did not significantly differ between trial groups among residents with and without advanced illness. Based on champions' reports, 912 of 4171 residents with advanced illness (21.9%) viewed ACP videos. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities [11.8%]) to more than 40% (22 facilities [18.5%]). CONCLUSIONS AND RELEVANCE This study found that an ACP video program was not effective in reducing hospital transfers, decreasing burdensome treatment use, or increasing hospice enrollment among long-stay residents with or without advanced illness. Intervention fidelity was low, highlighting the challenges of implementing new programs in nursing homes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688.
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Affiliation(s)
- Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Angelo E Volandes
- Section of General Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ruoshui Zhai
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
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Takazono T, Imamura Y, Kawakami K, Yamasaki N, Shimizu H, Usuki K, Kiyohara M, Hirayama T, Tashiro M, Hosogaya N, Saijo T, Yamamoto K, Miyazaki T, Yanagihara K, Izumikawa K, Mukae H. Discrepancies in preferences regarding the care of terminal-phase pneumonia in elderly patients among patients, families, and doctors: A multicenter questionnaire survey in nagasaki, Japan. Respir Investig 2020; 58:488-494. [PMID: 32631765 DOI: 10.1016/j.resinv.2020.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Before advance care planning, it is essential to understand the differences in preferences for medical care of terminal-phase pneumonia in elderly patients among the patients, their families, and their doctors. This study aimed to clarify these differences and investigate the actual care provided to elderly patients with pneumonia in nursing hospitals. METHODS Multicenter questionnaire surveys of 179 patients admitted to nursing homes and long-term care beds in hospitals of three healthcare corporations, their families, and their physicians were conducted between January and August 2018. The questionnaires mainly assessed preferences for life-prolonging medical care procedures, including antibiotic treatments, in terminal-phase pneumonia. A follow-up survey regarding the prognosis and the actual care provided by the physicians was conducted 1 year after the first survey. RESULTS Only 16.2% of the patients had sufficient prior discussions with their families about their care. More families preferred cardiac massage, intubation, and tracheostomy, while fewer families preferred peripheral intravenous fluids or antibiotics than physicians. A total of 30 patients' families (16.7%) answered to withhold antibiotic treatment, while all physicians supported antibiotic administration. The only significant factor related to withholding antibiotics was high age (P = 0.0057). The follow-up survey administered to the doctors revealed that 49 patients (35.7%) had died within one year. Of the 137 patients, 54 patients (39.4%) had developed pneumonia during this observation period and all were treated with antibiotics. CONCLUSIONS This study revealed large discrepancies between patients/families and physicians regarding preferences for care. Medical staff should make efforts to fill the gap by ensuring advance care planning.
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Affiliation(s)
- Takahiro Takazono
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan.
| | - Yoshifumi Imamura
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Kaoru Kawakami
- Health Care Corporation Syowakai, Syowakai Hospital, Nagasaki, Japan
| | - Naoya Yamasaki
- Health Care Corporation Keiseikai, Shimizu Hospital, Nagasaki, Japan
| | - Hiroyoshi Shimizu
- Health Care Corporation Keiseikai, Shimizu Hospital, Nagasaki, Japan
| | - Katsuhiro Usuki
- Health Care Corporation Hakuwakai, Atago Hospital, Nagasaki, Japan
| | - Maiko Kiyohara
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Tatsuro Hirayama
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Masato Tashiro
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Naoki Hosogaya
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Tomomi Saijo
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Kazuko Yamamoto
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Taiga Miyazaki
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
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Dowson L, Friedman ND, Marshall C, Stuart RL, Buising K, Rajkhowa A, Gotterson F, Kong DC. Antimicrobial stewardship near the end of life in aged care homes. Am J Infect Control 2020; 48:688-694. [PMID: 31806238 DOI: 10.1016/j.ajic.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The objective of this study was to understand how aged care home health professionals perceive antimicrobial use near the end of life and how they perceive potential antimicrobial stewardship activities near the end of life in aged care homes. METHODS Qualitative semi-structured interviews were undertaken with general practitioners, nurses, and pharmacists who provide routine care in aged care homes in Victoria, Australia. Interviews were coded using frameworks for understanding behavior change. RESULTS Themes were established within 14 interviews, and an additional 6 interviews were undertaken to ensure thematic saturation. Two major themes emerged: (i) Antimicrobial stewardship activities near the end of life in aged care homes need to enable aged care home nurses to make decisions substantiated by evidence-based clinical knowledge. Antimicrobial stewardship should clearly be part of an aged care home nurse's role, and accreditation standards provide powerful motivation for behavior change. (ii) Antimicrobial stewardship activities near the end of life in aged care homes must address family confidence in resident wellbeing. Antimicrobial stewardship activities should be inclusive of family involvement, and messages should highlight the point that antimicrobial stewardship improves care. CONCLUSIONS Antimicrobial stewardship activities that reinforce evidence-based clinical decision-making by aged care home nurses and address family confidence in resident wellbeing are required near the end of life in aged care homes. Accreditation standards are important motivators for behavior change in aged care homes.
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Pettigrew C, Brichko R, Black B, O’Connor MK, Austrom MG, Robinson MT, Lindauer A, Shah RC, Peavy GM, Meyer K, Schmitt FA, Lingler JH, Domoto-Reilly K, Farrar-Edwards D, Albert M. Attitudes toward advance care planning among persons with dementia and their caregivers. Int Psychogeriatr 2020; 32:585-599. [PMID: 31309906 PMCID: PMC6962575 DOI: 10.1017/s1041610219000784] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To examine factors that influence decision-making, preferences, and plans related to advance care planning (ACP) and end-of-life care among persons with dementia and their caregivers, and examine how these may differ by race. DESIGN Cross-sectional survey. SETTING 13 geographically dispersed Alzheimer's Disease Centers across the United States. PARTICIPANTS 431 racially diverse caregivers of persons with dementia. MEASUREMENTS Survey on "Care Planning for Individuals with Dementia." RESULTS The respondents were knowledgeable about dementia and hospice care, indicated the person with dementia would want comfort care at the end stage of illness, and reported high levels of both legal ACP (e.g., living will; 87%) and informal ACP discussions (79%) for the person with dementia. However, notable racial differences were present. Relative to white persons with dementia, African American persons with dementia were reported to have a lower preference for comfort care (81% vs. 58%) and lower rates of completion of legal ACP (89% vs. 73%). Racial differences in ACP and care preferences were also reflected in geographic differences. Additionally, African American study partners had a lower level of knowledge about dementia and reported a greater influence of religious/spiritual beliefs on the desired types of medical treatments. Notably, all respondents indicated that more information about the stages of dementia and end-of-life health care options would be helpful. CONCLUSIONS Educational programs may be useful in reducing racial differences in attitudes towards ACP. These programs could focus on the clinical course of dementia and issues related to end-of-life care, including the importance of ACP.
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Affiliation(s)
- Corinne Pettigrew
- Department of Neurology, Johns Hopkins School of Medicine, 1620 McElderry St., Baltimore, MD, 21205, USA
| | - Rostislav Brichko
- Department of Neurology, Johns Hopkins School of Medicine, 1620 McElderry St., Baltimore, MD, 21205, USA
| | - Betty Black
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, 5300 Alpha Commons Dr., Baltimore, MD 21224, USA
| | - Maureen K. O’Connor
- Department of Neurology, Boston University School of Medicine, 72 East Concord St., B-7800, Boston, MA 02118, USA
| | - Mary Guerriero Austrom
- Department of Psychiatry, Indiana University School of Medicine, 355 W. 16 St., Goodman Hall, Suite 2800, Indianapolis, IN 46202, USA
| | - Maisha T. Robinson
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
| | - Allison Lindauer
- Department of Neurology, Layton Aging and Alzheimer’s Disease Center, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97239, USA
| | - Raj C. Shah
- Department of Family Medicine and the Rush Alzheimer’s Disease Center, Rush University Medical Center, 1750 W. Harrison Street., Suite 1000, Chicago, IL 60612, USA
| | - Guerry M. Peavy
- Department of Neurosciences, University of California, San Diego School of Medicine, 9444 Medical Center Drive, Suite 1-100, La Jolla, CA 92037, USA
| | - Kayla Meyer
- Department of Neurology, University of Kansas Medical Center, 4350 Shawnee Mission Parkway, MS 6002, Fairway, KS 66205, USA
| | - Frederick A. Schmitt
- Department of Neurology & Sanders-Brown Center on Aging, University of Kentucky, 800 South Limestone St., Lexington, KY 40536, USA
| | - Jennifer H. Lingler
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, 415 Victoria Hall, 3500 Victoria St., Pittsburgh, PA 15261, USA
| | - Kimiko Domoto-Reilly
- Department of Neurology, University of Washington, 325 9th Ave., 3 Floor West Clinic, Seattle, WA 98104, USA
| | - Dorothy Farrar-Edwards
- Department of Kinesiology-Occupational Therapy, University of Wisconsin Madison School of Education, 2170 Medical Sciences Center, 1300 University Ave., Madison, WI 53706, USA
| | - Marilyn Albert
- Department of Neurology, Johns Hopkins School of Medicine, 1620 McElderry St., Baltimore, MD, 21205, USA
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Puente-Fernández D, Roldán-López CB, Campos-Calderón CP, Hueso-Montoro C, García-Caro MP, Montoya-Juarez R. Prospective Evaluation of Intensity of Symptoms, Therapeutic Procedures and Treatment in Palliative Care Patients in Nursing Homes. J Clin Med 2020; 9:jcm9030750. [PMID: 32164342 PMCID: PMC7141278 DOI: 10.3390/jcm9030750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 02/04/2023] Open
Abstract
The aim of the study is to evaluate the intensity of symptoms, and any treatment and therapeutic procedures received by advanced chronic patients in nursing homes. A multi-centre prospective study was conducted in six nursing homes for five months. A nurse trainer selected palliative care patients from whom the sample was randomly selected for inclusion. The Edmonton Symptoms Assessment Scale, therapeutic procedures, and treatment were evaluated. Parametric and non-parametric tests were used to evaluate month-to-month differences and differences between those who died and those who did not. A total of 107 residents were evaluated. At the end of the follow-up, 39 had (34.6%) died. All symptoms (p < 0.050) increased in intensity in the last week of life. Symptoms were more intense in those who had died at follow-up (p < 0.05). The use of aerosol sprays (p = 0.008), oxygen therapy (p < 0.001), opioids (p < 0.001), antibiotics (p = 0.004), and bronchodilators (p = 0.003) increased in the last week of life. Peripheral venous catheters (p = 0.022), corticoids (p = 0.007), antiemetics (p < 0.001), and antidepressants (p < 0.05) were used more in the patients who died. In conclusion, the use of therapeutic procedures (such as urinary catheters, peripheral venous catheter placement, and enteral feeding) and drugs (such as antibiotics, anxiolytics, and new antidepressant prescriptions) should be carefully considered in this clinical setting.
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Affiliation(s)
- Daniel Puente-Fernández
- Doctoral Program of Clinical Medicine and Public Health, University of Granada, 18071 Granada, Spain;
| | - Concepción B. Roldán-López
- Department of Statistics and Operational Research, Faculty of Medicine, University of Granada, 1016 Granada, Spain;
| | | | - Cesar Hueso-Montoro
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
| | - María P. García-Caro
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
| | - Rafael Montoya-Juarez
- Department of Nursing, Faculty of Health Sciences, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Spain; (C.H.-M.); (M.P.G.-C.); (R.M.-J.)
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McCarthy EP, Ogarek JA, Loomer L, Gozalo PL, Mor V, Hamel MB, Mitchell SL. Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations. JAMA Intern Med 2020; 180:385-394. [PMID: 31886827 PMCID: PMC6990757 DOI: 10.1001/jamainternmed.2019.6130] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population. OBJECTIVE To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019. MAIN OUTCOMES AND MEASURES The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained. RESULTS The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%). CONCLUSIONS AND RELEVANCE The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.
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Affiliation(s)
- Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, US Department of Veterans Affairs Medical Center, Providence, Rhode Island
| | - Mary Beth Hamel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Eisenmann Y, Golla H, Schmidt H, Voltz R, Perrar KM. Palliative Care in Advanced Dementia. Front Psychiatry 2020; 11:699. [PMID: 32792997 PMCID: PMC7394698 DOI: 10.3389/fpsyt.2020.00699] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/02/2020] [Indexed: 12/20/2022] Open
Abstract
Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.
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Affiliation(s)
- Yvonne Eisenmann
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Holger Schmidt
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Klaus Maria Perrar
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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Luckett T, Luscombe G, Phillips J, Beattie E, Chenoweth L, Davidson PM, Goodall S, Pond D, Mitchell G, Agar M. Australian long-term care personnel's knowledge and attitudes regarding palliative care for people with advanced dementia. DEMENTIA 2019; 20:427-443. [PMID: 31707844 DOI: 10.1177/1471301219886768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
This study aimed to describe Australian long-term care (LTC) personnel's knowledge and attitudes concerning palliative care for residents with advanced dementia, and explore relationships with LTC facility/personnel characteristics. An analysis was undertaken of baseline data from a cluster randomised controlled trial of facilitated family case conferencing for improving palliative care of LTC residents with advanced dementia (the 'IDEAL Study'). Participants included any LTC personnel directly involved in residents' care. Knowledge and attitudes concerning palliative care for people with advanced dementia were measured using the questionnaire on Palliative Care for Advanced Dementia. Univariate and multivariate analyses explored relationships between personnel knowledge/attitudes and facility/personnel characteristics. Of 307 personnel in the IDEAL Study, 290 (94.5%) from 19/20 LTCFs provided sufficient data for inclusion. Participants included 9 (2.8%) nurse managers, 59 (20.5%) registered nurses, 25 (8.7%) enrolled nurses, 187 (64.9%) assistants in nursing/personal care assistants and 9 (3.1%) care service employees. In multivariate analyses, a facility policy not to rotate personnel through dementia units was the only variable associated with more favourable overall personnel knowledge and attitudes. Other variables associated with favourable knowledge were a designation of nursing manager or registered or enrolled nurse, and having a preferred language of English. Other variables associated with favourable attitudes were tertiary level of education and greater experience in dementia care. Like previous international research, this study found Australian LTC personnel knowledge and attitudes regarding palliative care for people with advanced dementia to be associated with both facility and personnel characteristics. Future longitudinal research is needed to better understand the relationships between knowledge and attitudes, as well as between these attributes and quality of care.
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Affiliation(s)
- Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Georgina Luscombe
- School of Rural Health, The University of Sydney, Orange/Dubbo, Australia
| | - Jane Phillips
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Elizabeth Beattie
- School of Nursing, Queensland University of Technology, Herston, Australia
| | - Lynnette Chenoweth
- Centre for Healthy Brain Ageing, University of New South Wales, Randwick, Australia
| | - Patricia M Davidson
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Australia; School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Stephen Goodall
- Centre for Health Research and Evaluation (CHERE), Faculty of Business, University of Technology Sydney, Haymarket, Australia
| | - Dimity Pond
- School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
| | - Geoffrey Mitchell
- Faculty of Medicine, The University of Queensland, St Lucia, Australia
| | - Meera Agar
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Ingham Institute for Applied Medical Research, Liverpool, Australia
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Loizeau AJ, D'Agata EMC, Shaffer ML, Hanson LC, Anderson RA, Tsai T, Habtemariam DA, Bergman EH, Carroll RP, Cohen SM, Scott EME, Stevens E, Whyman JD, Bennert EH, Mitchell SL. The trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias: study protocol for a cluster randomized controlled trial. Trials 2019; 20:594. [PMID: 31615540 PMCID: PMC6794759 DOI: 10.1186/s13063-019-3675-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infections are common in nursing home (NH) residents with advanced dementia but are often managed inappropriately. Antimicrobials are extensively prescribed, but frequently with insufficient evidence to support a bacterial infection, promoting the emergence of multidrug-resistant organisms. Moreover, the benefits of antimicrobials remain unclear in these seriously ill residents for whom comfort is often the goal of care. Prior NH infection management interventions evaluated in randomized clinical trials (RCTs) did not consider patient preferences and lack evidence to support their effectiveness in 'real-world' practice. METHODS This report presents the rationale and methodology of TRAIN-AD (Trial to reduce antimicrobial use in nursing home residents with Alzheimer's disease and other dementias), a parallel group, cluster RCT evaluating a multicomponent intervention to improve infection management for suspected urinary tract infections (UTIs) and lower respiratory tract infections (LRIs) among NH residents with advanced dementia. TRAIN-AD is being conducted in 28 facilities in the Boston, USA, area randomized in waves using minimization to achieve a balance on key characteristics (N = 14 facilities/arm). The involvement of the facilities includes a 3-month start-up period and a 24-month implementation/data collection phase. Residents are enrolled during the first 12 months of the 24-month implementation period and followed for up to 12 months. Individual consent is waived, thus almost all eligible residents are enrolled (target sample size, N = 410). The intervention integrates infectious disease and palliative care principles and includes provider training delivered through multiple modalities (in-person seminar, online course, management algorithms, and prescribing feedback) and an information booklet for families. Control facilities employ usual care. The primary outcome, abstracted from the residents' charts, is the number of antimicrobial courses prescribed for UTIs and LRIs per person-year alive. DISCUSSION TRAIN-AD is the first cluster RCT testing a multicomponent intervention to improve infection management in NH residents with advanced dementia. Its findings will provide an evidence base to support the benefit of a program addressing the critical clinical and public health problem of antimicrobial misuse in these seriously ill residents. Moreover, its hybrid efficacy-effectiveness design will inform the future conduct of cluster RCTs evaluating nonpharmacological interventions in the complex NH setting in a way that is both internally valid and adaptable to the 'real-world'. TRIAL REGISTRATION ClinicalTrials.gov, NCT03244917 . Registered on 10 August 2017.
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Affiliation(s)
- Andrea J Loizeau
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA.
| | - Erika M C D'Agata
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Michele L Shaffer
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Palliative Care Program, Chapel Hill, NC, USA
| | - Ruth A Anderson
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy Tsai
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Daniel A Habtemariam
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Elaine H Bergman
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Ruth P Carroll
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Simon M Cohen
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA
| | - Erin M E Scott
- Division of Palliative Care and Geriatrics, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Erin Stevens
- Division of Palliative Care and Geriatrics, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremy D Whyman
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, 1200 Centre Street, Boston, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Stone PW, Agarwal M, Ye F, Sorbero M, Miller SC, Dick AW. Integration of Palliative Care and Infection Management at the End of Life in U.S. Nursing Homes. J Pain Symptom Manage 2019; 58:408-416.e1. [PMID: 31195078 PMCID: PMC6708746 DOI: 10.1016/j.jpainsymman.2019.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/13/2019] [Accepted: 06/03/2019] [Indexed: 11/23/2022]
Abstract
CONTEXT Infections in nursing home (NH) residents are often terminal illnesses. Integration of palliative care (PC) and infection management (IM) is a new concept that can help reduce burdensome treatments and improve quality of care for NH residents at the end of life. OBJECTIVES To develop measures of integration, describe the integration in U.S. NHs, and examine predictors of integration. METHODS A nationally representative sample of NHs was surveyed. An instrument to measure integration was tested using factor analyses. Descriptive analyses of each integration factor were conducted, construct validity was examined using correlations between the integration factors and validated measures of PC and IM, and multivariable linear regression models were developed to identify NH characteristics associated with integration. RESULTS A total of 892 NH surveys were returned (49% response rate), 859 with complete data. Three integration factors were identified: patient involvement in care planning (Involvement), formalized advance care planning (Advance Care Planning), and routine practices of integration (Routine Practices). The highest level of integration in NHs was reported for Involvement (mean (μ) = 73.2, standard error [SE] = 1.57), with lower rates for Advance Care Planning and Routine Practices (respectively, μ = 34.1, SE = 1.05; μ = 31.4, SE = 1.48). Each integration measure was weakly, positively associated with the PC and IM measures (r ≤ 0.25, P ≤ 0.01). There were few associations between NH characteristics and integration. CONCLUSION Integration is a distinct concept that is associated with, but different from, PC and IM. Results serve as a baseline assessment of integration in NHs. Continued refinement of the integration instrument is recommended, as is studying if higher integration leads to better resident outcomes.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA.
| | - Feifei Ye
- RAND Corporation, Pittsburgh, Pennsylvania, USA
| | | | - Susan C Miller
- Brown University School of Public Health, Providence, Rhode Island, USA
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Childs A, Zullo AR, Joyce NR, McConeghy KW, van Aalst R, Moyo P, Bosco E, Mor V, Gravenstein S. The burden of respiratory infections among older adults in long-term care: a systematic review. BMC Geriatr 2019; 19:210. [PMID: 31382895 PMCID: PMC6683564 DOI: 10.1186/s12877-019-1236-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/30/2019] [Indexed: 11/22/2022] Open
Abstract
Background Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature. Methods We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively. Results A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%. Conclusions The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts. Electronic supplementary material The online version of this article (10.1186/s12877-019-1236-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arielle Childs
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - Andrew R Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA. .,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA. .,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.
| | - Nina R Joyce
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - Kevin W McConeghy
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Robertus van Aalst
- Sanofi Pasteur, Swiftwater, PA, USA.,Faculty of Medical Sciences, University of Groningen, Groningen, NL, the Netherlands
| | - Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - Elliott Bosco
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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Stall NM, Fischer HD, Fung K, Giannakeas V, Bronskill SE, Austin PC, Matlow JN, Quinn KL, Mitchell SL, Bell CM, Rochon PA. Sex-Specific Differences in End-of-Life Burdensome Interventions and Antibiotic Therapy in Nursing Home Residents With Advanced Dementia. JAMA Netw Open 2019; 2:e199557. [PMID: 31418809 PMCID: PMC6704739 DOI: 10.1001/jamanetworkopen.2019.9557] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/29/2019] [Indexed: 01/11/2023] Open
Abstract
Importance Nursing home residents with advanced dementia have limited life expectancies yet are commonly subjected to burdensome interventions at the very end of life. Whether sex-specific differences in the receipt of these interventions exist and what levels of physical restraints and antibiotics are used in this terminal setting are unknown. Objective To evaluate the population-based frequency, factors, and sex differences in burdensome interventions and antibiotic therapy among nursing home residents with advanced dementia. Design, Setting, and Participants This population-based cohort study from Ontario, Canada, used linked administrative databases held at ICES, including the Continuing Care Resident Reporting System Long-Term Care database, which contains data from the Resident Assessment Instrument Minimum Data Set, version 2.0. Nursing home residents (n = 27 243) with advanced dementia who died between June 1, 2010, and March 31, 2015, at 66 years or older were included in the analysis. Initial statistical analysis was completed in May 2017, and analytical revisions were conducted from November 2018 to January 2019. Exposure Sex of the nursing home resident. Main Outcomes and Measures Burdensome interventions (transitions of care, invasive procedures, and physical restraints) and antibiotic therapy in the last 30 days of life. Results The final cohort included 27 243 nursing home residents with advanced dementia (19 363 [71.1%] women) who died between June 1, 2010, and March 31, 2015, at the median (interquartile range) age of 88 (83-92) years. In the last 30 days of life, burdensome interventions were common, especially among men: 5940 (21.8%) residents were hospitalized (3661 women [18.9%] vs 2279 men [28.9%]; P < .001), 2433 (8.9%) had an emergency department visit (1579 women [8.2%] vs 854 men [10.8%]; P < .001), and 3701 (13.6%) died in an acute care facility (2276 women [11.8%] vs 1425 men [18.1%]; P < .001). Invasive procedures were also common; 2673 residents (9.8%) were attended for life-threatening critical care (1672 women [8.6%] vs 1001 men [12.7%]; P < .001), and 210 (0.8%) received mechanical ventilation (113 women [0.6%] vs 97 men [1.2%]; P < .001). Among the 9844 residents (36.1%) who had a Resident Assessment Instrument Minimum Data Set, version 2.0, completed in the last 30 days of life, 2842 (28.9%) were physically restrained (2002 women [28.3%] vs 840 men [30.4%]; P = .005). More than one-third (9873 [36.2%]) of all residents received an antibiotic (6599 women [34.1%] vs 3264 men [41.4%]; P < .001). In multivariable models, men were more likely to have a transition of care (adjusted odds ratio, 1.41; 95% CI, 1.33-1.49; P < .001) and receive antibiotics (adjusted odds ratio, 1.33; 95% CI, 1.26-1.41; P < .001). Only 3309 residents (12.1%; 2382 women [12.3%] vs 927 men [11.8%]) saw a palliative care physician in the year before death, but those who did experienced greater than 50% lower odds of an end-of-life transition of care (adjusted odds ratio, 0.48; 95% CI, 0.43-0.54); P < .001) and greater than 25% lower odds of receiving antibiotics (adjusted odds ratio, 0.74; 95% CI, 0.68-0.81; P < .001). Conclusions and Relevance In this study, many nursing home residents with advanced dementia, especially men, received burdensome interventions and antibiotics in their final days of life. These findings appear to emphasize the need for sex-specific analysis in dementia research as well as the expansion of palliative care and end-of-life antimicrobial stewardship in nursing homes.
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Affiliation(s)
- Nathan M. Stall
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | | | | | - Vasily Giannakeas
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Susan E. Bronskill
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Austin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy N. Matlow
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kieran L. Quinn
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Susan L. Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts
| | - Chaim M. Bell
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Paula A. Rochon
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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46
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Chor WPD, Wong SYP, Ikbal MFBM, Kuan WS, Chua MT, Pal RY. Initiating End-of-Life Care at the Emergency Department: An Observational Study. Am J Hosp Palliat Care 2019; 36:941-946. [PMID: 30862168 DOI: 10.1177/1049909119836931] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Terminally ill patients at their end-of-life (EOL) phase attending the emergency department (ED) may have complex and specialized care needs frequently overlooked by ED physicians. To tailor to the needs of this unique group, the ED in a tertiary hospital implemented an EOL pathway since 2014. The objective of our study is to describe the epidemiological characteristics, symptom burden and management of patients using a protocolized management care bundle. METHODS We conducted an observational study on the database of EOL patients over a 28-month period. Patients aged 21 years and above, who attended the ED and were managed according to these guidelines, were included. Clinical data were extracted from the hospital's electronic medical records system. RESULTS Two hundred five patients were managed under the EOL pathway, with a slight male predominance (106/205, 51.7%) and a median age of 78 (interquartile range 69-87) years. The majority were chronically frail (42.0%) or diagnosed with cancer or other terminal illnesses (32.7%). The 3 most commonly experienced symptoms were drowsiness (66.3%), dyspnea (61.5%), and fever (29.7%). Through the protocolized management care bundle, 74.1% of patients with dyspnea and/or pain received opiates while 59.5% with copious secretions received hyoscine butylbromide for symptomatic relief. CONCLUSION The institution of a protocolized care bundle is feasible and provides ED physicians with a guide in managing EOL patients. Though still suboptimal, considerable advances in EOL care at the ED have been achieved and may be further improved through continual education and enhancements in the care bundle.
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Affiliation(s)
- Wei Ping Daniel Chor
- 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
| | | | | | - Win Sen Kuan
- 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore.,3 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mui Teng Chua
- 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore.,3 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rakhee Yash Pal
- 1 Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
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47
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Juthani-Mehta M, Allore HG. Design and analysis of longitudinal trials of antimicrobial use at the end of life: to give or not to give? Ther Adv Drug Saf 2019; 10:2042098618820210. [PMID: 30800269 PMCID: PMC6378640 DOI: 10.1177/2042098618820210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/28/2018] [Indexed: 01/22/2023] Open
Abstract
This perspective review considers analytic features of the design of a longitudinal trial regarding antimicrobial therapy in older terminal cancer patients receiving palliative care. We first overview antimicrobial use at the end of life; both the potential hazards and benefits. Antimicrobial prescribing should consider both initiation as well as cessation of medications when analyzing the burden of medications. Approaches to decision making regarding antimicrobial use are presented and the importance of health literacy in these decision processes. We next present aspects of both feasibility and comparative trial design with a health literacy intervention to reduce antimicrobial use in older terminal cancer patients receiving palliative care. Considerations to clustered randomization and given that infections can reoccur over a trial period, we share suggestions of longitudinal modeling of clustered randomized trial data.
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Affiliation(s)
| | - Heather G Allore
- Yale University School of Medicine, 300 George St, Suite 775, New Haven, CT 06511, USA
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48
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Dyer J, Vaux L, Broom A, Broom J. Antimicrobial use in patients at the end of life in an Australian hospital. Infect Dis Health 2019; 24:92-97. [PMID: 30655096 DOI: 10.1016/j.idh.2018.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/14/2018] [Accepted: 12/16/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Antimicrobial resistance is increasing and there is an urgent international imperative to optimise use within hospitals. Antibiotic use at the end of life is frequent in the hospital setting, but data on use in Australian hospitals in this context is limited, and optimisation is complicated by clinical/diagnostic, ethical and humanistic considerations. As yet there is little data available on baseline use in hospital end of life settings, an empirical gap we sought to begin to fill here. METHODS A retrospective review of antibiotic use in patients who died in a Queensland hospital between January 2015 and July 2015. RESULTS One hundred and thirty-seven patients were included, of which 73 were male (53.3%) and the median age was 81 years. Of these patients, 86 received antibiotics at the end of life. The most common antibiotic prescribed was piperacillin/tazobactam (41.9%). The most common site of infection was pulmonary (32.8%). Of 86 patients prescribed antibiotics, 29 patients (33.7%) received antibiotics after futility was documented. 83 patients (96.5%) were administered their antibiotics intravenously. CONCLUSION Antimicrobial use at the end of life is frequent, with greater than one third of the patients who died in hospital having their antibiotics continued after discussion of futility. Antimicrobial use in this setting is complex with significant clinical, social and ethical considerations which need to be addressed if antibiotic optimization in this area (and more broadly in the hospital) is to be achieved.
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Affiliation(s)
- Jane Dyer
- Department of Medicine, Sunshine Coast Hospital and Health Service, Hospital Road, Nambour, QLD, 5470, Australia.
| | - Lucinda Vaux
- Department of Medicine, Sunshine Coast Hospital and Health Service, Hospital Road, Nambour, QLD, 5470, Australia
| | - Alex Broom
- School of Social Sciences, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Jennifer Broom
- Department of Medicine, Sunshine Coast Hospital and Health Service, Hospital Road, Nambour, QLD, 5470, Australia
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49
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Loizeau AJ, Theill N, Cohen SM, Eicher S, Mitchell SL, Meier S, McDowell M, Martin M, Riese F. Fact Box decision support tools reduce decisional conflict about antibiotics for pneumonia and artificial hydration in advanced dementia: a randomized controlled trail. Age Ageing 2019; 48:67-74. [PMID: 30321268 DOI: 10.1093/ageing/afy149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/31/2018] [Indexed: 01/16/2023] Open
Abstract
Background fact Boxes are decision support tools that can inform about treatment effects. Objectives to test whether Fact Box decision support tools impacted decisional conflict, knowledge and preferences about the use of antibiotics and artificial hydration in advanced dementia. Design randomized controlled trial. Setting Swiss-German region of Switzerland. Subjects two hundred thirty-two participants (64 physicians, 100 relatives of dementia patients, 68 professional guardians) randomly allocated to intervention (N = 114) or control (N = 118). Intervention two-page Fact Box decision support tools on antibiotics for pneumonia and artificial hydration in advanced dementia (at 1-month). Methods participants were mailed questionnaires at baseline and one month later that asked questions about treatments based on hypothetical scenarios. The primary outcome was change in decisional conflict (DCS-D; range 0 < 100) about treatment decisions. Secondary outcomes included knowledge about treatments (range 0 < 7) and preferences to forego treatments. Results participants were: mean age, 55.6 years; female, 62.8%. Relative to control participants, intervention participants experienced less decisional conflict about using antibiotics (unstandardized beta (b) = -8.35, 95% Confidence Interval (CI), -12.43, -4.28) and artificial hydration (b = -6.02, 95% CI, -9.84, -2.20) at 1-month compared to baseline. Intervention participants displayed greater knowledge about the use of antibiotics (b = 2.24, 95% CI, 1.79, 2.68) and artificial hydration (b = 3.01, 95% CI, 2.53, 3.49), and were significantly more likely to prefer to forego antibiotics (odds ratio, 2.29, 95% CI, 1.08, 4.84) but not artificial hydration. Conclusions fact Box decision support tools reduced decisional conflict, increased knowledge and promoted preferences to forego antibiotics in advanced dementia among various decision-makers. Trial registration FORSbase (12091).
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Affiliation(s)
- Andrea J Loizeau
- University Research Priority Program ‘Dynamics of Healthy Aging’, University of Zurich, Zurich, Switzerland
- Center for Gerontology, University of Zurich, Zurich, Switzerland
- Hebrew SeniorLife Institute for Aging Research, Roslindale, MA, USA
| | - Nathan Theill
- University Research Priority Program ‘Dynamics of Healthy Aging’, University of Zurich, Zurich, Switzerland
- Center for Gerontology, University of Zurich, Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich, Switzerland
| | - Simon M Cohen
- Hebrew SeniorLife Institute for Aging Research, Roslindale, MA, USA
| | - Stefanie Eicher
- University Research Priority Program ‘Dynamics of Healthy Aging’, University of Zurich, Zurich, Switzerland
- Center for Gerontology, University of Zurich, Zurich, Switzerland
| | - Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Roslindale, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Silvio Meier
- Center for Gerontology, University of Zurich, Zurich, Switzerland
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Michelle McDowell
- Harding Center for Risk Literacy, Max Planck Institute for Human Development, Berlin, Germany
| | - Mike Martin
- University Research Priority Program ‘Dynamics of Healthy Aging’, University of Zurich, Zurich, Switzerland
- Center for Gerontology, University of Zurich, Zurich, Switzerland
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Florian Riese
- University Research Priority Program ‘Dynamics of Healthy Aging’, University of Zurich, Zurich, Switzerland
- Division of Psychiatry Research and Psychogeriatric Medicine, University of Zurich, Zurich, Switzerland
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50
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Cohen SM, Volandes AE, Shaffer ML, Hanson LC, Habtemariam D, Mitchell SL. Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial. J Pain Symptom Manage 2019; 57:37-46.e1. [PMID: 30273717 PMCID: PMC6310643 DOI: 10.1016/j.jpainsymman.2018.09.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/14/2018] [Accepted: 09/20/2018] [Indexed: 11/23/2022]
Abstract
CONTEXT Care consistent with goals is the desired outcome of advance care planning (ACP). OBJECTIVES The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance. METHODS Data were from Educational Video to Improve Nursing home Care in End-stage dementia, a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N = 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube-feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined. RESULTS Among the residents (mean age, 86.6 years; 19.5% male), the most prevalent directive was DNR (89.3%) and foregoing antibiotics was least common (parenteral, 8.2%; any type, 4.0%). Concordance between directives and each level of care preference was as follows: comfort, 7%; basic, 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% vs. 2.5%; adjusted odds ratio, 2.48; 95% CI, 1.01-6.09). CONCLUSION Better alignment between preferences for comfort-focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal.
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Affiliation(s)
- Simon M Cohen
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA
| | - Angelo E Volandes
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele L Shaffer
- Department of Statistics, University of Washington, Seattle, Washington, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Cecil G. Sheps Center for Health Services Research and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel Habtemariam
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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