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Gombault-Datzenko E, Costa N, Mounié M, Tavassoli N, Mathieu C, Roussel H, Lagarrigue JM, Berard E, Rolland Y, Molinier L. Cost of care pathways before and after appropriate and inappropriate transfers to the emergency department among nursing home residents: results from the FINE study. BMC Geriatr 2024; 24:353. [PMID: 38641801 PMCID: PMC11027376 DOI: 10.1186/s12877-024-04946-x] [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: 07/04/2023] [Accepted: 04/03/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Transfers of nursing home (NH) residents to the emergency department (ED) is frequent. Our main objective was to assess the cost of care pathways 6 months before and after the transfer to the emergency department among NH residents, according to the type of transfer (i.e. appropriate or inappropriate). METHODS This was a part of an observational, multicenter, case-control study: the Factors associated with INappropriate transfer to the Emergency department among nursing home residents (FINE) study. Sixteen public hospitals of the former Midi-Pyrénées region participated in recruitment, in 2016. During the inclusion period, all NH residents arriving at the ED were included. A pluri-disciplinary team categorized each transfer to the ED into 2 groups: appropriate or inappropriate. Direct medical and nonmedical costs were assessed from the French Health Insurance (FHI) perspective. Healthcare resources were retrospectively gathered from the FHI database and valued using the tariffs reimbursed by the FHI. Costs were recorded over a 6-month period before and after transfer to the ED. Other variables were used for analysis: sex, age, Charlson score, season, death and presence inside the NH of a coordinating physician or a geriatric nursing assistant. RESULTS Among the 1037 patients initially included in the FINE study, 616 who were listed in the FHI database were included in this economic study. Among them, 132 (21.4%) had an inappropriate transfer to the ED. In the 6 months before ED transfer, total direct costs on average amounted to 8,145€ vs. 6,493€ in the inappropriate and appropriate transfer groups, respectively. In the 6 months after ED transfer, they amounted on average to 9,050€ vs. 12,094€. CONCLUSIONS Total costs on average are higher after transfer to the ED, but there is no significant increase in healthcare expenditure with inappropriate ED transfer. Support for NH staff and better pathways of care could be necessary to reduce healthcare expenditures in NH residents. TRIAL REGISTRATION clinicaltrials.gov, NCT02677272.
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Affiliation(s)
- E Gombault-Datzenko
- Present address: Department of Medical Information (DIM), Toulouse University Hospital, 2 rue Viguerie, Toulouse Cedex 9, 31059, France.
| | - N Costa
- Present address: Department of Medical Information (DIM), Toulouse University Hospital, 2 rue Viguerie, Toulouse Cedex 9, 31059, France
- INSERM, UMR 1295, Toulouse, France
| | - M Mounié
- Present address: Department of Medical Information (DIM), Toulouse University Hospital, 2 rue Viguerie, Toulouse Cedex 9, 31059, France
- INSERM, UMR 1295, Toulouse, France
| | - N Tavassoli
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - C Mathieu
- Gérontopôle, Toulouse University Hospital, Toulouse, France
- CREAI-ORS Occitanie, Toulouse, France
| | - H Roussel
- CNAM, DRSM Occitanie, 2 rue Georges Vivent, Toulouse, 31082, France
| | - J M Lagarrigue
- MSA Midi-Pyrénées Nord, 180 Avenue Marcel Unal, Montauban, 82000, France
| | - E Berard
- INSERM, UMR 1295, Toulouse, France
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, Toulouse, 31000, France
| | - Y Rolland
- INSERM, UMR 1295, Toulouse, France
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - L Molinier
- Present address: Department of Medical Information (DIM), Toulouse University Hospital, 2 rue Viguerie, Toulouse Cedex 9, 31059, France
- INSERM, UMR 1295, Toulouse, France
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Nandi A, Counts N, Bröker J, Malik S, Chen S, Han R, Klusty J, Seligman B, Tortorice D, Vigo D, Bloom DE. Cost of care for Alzheimer's disease and related dementias in the United States: 2016 to 2060. NPJ AGING 2024; 10:13. [PMID: 38331952 PMCID: PMC10853249 DOI: 10.1038/s41514-024-00136-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024]
Abstract
Medical and long-term care for Alzheimer's disease and related dementias (ADRDs) can impose a large economic burden on individuals and societies. We estimated the per capita cost of ADRDs care in the in the United States in 2016 and projected future aggregate care costs during 2020-2060. Based on a previously published methodology, we used U.S. Health and Retirement Survey (2010-2016) longitudinal data to estimate formal and informal care costs. In 2016, the estimated per patient cost of formal care was $28,078 (95% confidence interval [CI]: $25,893-$30,433), and informal care cost valued in terms of replacement cost and forgone wages was $36,667 ($34,025-$39,473) and $15,792 ($12,980-$18,713), respectively. Aggregate formal care cost and formal plus informal care cost using replacement cost and forgone wage methods were $196 billion (95% uncertainty range [UR]: $179-$213 billion), $450 billion ($424-$478 billion), and $305 billion ($278-$333 billion), respectively, in 2020. These were projected to increase to $1.4 trillion ($837 billion-$2.2 trillion), $3.3 trillion ($1.9-$5.1 trillion), and $2.2 trillion ($1.3-$3.5 trillion), respectively, in 2060.
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Affiliation(s)
- Arindam Nandi
- The Population Council, 1 Dag Hammarskjold Plaza, New York, NY, 10017, USA.
- One Health Trust, Washington, DC, USA.
| | - Nathaniel Counts
- Office of the Commissioner of Health & Mental Hygiene for the City of New York, New York, NY, USA
| | | | | | - Simiao Chen
- University of Heidelberg, Heidelberg, Germany
| | - Rachael Han
- Department of Molecular and Cellular Biology and The Center for Brain Science, Harvard University, Cambridge, MA, USA
| | | | - Benjamin Seligman
- Division of Geriatric Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Geriatrics Research, Education, and Clinical Center, Greater Los Angeles VA Health Care System, Los Angeles, CA, USA
| | | | - Daniel Vigo
- University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - David E Bloom
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Rashid N, Wetmore JB, Irfan M, Abler V. Economic Evaluation of Healthcare Resource Utilization and Costs for Newly Diagnosed Dementia-Related Psychosis. Geriatrics (Basel) 2022; 7:geriatrics7020029. [PMID: 35314601 PMCID: PMC8938820 DOI: 10.3390/geriatrics7020029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/15/2022] [Accepted: 02/26/2022] [Indexed: 11/16/2022] Open
Abstract
This retrospective cohort study described changes in all-cause healthcare resource utilization (HCRU) and associated costs in dementia patients newly diagnosed with psychosis. Dementia and incident psychosis were identified using diagnostic and pharmacy claims using a Medicare 20% random sample dataset. All-cause HCRU and unweighted and weighted (by person-years of follow-up) HCRU-associated costs were evaluated in the year prior to and the 4 years following diagnosis of psychosis. In 49,509 dementia patients with psychosis, physician visits per patient per year increased from a mean of 26.7 (standard deviation (SD) 20.0) prior to psychosis to 38.4 (SD 41.9) post-psychosis diagnosis. The number of inpatient stay claims increased from 1.0 (SD 1.4) to 1.7 (SD 5.8). Mean unweighted costs for inpatient stays and home healthcare/hospice during 2008–2016 were USD 9989 and USD 3279 prior to a diagnosis of psychosis but increased to USD 25,982 and USD 9901 (weighted: USD 11,779 and USD 6709), respectively, in the year after a psychosis diagnosis. This pattern of a sharp increase in mean costs was also observed in costs adjusted to 2015 USD, and in both unweighted and weighted total and psychosis-related costs. These results indicate the importance of identifying newly diagnosed psychosis in dementia patients as well as the pressing need for management strategies and treatments that can reduce HCRU and costs.
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Affiliation(s)
- Nazia Rashid
- Acadia Pharmaceuticals Inc., San Diego, CA 92130, USA;
- Correspondence: ; Tel.: +1-858-558-2871
| | - James B. Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN 55415, USA;
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN 55404, USA
| | - Muna Irfan
- Veterans Affairs Medical Center, University of Minnesota, Minneapolis, MN 55417, USA;
| | - Victor Abler
- Acadia Pharmaceuticals Inc., San Diego, CA 92130, USA;
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4
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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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Leniz J, Yi D, Yorganci E, Williamson LE, Suji T, Cripps R, Higginson IJ, Sleeman KE. Exploring costs, cost components, and associated factors among people with dementia approaching the end of life: A systematic review. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12198. [PMID: 34541291 PMCID: PMC8438684 DOI: 10.1002/trc2.12198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/20/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Understanding costs of care for people dying with dementia is essential to guide service development, but information has not been systematically reviewed. We aimed to understand (1) which cost components have been measured in studies reporting the costs of care in people with dementia approaching the end of life, (2) what the costs are and how they change closer to death, and (3) which factors are associated with these costs. METHODS We searched the electronic databases CINAHL, Medline, Cochrane, Web of Science, EconLit, and Embase and reference lists of included studies. We included any type of study published between 1999 and 2019, in any language, reporting primary data on costs of health care in individuals with dementia approaching the end of life. Two independent reviewers screened all full-text articles. We used the Evers' Consensus on Health Economic Criteria checklist to appraise the risk of bias of included studies. RESULTS We identified 2843 articles after removing duplicates; 19 studies fulfilled the inclusion criteria, 16 were from the United States. Only two studies measured informal costs including out-of-pocket expenses and informal caregiving. The monthly total direct cost of care rose toward death, from $1787 to $2999 USD in the last 12 months, to $4570 to $11921 USD in the last month of life. Female sex, Black ethnicity, higher educational background, more comorbidities, and greater cognitive impairment were associated with higher costs. DISCUSSION Costs of dementia care rise closer to death. Informal costs of care are high but infrequently included in analyses. Research exploring the costs of care for people with dementia by proximity to death, including informal care costs and from outside the United States, is urgently needed.
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Affiliation(s)
- Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Emel Yorganci
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Lesley E. Williamson
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Trisha Suji
- School of Medical EducationFaculty of Life Science and MedicineKing's College LondonLondonUK
| | - Rachel Cripps
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Katherine E. Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
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Healthcare Utilization in Different Stages among Patients with Dementia: A Nationwide Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115705. [PMID: 34073398 PMCID: PMC8199003 DOI: 10.3390/ijerph18115705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022]
Abstract
To evaluate the trend of healthcare utilization among patients with dementia (PwD) in different post-diagnosis periods, Taiwan's nationwide population database was used in this study. PwD were identified on the basis of dementia diagnoses during 2002-2011. We further subdivided the cases into 10 groups from the index year to the 10th year after diagnosis. The frequency of emergency department visits and hospitalizations, the length of stay, outpatient and department visits, and the number of medications used were retrieved. The Joinpoint regression approach was used to estimate the annual percent change (APC) of healthcare utilization. The overall trend of healthcare utilization increased with the progression of dementia, with a significant APC during the first to second year after diagnosis (p < 0.01), except that the frequency of outpatient visits showed a decreasing trend with a significant APC from the first to fifth year. All sex- and age-stratified analyses revealed that male gender and old age contributed to greater use of healthcare services but did not change the overall trend. This study provides a better understanding of medical resource utilization across the full spectrum of dementia, which can allow policymakers, physicians, and caregivers to devise better care plans for PwD.
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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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Pickard SS, Prakash A, Newburger JW, Malek AM, Wong JB. Screening for Intracranial Aneurysms in Coarctation of the Aorta: A Decision and Cost-Effectiveness Analysis. Circ Cardiovasc Qual Outcomes 2020; 13:e006406. [PMID: 32762482 DOI: 10.1161/circoutcomes.119.006406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with coarctation of the aorta have a high prevalence of intracranial aneurysms (IA) and suffer subarachnoid hemorrhage (SAH) at younger ages than the general population. American Heart Association/American College of Cardiology guidelines recommend IA screening, but appropriate age and interval of screening and its effectiveness remain a critical knowledge gap. METHODS AND RESULTS To evaluate the benefits and cost-effectiveness of magnetic resonance angiography screening for IA in patients with coarctation of the aorta, we developed and calibrated a Markov model to match published IA prevalence estimates. The primary outcome was the incremental cost-effectiveness ratio. Secondary outcomes included lifetime cumulative incidence of prophylactic IA treatment and mortality and SAH deaths prevented. Using a payer perspective, a lifetime horizon, and a willingness-to-pay of $150 000 per quality-adjusted life-year gained, we applied a 3% annual discounting rate to costs and effects and performed 1-way, 2-way, and probabilistic sensitivity analyses. In a simulated cohort of 10 000 patients, no screening resulted in a 10.1% lifetime incidence of SAH and 183 SAH-related deaths. Screening at ages 10, 20, and 30 years led to 978 prophylactic treatments for unruptured aneurysms, 19 procedure-related deaths, and 65 SAH-related deaths. Screening at ages 10, 20, and 30 years was cost-effective compared with screening at ages 10 and 20 years (incremental cost-effectiveness ratio $106 841/quality-adjusted life-year). Uncertainty in the outcome after aneurysm treatment and quality of life after SAH influenced the preferred screening strategy. In probabilistic sensitivity analysis, screening at ages 10, 20, and 30 years was cost-effective in 41% of simulations and at ages 10 and 20 in 59% of simulations. CONCLUSIONS Our model supports the American Heart Association/American College of Cardiology recommendation to screen patients with coarctation of the aorta for IA and suggests screening at ages 10 and 20 or at 10, 20, and 30 years would extend life and be cost-effective.
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Affiliation(s)
- Sarah S Pickard
- Departments of Cardiology and of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA (S.S.P., A.P., J.W.N.). Cerebrovascular and Endovascular Division, Department of Neurosurgery (A.M.M.) and Division of Clinical Decision Making (J.B.W.), Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Ashwin Prakash
- Departments of Cardiology and of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA (S.S.P., A.P., J.W.N.). Cerebrovascular and Endovascular Division, Department of Neurosurgery (A.M.M.) and Division of Clinical Decision Making (J.B.W.), Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Jane W Newburger
- Departments of Cardiology and of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA (S.S.P., A.P., J.W.N.). Cerebrovascular and Endovascular Division, Department of Neurosurgery (A.M.M.) and Division of Clinical Decision Making (J.B.W.), Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Adel M Malek
- Departments of Cardiology and of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA (S.S.P., A.P., J.W.N.). Cerebrovascular and Endovascular Division, Department of Neurosurgery (A.M.M.) and Division of Clinical Decision Making (J.B.W.), Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - John B Wong
- Departments of Cardiology and of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA (S.S.P., A.P., J.W.N.). Cerebrovascular and Endovascular Division, Department of Neurosurgery (A.M.M.) and Division of Clinical Decision Making (J.B.W.), Tufts Medical Center, Tufts University School of Medicine, Boston, MA
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Iturbide-Casas MA, Cámara-Martos F, Molina-Luque R, Molina-Recio G. Survival Analysis of Enterally Fed Patients: Prognosis and Mortality Risk According to Baseline Characteristics. JPEN J Parenter Enteral Nutr 2019; 44:1057-1065. [PMID: 31736137 DOI: 10.1002/jpen.1745] [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: 06/20/2019] [Revised: 10/09/2019] [Accepted: 10/25/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Enteral nutrition is widely used. However, its benefits remain unclear in specific conditions like dementia. This study assesses the survival of enterally fed patients and the baseline characteristics associated with higher mortality. METHODS A retrospective analysis of biochemical and clinical data from 377 patients (age 77.5 ± 13.8) who received enteral tube feeding (ETF) at a tertiary hospital in Spain was performed. Kaplan-Meier and Cox regressions were used to analyze survival expectancy and mortality risk (MR). Risk was evaluated for 30/180 days and up to 5 years. RESULTS The most common individual diagnoses leading to ETF prescription were dementia (37.9%) and head/neck/upper-gastrointestinal-tract cancer (17.5%). Comorbidities (high blood pressure [HBP] and/or diabetes) were present in 72.4% of patients. The first 30 days after tube placement showed the highest mortality rate, corresponding to 85.4% of patients that did not continue being tube-fed. Multivariate Cox analysis (P < .05, 95% CI) showed HBP and glycemia to be predictive of overall (hazard ratio [HR] = 1.600; HR = 1.756) and long-term (HR = 3.092; HR = 4.539) death. In the short-term, only glycemia showed an increased MR (HR = 1.572). CONCLUSION This enterally fed population showed a noticeably high initial mortality rate. Despite official recommendations against it, ETF is very common in advanced dementia. Baseline characteristics are useful for identifying patients that would be less benefited by the intervention. Accordingly, families should be informed about realistic outcomes and risks derived from this procedure.
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Affiliation(s)
| | - Fernando Cámara-Martos
- Departamento de Bromatología y Tecnología de los Alimentos, Universidad de Córdoba, Córdoba, Spain
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Wang L, Sha L, Lakin JR, Bynum J, Bates DW, Hong P, Zhou L. Development and Validation of a Deep Learning Algorithm for Mortality Prediction in Selecting Patients With Dementia for Earlier Palliative Care Interventions. JAMA Netw Open 2019; 2:e196972. [PMID: 31298717 PMCID: PMC6628612 DOI: 10.1001/jamanetworkopen.2019.6972] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/20/2019] [Indexed: 11/26/2022] Open
Abstract
Importance Early palliative care interventions drive high-value care but currently are underused. Health care professionals face challenges in identifying patients who may benefit from palliative care. Objective To develop a deep learning algorithm using longitudinal electronic health records to predict mortality risk as a proxy indicator for identifying patients with dementia who may benefit from palliative care. Design, Setting, and Participants In this retrospective cohort study, 6-month, 1-year, and 2-year mortality prediction models with recurrent neural networks used patient demographic information and topics generated from clinical notes within Partners HealthCare System, an integrated health care delivery system in Boston, Massachusetts. This study included 26 921 adult patients with dementia who visited the health care system from January 1, 2011, through December 31, 2017. The models were trained using a data set of 24 229 patients and validated using another data set of 2692 patients. Data were analyzed from September 18, 2018, to May 15, 2019. Main Outcomes and Measures The area under the receiver operating characteristic curve (AUC) for 6-month and 1- and 2-year mortality prediction models and the factors contributing to the predictions. Results The study cohort included 26 921 patients (16 263 women [60.4%]; mean [SD] age, 74.6 [13.5] years). For the 24 229 patients in the training data set, mean (SD) age was 74.8 (13.2) years and 14 632 (60.4%) were women. For the 2692 patients in the validation data set, mean (SD) age was 75.0 (12.6) years and 1631 (60.6%) were women. The 6-month model reached an AUC of 0.978 (95% CI, 0.977-0.978); the 1-year model, 0.956 (95% CI, 0.955-0.956); and the 2-year model, 0.943 (95% CI, 0.942-0.944). The top-ranked latent topics associated with 6-month and 1- and 2-year mortality in patients with dementia include palliative and end-of-life care, cognitive function, delirium, testing of cholesterol levels, cancer, pain, use of health care services, arthritis, nutritional status, skin care, family meeting, shock, respiratory failure, and swallowing function. Conclusions and Relevance A deep learning algorithm based on patient demographic information and longitudinal clinical notes appeared to show promising results in predicting mortality among patients with dementia in different time frames. Further research is necessary to determine the feasibility of applying this algorithm in clinical settings for identifying unmet palliative care needs earlier.
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Affiliation(s)
- Liqin Wang
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Long Sha
- Michtom School of Computer Science, Brandeis University, Waltham, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Julie Bynum
- Division of Geriatrics and Palliative Care, Department of Medicine, University of Michigan School of Medicine, Ann Arbor
| | - David W. Bates
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Pengyu Hong
- Michtom School of Computer Science, Brandeis University, Waltham, Massachusetts
| | - Li Zhou
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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11
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White L, Fishman P, Basu A, Crane PK, Larson EB, Coe NB. Medicare expenditures attributable to dementia. Health Serv Res 2019; 54:773-781. [PMID: 30868557 DOI: 10.1111/1475-6773.13134] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To estimate dementia's incremental cost to the traditional Medicare program. DATA SOURCES Health and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012. STUDY DESIGN We compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group. DATA COLLECTION/EXTRACTION METHODS We used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components. PRINCIPAL FINDINGS Dementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia. CONCLUSIONS Dementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings.
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Affiliation(s)
- Lindsay White
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Anirban Basu
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington.,Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Paul K Crane
- Division of General Internal Medicine, School of Medicine, University of Washington, Seattle, Washington
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington
| | - Norma B Coe
- National Bureau of Economic Research, Cambridge, Massachusetts.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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12
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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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13
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Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An Advance Care Planning Video Decision Support Tool for Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial. JAMA Intern Med 2018; 178:961-969. [PMID: 29868778 PMCID: PMC6033645 DOI: 10.1001/jamainternmed.2018.1506] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Better advance care planning (ACP) can help promote goal-directed care in patients with advanced dementia. OBJECTIVES To test whether an ACP video (vs usual care) has an effect on documented advance directives, level of care preferences, goals-of-care discussions, and burdensome treatments among nursing home residents with advanced dementia. DESIGN, SETTING, AND PARTICIPANTS The Educational Video to Improve Nursing home Care in End-stage dementia (EVINCE) trial was a cluster randomized clinical trial conducted between February 2013 and July 2017, at 64 Boston-area nursing homes (32 facilities per arm). A total of 402 residents with advanced dementia and their proxies (intervention arm, n = 212; control arm, n = 190) were assessed quarterly for 12 months. INTERVENTIONS A 12-minute ACP video for proxies with written communication of their preferred level of care (comfort, basic, or intensive) to the primary care team. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of residents with do-not-hospitalize (DNH) directives by 6 months. Secondary outcomes included preference for comfort care, documented directives to withhold tube-feeding and intravenous hydration, documented goals-of-care discussions, and burdensome treatments (hospital transfers, tube-feeding, or parenteral therapy) per 1000 resident-days. Exploratory analyses examined associations between trial arm and documented advance directives when comfort care was preferred. RESULTS The mean age of the 402 study residents was 86.7 years [range, 67-102 years]; 350 were white (87.1%) and 323 were female (80.3%), with DNH directives that by 6 months did not differ between arms (63% in both arms; adjusted odds ratio [AOR], 1.08; 95% CI, 0.69-1.69). Preferences for comfort care, directives to withhold intravenous hydration, and burdensome treatments did not differ between arms. Residents in intervention vs control facilities were more likely to have directives for no tube-feeding at 6 months (70.10% vs 61.90%; AOR, 1.79; 95% CI, 1.13-2.82) and all other time periods, and documented goals-of-care discussions at 3 months (16.10% vs 7.90%; AOR, 2.58; 95% CI, 1.20-5.54). When comfort care was preferred, residents in the intervention arm were more likely to have both DNH and no tube-feeding directives (72.20% vs 52.80%; AOR, 2.68; 95% CI, 2.68-5.85). CONCLUSIONS AND RELEVANCE An ACP video did not have an effect on preferences, DNH status, or burdensome treatments among residents with advanced dementia, but did increase directives to withhold tube-feeding. When proxies preferred comfort care, advance directives of residents in the intervention arm were more likely to align with that preference. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01774799.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Simon Cohen
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research and School of Medicine, Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill
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14
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Givens JL, Sudore RL, Marshall GA, Dufour AB, Kopits I, Mitchell SL. Advance Care Planning in Community-Dwelling Patients With Dementia. J Pain Symptom Manage 2018; 55:1105-1112. [PMID: 29247754 PMCID: PMC5866907 DOI: 10.1016/j.jpainsymman.2017.12.473] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/06/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Little is known about advance care planning (ACP) among community-dwelling patients with dementia. OBJECTIVES To describe aspects of ACP among patients with dementia and examine the association between ACP and health care proxy (HCP) acceptance of patients' illness. METHODS Cross-sectional observational survey of 62 HCPs of patients with dementia (N = 14 mild, N = 48 moderate/severe), from seven outpatient geriatric and memory disorder clinics in Boston. Aspects of ACP included HCP's report of patients' preferences for level of future care, communication with HCP and physician regarding care preferences, and proxy preparedness for shared decision making. The association between ACP and HCP acceptance with patients' illness was examined using the Peace, Equanimity, and Acceptance subscale of the Cancer Experience Scale. RESULTS Eleven percent of proxies believed that the patient would want life-prolonging treatment, 31% a time-limited trial of curative treatment, and 47% comfort-focused care. Thirty-one percent reported that the patient had communicated with their physician regarding preferences for care, and 77% had communicated with the HCP. Forty-four percent of HCPs wanted more discussion with the patient regarding care preferences. The HCP having discussed care preferences with the patient was associated with greater acceptance of the patient's illness (P = 0.004). CONCLUSION Our findings support need for greater ACP discussions between patients and proxies. Discussions regarding goals of care are likely to benefit patients through delivery of care congruent with their wishes and HCPs in terms of greater acceptance of patients' illness.
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Affiliation(s)
- Jane L Givens
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Gad A Marshall
- Department of Neurology, Brigham and Women's Hospital, Center for Alzheimer Research and Treatment, Boston, Massachusetts, USA; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alyssa B Dufour
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ilona Kopits
- Division of Geriatrics, Boston Medical Center, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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15
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Li S, Middleton A, Ottenbacher KJ, Goodwin JS. Trajectories Over the First Year of Long-Term Care Nursing Home Residence. J Am Med Dir Assoc 2017; 19:333-341. [PMID: 29108886 DOI: 10.1016/j.jamda.2017.09.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/19/2017] [Accepted: 09/20/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe the trajectories in the first year after individuals are admitted to long-term care nursing homes. DESIGN Retrospective cohort study. SETTING US long-term care facilities. PARTICIPANTS Medicare fee-for-service beneficiaries newly admitted to long-term care nursing homes from July 1, 2012, to December 31, 2013 (N=535,202). MEASUREMENTS Demographic characteristics were from Medicare data. Individual trajectories were conducted using the Minimum Data Set for determining long-term care stays and community discharge, and Medicare Provider and Analysis Reviews claims data for determining hospitalizations, skilled nursing facility stays, inpatient rehabilitation, long-term acute hospital and psychiatric hospital stays. RESULTS The median length of stay in a long-term care nursing home over the 1 year following admission was 127 [interquartile range (IQR): 24, 356] days. The median length of stay in any institution was 158 (IQR: 38, 365). Residents experienced a mean of 2.1 ± 2.8 (standard deviation) transitions over the first year. The community discharge rate was 36.5% over the 1-year follow-up, with 20.8% discharged within 30 days and 31.2% discharged within 100 days. The mortality rate over the first year of nursing home residence was 35.0%, with 16.3% deaths within 100 days. At 12 months post long-term care admission, 36.9% of the cohort were in long-term care, 23.4% were in community, 4.7% were in acute care hospitals or other institutions, and 35.0% had died. CONCLUSION After a high initial community discharge rate, the majority of patients newly admitted to long-term care experienced multiple transitions while remaining institutionalized until death or the end of 1-year follow-up.
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Affiliation(s)
- Shuang Li
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - Addie Middleton
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX; Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Kenneth J Ottenbacher
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX; Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - James S Goodwin
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, Division of Geriatric Medicine, University of Texas Medical Branch, Galveston, TX.
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16
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Jutkowitz E, Kane RL, Dowd B, Gaugler JE, MacLehose RF, Kuntz KM. Effects of Cognition, Function, and Behavioral and Psychological Symptoms on Medicare Expenditures and Health Care Utilization for Persons With Dementia. J Gerontol A Biol Sci Med Sci 2017; 72:818-824. [PMID: 28369209 DOI: 10.1093/gerona/glx035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/22/2017] [Indexed: 11/14/2022] Open
Abstract
Background Clinical features of dementia (cognition, function, and behavioral/psychological symptoms [BPSD]) may differentially affect Medicare expenditures/health care utilization. Methods We linked cross-sectional data from the Aging, Demographics, and Memory Study to Medicare data to evaluate the association between dementia clinical features among those with dementia and Medicare expenditures/health care utilization (n = 234). Cognition was evaluated using the Mini-Mental State Examination (MMSE). Function was evaluated as the number of functional limitations (0-10). BPSD was evaluated as the number of symptoms (0-12). Expenditures were estimated with a generalized linear model (log-link and gamma distribution). Number of hospitalizations, institutional outpatient visits, and physician visits were estimated with a negative binomial regression. Medicare covered skilled nursing days were estimated with a zero-inflated negative binomial model. Results Cognition and BPSD were not associated with expenditures. Among individuals with less than seven functional limitations, one additional limitation was associated with $123 (95% confidence interval: $19-$227) additional monthly Medicare spending. Better cognition and poorer function were associated with more hospitalizations among those with an MMSE less than three and less than six functional limitations, respectively. BPSD had no effect on hospitalizations. Poorer function and fewer BPSD were associated with more skilled nursing among individuals with one to seven functional limitations and more than four symptoms, respectively. Cognition had no effect on skilled nursing care. No clinical feature was associated with institutional outpatient care. Of individuals with an MMSE less than 15, poorer cognition was associated with fewer physician visits. Among those with more than six functional limitations, poorer function was associated with fewer physician visits. Conclusions Poorer function, not cognition or BPSD, was associated with higher Medicare expenditures.
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Affiliation(s)
- Eric Jutkowitz
- Division of Health Policy and Management, School of Public Health
| | - Robert L Kane
- Division of Health Policy and Management, School of Public Health
| | - Bryan Dowd
- Division of Health Policy and Management, School of Public Health
| | | | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
| | - Karen M Kuntz
- Division of Health Policy and Management, School of Public Health
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Temporal Trends and Rural-Urban Differences in Hospital Length of Stay for Alzheimer Disease and Related Disorders. Alzheimer Dis Assoc Disord 2017; 31:244-248. [DOI: 10.1097/wad.0000000000000183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chen YH, Ho CH, Huang CC, Hsu YW, Chen YC, Chen PJ, Chen GT, Wang JJ. Comparison of healthcare utilization and life-sustaining interventions between elderly patients with dementia and those with cancer near the end of life: A nationwide, population-based study in Taiwan. Geriatr Gerontol Int 2017. [DOI: 10.1111/ggi.13084] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yu-Han Chen
- Palliative Care Center; Chi-Mei Medical Center; Tainan Taiwan
- Department of Family Medicine; Chi-Mei Medical Center; Tainan Taiwan
| | - Chung-Han Ho
- Department of Medical Research; Chi-Mei Medical Center; Tainan Taiwan
- Department of Hospital and Health Care Administration; Chia Nan University of Pharmacy and Science; Tainan Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine; Chi-Mei Medical Center; Tainan Taiwan
- Department of Geriatrics and Gerontology; Chi-Mei Medical Center; Tainan Taiwan
- Department of Environmental and Occupational Health; College of Medicine National Cheng Kung University; Tainan Taiwan
- Bachlor Program of Senior Services; Southern Taiwan University of Science and Technology; Tainan Taiwan
| | - Ya-Wen Hsu
- Department of Medical Research; Chi-Mei Medical Center; Tainan Taiwan
- Department of Hospital and Health Care Administration; Chia Nan University of Pharmacy and Science; Tainan Taiwan
| | - Yueh-Chun Chen
- Palliative Care Center; Chi-Mei Medical Center; Tainan Taiwan
- Department of Nursing; Chi-Mei Medical Center; Tainan Taiwan
| | - Ping-Jen Chen
- Palliative Care Center; Chi-Mei Medical Center; Tainan Taiwan
- Department of Geriatrics and Gerontology; Chi-Mei Medical Center; Tainan Taiwan
- Bachlor Program of Senior Services; Southern Taiwan University of Science and Technology; Tainan Taiwan
| | - Guan-Ting Chen
- Palliative Care Center; Chi-Mei Medical Center; Tainan Taiwan
- Department of Anesthesiology; Chi-Mei Medical Center; Tainan Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research; Chi-Mei Medical Center; Tainan Taiwan
- Department of Anesthesiology; Chi-Mei Medical Center; Tainan Taiwan
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Palan Lopez R, Mitchell SL, Givens JL. Preventing Burdensome Transitions of Nursing Home Residents with Advanced Dementia: It's More than Advance Directives. J Palliat Med 2017; 20:1205-1209. [PMID: 28504894 DOI: 10.1089/jpm.2017.0050] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although a palliative approach to care is recommended for people with advanced dementia, many nursing home (NH) residents with dementia experience burdensome interventions such as hospital transfers at the end of life. OBJECTIVE The goal of this study was to examine how decisions to transfer NH residents with advanced dementia are made, from the perspective of NH nurses and physicians. METHODS A qualitative, descriptive method was used. Purposive sampling was used to recruit 20 healthcare providers from 9 NHs. Data collection included semistructured, open-ended interviews. RESULTS Decision making regarding hospital transfer comprised two phases. Phase one, laying the groundwork, was influenced by the ability of the providers to effectively establish trust, foreshadow, and illuminate hazards of hospitalization. Phase two, responding to an acute event, began at the start of an acute event and ended when a decision was made to either treat the resident in the NH or transfer to the hospital. Responding to the acute event was influenced by the ability to care for residents in the NH, the providers' comfort with end-of-life conversations, and surrogates' preferences. CONCLUSIONS Advance care planning before an acute event is only the first step in a process of decision making. Attention to and support for decision making is needed at the time of each acute event to ensure that goals of care are maintained.
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Affiliation(s)
- Ruth Palan Lopez
- 1 MGH Institute of Health Professions , Charlestown, Massachusetts
| | | | - Jane L Givens
- 3 Institute for Aging Research , Hebrew SeniorLife, Boston, Massachusetts
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20
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Are Hospital/ED Transfers Less Likely Among Nursing Home Residents With Do-Not-Hospitalize Orders? J Am Med Dir Assoc 2017; 18:438-441. [DOI: 10.1016/j.jamda.2016.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 11/21/2022]
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21
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Deb A, Thornton JD, Sambamoorthi U, Innes K. Direct and indirect cost of managing alzheimer's disease and related dementias in the United States. Expert Rev Pharmacoecon Outcomes Res 2017; 17:189-202. [PMID: 28351177 DOI: 10.1080/14737167.2017.1313118] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Care of individuals with Alzheimer's Disease and Related Dementias (ADRD) poses special challenges. As the disease progresses, individuals with ADRD require increasing levels of medical care, caregiver support, and long-term care which can lead to substantial economic burden. Areas covered: In this expert review, we synthesized findings from studies of costs of ADRD in the United States that were published between January 2006 and February 2017, highlighted major sources of variation in costs, identified knowledge gaps and briefly outlined directions for future research and implications for policy and program planning. Expert commentary: A consistent finding of all studies comparing individuals with and without ADRD is that the average medical, non-medical, and indirect costs of individuals with ADRD are higher than those without ADRD, despite the differences in the methods of identifying ADRD, duration of the study, payer type and settings of study population. The economic burden of ADRD may be underestimated because many components such as direct non-medical costs for home safety modifications and adult day care services and indirect costs due to the adverse impact of ADRD on caregivers' health and productivity are not included in cost estimates.
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Affiliation(s)
- Arijita Deb
- a School of Pharmacy , Department of Pharmaceutical Systems and Policy, West Virginia University, Morgantown, USA
| | - James Douglas Thornton
- a School of Pharmacy , Department of Pharmaceutical Systems and Policy, West Virginia University, Morgantown, USA
| | - Usha Sambamoorthi
- a School of Pharmacy , Department of Pharmaceutical Systems and Policy, West Virginia University, Morgantown, USA
| | - Kim Innes
- b School of Public Health, Department of Epidemiology , West Virginia University, Morgantown, USA
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Daras LC, Feng Z, Wiener JM, Kaganova Y. Medicare Expenditures Associated With Hospital and Emergency Department Use Among Beneficiaries With Dementia. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2017; 54:46958017696757. [PMID: 28301976 PMCID: PMC5798704 DOI: 10.1177/0046958017696757] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/16/2017] [Accepted: 01/25/2017] [Indexed: 02/05/2023]
Abstract
Understanding expenditure patterns for hospital and emergency department (ED) use among individuals with dementia is crucial to controlling Medicare spending. We analyzed Health and Retirement Study data and Medicare claims, stratified by beneficiaries' residence and proximity to death, to estimate Medicare expenditures for all-cause and potentially avoidable hospitalizations and ED visits. Analysis was limited to the Medicare fee-for-service population age 65 and older. Compared with people without dementia, community residents with dementia had higher average expenditures for hospital and ED services; nursing home residents with dementia had lower average expenditures for all-cause hospitalizations. Decedents with dementia had lower expenditures than those without dementia in the last year of life. Medicare expenditures for individuals with and without dementia vary by residential setting and proximity to death. Results highlight the importance of addressing the needs specific to the population with dementia. There are many initiatives to reduce hospital admissions, but few focus on people with dementia.
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Lin HR, Otsubo T, Sasaki N, Imanaka Y. The determinants of long-term care expenditure and their interactions. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2016. [DOI: 10.1080/20479700.2016.1141469] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Expectation Conversations About the Very Predictable Events in Advanced Dementia. J Am Med Dir Assoc 2015; 16:724-7. [DOI: 10.1016/j.jamda.2015.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 05/12/2015] [Indexed: 11/21/2022]
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Hess W, Schwarzkopf L, Hunger M, Holle R. Competing-risks duration models with correlated random effects: an application to dementia patients' transition histories. Stat Med 2014; 33:3919-31. [PMID: 24827139 DOI: 10.1002/sim.6206] [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: 05/29/2013] [Revised: 02/13/2014] [Accepted: 04/23/2014] [Indexed: 11/09/2022]
Abstract
Multi-state transition models are widely applied tools to analyze individual event histories in the medical or social sciences. In this paper, we propose the use of (discrete-time) competing-risks duration models to analyze multi-transition data. Unlike conventional Markov transition models, these models allow the estimated transition probabilities to depend on the time spent in the current state. Moreover, the models can be readily extended to allow for correlated transition probabilities. A further virtue of these models is that they can be estimated using conventional regression tools for discrete-response data, such as the multinomial logit model. The latter is implemented in many statistical software packages and can be readily applied by empirical researchers. Moreover, model estimation is feasible, even when dealing with very large data sets, and simultaneously allowing for a flexible form of duration dependence and correlation between transition probabilities. We derive the likelihood function for a model with three competing target states and discuss a feasible and readily applicable estimation method. We also present the results from a simulation study, which indicate adequate performance of the proposed approach. In an empirical application, we analyze dementia patients' transition probabilities from the domestic setting, taking into account several, partly duration-dependent covariates.
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Affiliation(s)
- Wolfgang Hess
- Department of Economics and Centre for Economic Demography, Lund University, Sweden; Department of Statistics, Ludwig Maximilian University of Munich, Germany
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26
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Hwang D, Teno JM, Gozalo P, Mitchell S. Feeding tubes and health costs postinsertion in nursing home residents with advanced dementia. J Pain Symptom Manage 2014; 47:1116-20. [PMID: 24112820 PMCID: PMC3979516 DOI: 10.1016/j.jpainsymman.2013.08.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 08/02/2013] [Accepted: 08/07/2013] [Indexed: 12/13/2022]
Abstract
CONTEXT The best evidence suggests that feeding tubes are ineffective in persons with advanced dementia. Little is known about their health care costs. OBJECTIVES To estimate Medicare costs attributable to inpatient care among nursing home (NH) residents with advanced dementia during the year following the placement of a percutaneous endoscopic gastrostomy (PEG) tube during an index hospitalization. METHODS Medicare claims (1999-2009) and Minimum Data Set data (1999-2009) were used to estimate Medicare costs attributable to inpatient care among NH residents with advanced dementia during the year following the placement of a PEG tube and compared with those who did not get a PEG tube. The study used a 3:1 propensity-matched cohort design. RESULTS Matched residents with (n=1924, 68.9% female, 28.8% African American, average age 83.1 years) and without (weighted n=1924, unique n=4337) PEG insertion showed comparable sociodemographic characteristics, similar rates of feeding tube risk factors, and similar mortality (51.9% 180 day mortality among those with a feeding tube vs. 49.8% among those without a feeding tube, P=0.11). One year hospital costs were $2224 higher in NH residents with a feeding tube ($10,191 vs. $7967, 95% CI of difference=$1514, $2933), with those with a feeding tube likely to spend more time in an intensive care unit (1.92 vs. 1.29 days, 95% CI of difference=0.34, 0.92 days). CONCLUSION In an analysis controlling for selection bias, PEG tube insertion is associated with a small but significant increase in annual inpatient health care costs, as well as in hospital and intensive care unit days, postinsertion.
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Affiliation(s)
- Deborah Hwang
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Joan M Teno
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.
| | - Pedro Gozalo
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Susan Mitchell
- Harvard Medical School, Hebrew Senior Life Institute for Aging Research, Boston, Massachusetts, USA
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Sleeman KE, Ho YK, Verne J, Gao W, Higginson IJ. Reversal of English trend towards hospital death in dementia: a population-based study of place of death and associated individual and regional factors, 2001-2010. BMC Neurol 2014; 14:59. [PMID: 24666928 PMCID: PMC3987058 DOI: 10.1186/1471-2377-14-59] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 03/18/2014] [Indexed: 11/11/2022] Open
Abstract
Background England has one of the highest rates of hospital death in dementia in Europe. How this has changed over time is unknown. This study aimed to analyse temporal trends in place of death in dementia over a recent ten year period. Methods Population-based study linking Office for National Statistics mortality data with regional variables, in England 2001–2010. Participants were adults aged over 60 with a death certificate mention of dementia. Multivariable Poisson regression was used to determine the proportion ratio (PR) for death in care home (1) and home/hospice (1) compared to hospital (0). Explanatory variables included individual factors (age, gender, marital status, underlying cause of death), and regional variables derived at area level (deprivation, care home bed provision, urbanisation). Results 388,899 deaths were included. Most people died in care homes (55.3%) or hospitals (39.6%). A pattern of increasing hospital deaths reversed in 2006, with a subsequent decrease in hospital deaths (−0.93% per year, 95% CI −1.08 to −0.79 p < 0.001), and an increase in care home deaths (0.60% per year, 95% CI 0.45 to 0.75 p < 0.001). Care home death was more likely with older age (PR 1.11, 1.10 to 1.13), and in areas with greater care home bed provision (PR 1.82, 1.79 to 1.85) and affluence (PR 1.29, 1.26 to 1.31). Few patients died at home (4.8%) or hospice (0.3%). Home/hospice death was more likely in affluent areas (PR 1.23, 1.18 to 1.29), for women (PR 1.61, 1.56 to 1.65), and for those with cancer as underlying cause of death (PR 1.84, 1.77 to 1.91), and less likely in the unmarried (PRs 0.51 to 0.66). Conclusions Two in five people with dementia die in hospital. However, the trend towards increasing hospital deaths has reversed, and care home bed provision is key to sustain this. Home and hospice deaths are rare. Initiatives which aim to support the end of life preferences for people with dementia should be investigated.
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Affiliation(s)
- Katherine E Sleeman
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, Bessemer Road, London SE5 9PJ, UK.
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Goldfeld KS, Grabowski DC, Caudry DJ, Mitchell SL. Health insurance status and the care of nursing home residents with advanced dementia. JAMA Intern Med 2013; 173:2047-53. [PMID: 24061265 PMCID: PMC3859713 DOI: 10.1001/jamainternmed.2013.10573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Nursing home residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve the quality of life. Fragmentation in health care has contributed to poor coordination of care for acutely ill nursing home residents. OBJECTIVE To compare patterns of care and quality outcomes for nursing home residents with advanced dementia covered by managed care with those covered by traditional fee-for-service Medicare. DESIGN, SETTING, AND PARTICIPANTS Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE) was a prospective cohort study including 22 nursing homes in the Boston, Massachusetts, area that monitored 323 nursing home residents for 18 months to better understand the course of advanced dementia at or near the end of life. Data from CASCADE and Medicare were linked to determine the health insurance status of study participants. EXPOSURES The health insurance status of the resident, either managed care or traditional fee for service. MAIN OUTCOMES AND MEASURES The outcomes included survival, symptoms related to comfort, treatment of pain and dyspnea, presence of pressure ulcers, presence of a do-not-hospitalize order, treatment of pneumonia, hospital transfer (admission or emergency department visit) for an acute illness, hospice referral, primary care visits, and family satisfaction with care. RESULTS Residents enrolled in managed care (n = 133) were more likely to have do-not-hospitalize orders compared with those in traditional Medicare fee for service (n = 158) (63.7% vs 50.9%; adjusted odds ratio, 1.9; 95% CI, 1.1-3.4), were less likely to be transferred to the hospital for acute illness (3.8% vs 15.7%; adjusted odds ratio, 0.2; 95% CI, 0.1-0.5), had more primary care visits per 90 days (mean [SD], 4.8 [2.6] vs 4.2 [5.0]; adjusted rate ratio, 1.3; 95% CI, 1.1-1.6), and had more nurse practitioner visits (3.0 [2.1] vs 0.8 [2.6]; adjusted rate ratio, 3.0; 95% CI, 2.2-4.1). Survival, comfort, and other treatment outcomes did not differ significantly across groups. CONCLUSIONS AND RELEVANCE Medicare managed-care programs may offer a promising approach to ensure that nursing homes are able to provide appropriate, less burdensome, and affordable care, especially at the end of life.
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Affiliation(s)
- Keith S Goldfeld
- Department of Population Health, New York University School of Medicine, New York
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Goldfeld KS, Hamel MB, Mitchell SL. The cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia. J Pain Symptom Manage 2013; 46:640-51. [PMID: 23571207 PMCID: PMC3708971 DOI: 10.1016/j.jpainsymman.2012.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 11/14/2012] [Accepted: 12/07/2012] [Indexed: 11/23/2022]
Abstract
CONTEXT Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported. OBJECTIVES To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia. METHODS NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months. RESULTS Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355). CONCLUSION Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.
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Affiliation(s)
- Keith S Goldfeld
- Department of Population Health, New York University School of Medicine, New York, New York, USA.
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30
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Does a palliative care consult decrease the cost of caring for hospitalized patients with dementia? Palliat Support Care 2013; 13:1535-40. [PMID: 24139019 DOI: 10.1017/s1478951513000795] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Advanced dementia (AD) is a terminal disease. Palliative care is increasingly becoming of critical importance for patients afflicted with AD. The primary objective of this study was to compare pharmacy cost before and after a palliative care consultation (PCC) in patients with end-stage dementia. A secondary objective was to investigate the cost of particular types of medication before and after a PCC. METHOD This was a retrospective study of 60 hospitalized patients with end-stage dementia at a large academic tertiary care hospital from January 1, 2010 to October 1, 2011, in order to investigate pharmacy costs before and after a PCC. In addition to demographics, we carried out a comparison of the average daily pharmacy cost and comparison of the proportion of subjects taking each medication type (cardiac, analgesics, antibiotics, antipsychotics and antiemetics) before and after a PCC. RESULTS There was a significant decrease in overall average daily pharmacy cost from before to after a PCC ($31.16 ± 24.71 vs. $20.83 ± 19.56; p < 0.003). There was also a significant difference in the proportion of subjects taking analgesics before and after PCC (55 vs. 73.3%; p < 0.009), with a significant average daily analgesic cost rise from pre- to post-PCC: $1.36 ± 5.07 (median = $0.05) versus. $2.35 ± 5.35 (median = $0.71), respectively, p < 0.011; average daily antiemetics cost showed a moderate increase from pre- to post-PCC: $0.08 ± 0.37 (median = $0) versus $0.23 ± 0.75 (median = $0), respectively, p < 0.047. SIGNIFICANCE OF RESULTS Our findings indicate that PCC is associated with overall decreased medication cost in hospitalized AD patients. Additionally, receiving a PCC was related to greater use of pain medications in hospitalized dementia patients. Our study corroborates the benefits of palliative care team intervention in managing elderly hospitalized dementia patients.
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Goldfeld K. Twice-weighted multiple interval estimation of a marginal structural model to analyze cost-effectiveness. Stat Med 2013; 33:1222-41. [DOI: 10.1002/sim.6017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 11/11/2022]
Affiliation(s)
- K.S. Goldfeld
- Department of Population Health; NYU School of Medicine; New York NY U.S.A
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Givens JL, Mitchell SL, Kuo S, Gozalo P, Mor V, Teno J. Skilled nursing facility admissions of nursing home residents with advanced dementia. J Am Geriatr Soc 2013; 61:1645-50. [PMID: 24117283 PMCID: PMC3801431 DOI: 10.1111/jgs.12476] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To describe the extent to which hospitalized nursing home (NH) residents with advanced dementia were admitted to a skilled nursing facility (SNF) after a qualifying hospitalization and to identify resident and nursing home characteristics associated with a greater likelihood of SNF admissions. DESIGN Cohort study using data from the Minimum Data Set, Medicare claims, and the On-line Survey Certification of Automated Records. SETTING United States, 2000-2006. PARTICIPANTS Nursing home residents with advanced dementia aged 65 and older with a 3-day hospitalization (N = 4,177). MEASUREMENTS The likelihood of SNF admission after hospitalization was calculated. Resident and nursing home factors associated with SNF admission were identified using hierarchical multivariable logistic regression. RESULTS Sixty-one percent of residents with advanced dementia were admitted to a SNF after their hospitalization. Percutaneous endoscopic gastrostomy (PEG) tube placement during hospitalization was strongly associated with SNF admission (adjusted odds ratio (AOR) = 2.31, 95% confidence interval (CI) = 1.85-2.88), as was better functional status (AOR = 1.21, 95% CI = 1.05-1.38). The presence of diabetes mellitus was associated with lower likelihood of SNF admission (AOR = 0.85, 95% CI = 0.73-0.99). Facility features significantly associated with SNF admission included more than 100 beds (AOR = 1.25, 95% CI = 1.07-1.46), being part of a chain (AOR = 1.31, 95% CI = 1.14-1.50), urban location (AOR = 1.21, 95% CI = 1.03-1.41), and for-profit status (AOR = 1.28, 95% CI = 1.09-1.51). CONCLUSION The majority of nursing home residents with advanced dementia are admitted to SNFs after a qualifying hospitalization. SNF admission is strongly associated with PEG tube insertion during hospitalization and with nursing home factors. Efforts to optimize appropriate use of SNF services in individuals with advanced dementia should focus on these factors.
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Affiliation(s)
- Jane L. Givens
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA
- Hebrew SeniorLife Institute for Aging Research, Boston, MA
| | - Susan L. Mitchell
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA
- Hebrew SeniorLife Institute for Aging Research, Boston, MA
| | - Sylvia Kuo
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Pedro Gozalo
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Vince Mor
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Joan Teno
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
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Ersek M, Carpenter JG. Geriatric palliative care in long-term care settings with a focus on nursing homes. J Palliat Med 2013; 16:1180-7. [PMID: 23984636 DOI: 10.1089/jpm.2013.9474] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Almost 1.7 million older Americans live in nursing homes, representing a large proportion of the frailest, most vulnerable elders needing long-term care. In the future, increasing numbers of older adults are expected to spend time and to die in nursing homes. Thus, understanding and addressing the palliative care needs of this population are critical. The goals of this paper are to describe briefly the current state of knowledge about palliative care needs, processes, and outcomes for nursing home residents; identify gaps in this knowledge; and propose priorities for future research in this area.
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Affiliation(s)
- Mary Ersek
- 1 Center for Health Equity Research and Promotion, Philadelphia VA Medical Center , Philadelphia, Pennsylvania
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Givens JL, Selby K, Goldfeld KS, Mitchell SL. Hospital transfers of nursing home residents with advanced dementia. J Am Geriatr Soc 2012; 60:905-9. [PMID: 22428661 DOI: 10.1111/j.1532-5415.2012.03919.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe diagnoses and factors associated with hospital transfer in nursing home (NH) residents with advanced dementia. DESIGN Prospective cohort study. SETTING Twenty-two Boston, Massachusetts-area NHs. PARTICIPANTS Three hundred twenty-three NH residents with advanced dementia. MEASUREMENTS Data were collected quarterly for up to 18 months. Data regarding transfers were collected with regard to hospitalization or emergency department (ED) visit, diagnosis, and duration of inpatient admission. Information on the occurrence of any acute medical event (pneumonia, febrile episode, or other acute illness) in the prior 90 days was obtained quarterly. Logistic regression conducted at the level of the acute medical event identified characteristics associated with hospital transfer. RESULTS The entire cohort experienced 74 hospitalizations and 60 ED visits. Suspected infections were the most common reason for hospitalization (44, 59%), most frequently attributable to a respiratory source (30, 41%). Feeding tube-related complications accounted for 47% of ED visits. In adjusted analysis conducted on acute medical events, younger resident age, event type (pneumonia or other event vs febrile episode), chronic obstructive pulmonary disease, and the lack of a do-not-hospitalize (DNH) order (adjusted odds ratio = 5.22, 95% confidence interval = 2.31-11.79) were associated with hospital transfer. CONCLUSION The majority of hospitalizations of NH residents with advanced dementia were due to infections and thus were potentially avoidable, because infections are often treatable in the NH. Feeding tube-related complications accounted for almost half of all ED visits, representing a common but underrecognized burden of this intervention. Advance care planning in the form of a DNH order was the only identified modifiable factor associated with avoiding hospitalization.
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Affiliation(s)
- Jane L Givens
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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35
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Kuhn DR, Forrest JM. Palliative care for advanced dementia: a pilot project in 2 nursing homes. Am J Alzheimers Dis Other Demen 2012; 27:33-40. [PMID: 22296910 PMCID: PMC10697225 DOI: 10.1177/1533317511432732] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
This article describes a pilot project involving training, case consultations, and administrative coaching over a period of 1 year aimed at introducing palliative care in 2 nursing homes among 31 residents with advanced dementia. Resident outcomes that examined numerous clinical measures were assessed at 3 points in time. Changes in the knowledge and attitudes of 80 staff members and 33 family members who participated in the multimodal intervention were also assessed at 3 points in time. Limited improvements were demonstrated on measures for residents, staff members, and family members at the first nursing home (site 1) and significant improvements were demonstrated at the other nursing home (site 2). Top leadership turned over 3 times at site 1 which limited the integration of palliative care, whereas leadership of site 2 remained stable. Implications for implementing a program of palliative care in nursing homes are discussed.
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Affiliation(s)
- Daniel R Kuhn
- Rainbow Hospice and Palliative Care, Mount Prospect, IL 60056, USA.
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Mitchell SL, Black BS, Ersek M, Hanson LC, Miller SC, Sachs GA, Teno JM, Morrison RS. Advanced dementia: state of the art and priorities for the next decade. Ann Intern Med 2012. [PMID: 22213494 DOI: 10.1059/0003-4819-156-1-201201030-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts 02131, USA
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Mitchell SL, Black BS, Ersek M, Hanson LC, Miller SC, Sachs GA, Teno JM, Morrison RS. Advanced dementia: state of the art and priorities for the next decade. Ann Intern Med 2012; 156:45-51. [PMID: 22213494 PMCID: PMC3261500 DOI: 10.7326/0003-4819-156-1-201201030-00008] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts 02131, USA
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