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Takekawa T, Katagi M, Kobayashi K, Toyoda S, Nakamura T, Yoshida H, Abo M. Factors influencing home discharge of hospitalized oldest-old patients (≥90 years): A retrospective quantitative case-control study. Geriatr Nurs 2024; 60:99-106. [PMID: 39236372 DOI: 10.1016/j.gerinurse.2024.08.021] [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: 02/03/2024] [Revised: 07/18/2024] [Accepted: 08/19/2024] [Indexed: 09/07/2024]
Abstract
The purpose of this retrospective study was to identify factors that could predict the discharge destination of oldest-old patients (patients aged ≥90 years). Information on the nutritional status, activities of daily living (ADL), nursing care needs based on nursing need degree (NND), rehabilitation therapy, and discharge destination was obtained from the medical records of 90 oldest-old patients aged ≥90 years admitted to our hospital, excluding orthopedic inpatients and short-term (≤5 days) inpatients. Of these, 64 were discharged home while 4 died during hospitalization. More than half had moderately low total lymphocyte count (<1200/μL). Home discharge was correlated with living with someone else and little need for assistance during eating and getting/standing-up at admission. The cutoff value for ability for basic movement scale (ABMS) at admission for home discharge was 18 points. Nutritional management and early mobilization are important aspects of clinical management of the oldest-olds.
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Affiliation(s)
- Toru Takekawa
- Chiba Prefectural University of Health Sciences, Chiba, 261-0014, Japan; Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, 105-8461, Japan.
| | - Mako Katagi
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, 105-8461, Japan; Ookurayama Memorial Hospital, Yokohama, 222-0001, Japan.
| | - Kazushige Kobayashi
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, 105-8461, Japan; Nomura Hospital, Tokyo, 181-8503, Japan.
| | - Shiori Toyoda
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, 105-8461, Japan.
| | - Takayoshi Nakamura
- Department of Rehabilitation Medicine, The Jikei University School of Medicine Katsushika Medical Center, Tokyo, 125-8506, Japan.
| | - Hiroaki Yoshida
- Department of Rehabilitation Medicine, The Jikei University Kashiwa Hospital, Chiba, 277-8567, Japan.
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, 105-8461, Japan.
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Vitous CA, Shabet C, Ferguson C, Edwards S, Duby A, Suwanabol PA. Family perspectives on end-of-life care after surgery: A qualitative analysis of the veteran affairs bereaved family surveys. Am J Surg 2024; 233:11-15. [PMID: 38168605 DOI: 10.1016/j.amjsurg.2023.12.016] [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: 10/22/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Using open-text responses from the Bereaved Family Survey (BFS), we sought to explore Veteran family experiences on end-of-life care after surgery. METHODS We evaluated 936 open-text responses for all decedents who underwent any high-risk surgical procedure across 124 Veterans Affairs facilities between 2010 and 2019. Data were analyzed using thematic analysis. RESULTS Respondents expressed a belief in the decedent's unnecessary pain, expressing distrust in the treatment decisions of the care team. Limited communication regarding the severity of disease or risks of surgery caused conflicting and unresolved narratives regarding the cause or timing of death. Respondents described feelings of disempowerment when they were not involved in decision-making and when their wishes were not respected. CONCLUSIONS Timely and sensitive conversations, including acknowledging uncertainty in outcomes, may ensure a more positive experience for bereaved families.
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Affiliation(s)
- C Ann Vitous
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States.
| | | | - Cara Ferguson
- University of Michigan Medical School, Ann Arbor, United States
| | - Sydney Edwards
- University of Michigan Medical School, Ann Arbor, United States
| | - Ashley Duby
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States
| | - Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor, United States; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, United States
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3
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Juan DWK, Ng IAT, Wong LCK, Fong WJ, Lee PP, Lie SA, Zhou JX, Cai M, Ong JCA, Seo JCJ, Chia CS, Wong JSM. Knowledge and thresholds for palliative care and surgery among healthcare providers caring for adults with serious illness. Front Med (Lausanne) 2024; 11:1351864. [PMID: 38882666 PMCID: PMC11179431 DOI: 10.3389/fmed.2024.1351864] [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: 12/18/2023] [Accepted: 05/20/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Timely palliative care and surgical interventions improve symptoms, health-related quality of life (HRQoL), and reduce medical cost for seriously ill adults at end of life (EOL). However, there is still poor delivery and underutilization of these palliative services. We hypothesize that the sub-optimal delivery is due to limited understanding among healthcare providers. Methods A nationwide cross-sectional online survey was conducted among primary and tertiary healthcare providers. The survey assessed challenges faced, palliative education, confidence in managing palliative patients, and knowledge on palliative surgery. Overall palliative care awareness and knowledge was assessed using a 6-point score. Likelihood of considering various palliative interventions at EOL was also determined using a threshold score (higher score = higher threshold). Results There were 145 healthcare providers who completed the survey (81.9% response rate); majority reported significant challenges in providing various aspects of palliative care: 57% (n = 82) in the provision of emotional support. Sixty-nine percent (n = 97) in managing social issues, and 71% (n = 103) in managing family expectations. Most expressed inadequate palliative care training in both under-graduate and post-graduate training and lack confidence in managing EOL issues. Up to 57% had misconceptions regarding potential benefits, morbidity and mortality after palliative surgery. In general, most providers had high thresholds for Intensive Care Unit admissions and palliative surgery, and were more likely to recommend endoscopic or interventional radiology procedures at EOL. Conclusion Healthcare providers in Singapore have poor knowledge and misconceptions about palliative care and surgery. Improving awareness and education among those caring for seriously ill adults is essential.
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Affiliation(s)
- Darryl Wen Kai Juan
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Irene Ai Ting Ng
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Louis Choon Kit Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Wei Jing Fong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Piea Peng Lee
- Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Sui An Lie
- Division of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Jamie Xuelian Zhou
- Division of Supportive and Palliative Care, National Cancer Centre, Singapore, Singapore
| | - Mingzhe Cai
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Johnny Chin-Ann Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
- Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore, Singapore
- Institute of Molecular and Cell Biology, ASTAR Research Entities, Singapore, Singapore
| | - Jane Chin Jin Seo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
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Rowe JT, Parrillo E, Stanford O, Wenzel J, Johnston FM. Individual and Systemic Barriers Blocking Community Health Workers from Helping the Seriously Ill. J Palliat Med 2024; 27:358-366. [PMID: 38010809 PMCID: PMC10903179 DOI: 10.1089/jpm.2022.0516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 11/29/2023] Open
Abstract
Background: Palliative care is a valuable component of health care that improves a patient's quality of life, yet its availability to patients with serious chronic illness remains relatively low. Due to their knowledge of community preferences and ability to improve patient education and access to care, community health workers (CHWs) can increase palliative care usage by patients. Notably, barriers to CHWs helping patients with serious chronic illness remain poorly understood. Objective: Explore the perception of barriers CHWs feel they face when attempting to support the health care of patients with serious chronic illness. Design: Qualitative semistructured individual interviews of CHWs and qualitative descriptive analysis. Setting/Subjects: Twelve CHWs who have worked with patients with serious chronic illness were recruited from the Johns Hopkins Healthcare LLC and the Baltimore Alliance for Careers in Healthcare organizations to virtually participate. Results: CHWs perceived both active and passive barriers that obstructed their efforts to work with seriously ill patients. CHWs shared that these barriers were dependent on themselves, their peers, and their work environments. Prevalent themes included interprofessional conflict, poor health care worker understanding of the CHW's role, and lack of access to quality resource organizations. CHWs noted job-specific training, better means to identify needed resources for patients, and inclusive health care teams as solutions to support their professional goals, while helping patients with serious illness. Conclusions: There are multiple perceived barriers to CHWs helping seriously ill patients. CHWs aiding patients with serious illness can be supported through better job training, better resource management tools, and improved communication between health care team members.
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Affiliation(s)
- Julian T. Rowe
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elaina Parrillo
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Olivia Stanford
- Community Outreach and Engagement Department, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Wenzel
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fabian M. Johnston
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Dualeh SH, Anderson MS, Abrahamse P, Kamdar N, Evans E, Suwanabol PA. Trends in End-of-Life Care and Satisfaction Among Veterans Undergoing Surgery. Ann Surg 2024:00000658-990000000-00792. [PMID: 38390769 PMCID: PMC11341773 DOI: 10.1097/sla.0000000000006253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To examine trends in end-of-life care services and satisfaction among Veterans undergoing any inpatient surgery. SUMMARY BACKGROUND DATA The Veterans Health Administration has undergone system-wide transformations to improve end-of-life care yet the impacts on end-of-life care services use and family satisfaction are unknown. METHODS We performed a retrospective, cross-sectional analysis of Veterans who died within 90 days of undergoing inpatient surgery between 01/2010 and 12/2019. Using the Veterans Affairs (VA) Bereaved Family Survey (BFS), we calculated the rates of palliative care and hospice use and examined satisfaction with end-of-life care. After risk and reliability adjustment for each VA hospital, we then performed multivariable linear regression model to identify factors associated with the greatest change. RESULTS Our cohort consisted of 155,250 patients with a mean age of 73.6 years (standard deviation 11.6). Over the study period, rates of palliative care consultation and hospice use increased more than two-fold (28.1% to 61.1% and 18.9% to 46.9%, respectively) while the rate of BFS excellent overall care score increased from 56.1% to 64.7%. There was wide variation between hospitals in the absolute change in rates of palliative care consultation, hospice use and BFS excellent overall care scores. Rural location and ACGME accreditation were hospital-level factors associated with the greatest changes. CONCLUSIONS Among Veterans undergoing inpatient surgery, improvements in satisfaction with end-of-life care paralleled increases in end-of-life care service use. Future work is needed to identify actionable hospital-level characteristics that may reduce heterogeneity between VA hospitals and facilitate targeted interventions to improve end-of-life care.
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Affiliation(s)
- Shukri H.A. Dualeh
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA
- University of Michigan, Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
| | - Maia S. Anderson
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA
- University of Michigan, Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
| | - Paul Abrahamse
- University of Michigan, Department of Biostatistics, School of Public Health, Ann Arbor, MI, USA
| | - Neil Kamdar
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Emily Evans
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Pasithorn A. Suwanabol
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA
- University of Michigan, Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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Giannitrapani KF, Sasnal M, McCaa M, Wu A, Morris AM, Connell NB, Aslakson RA, Schenker Y, Shreve S, Lorenz KA. Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. J Pain Symptom Manage 2023; 66:621-629.e5. [PMID: 37643653 DOI: 10.1016/j.jpainsymman.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. OBJECTIVES To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. METHODS We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). RESULTS Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. CONCLUSION The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.
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Affiliation(s)
- Karleen F Giannitrapani
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California.
| | - Marzena Sasnal
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | - Matthew McCaa
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California
| | - Adela Wu
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Neurosurgery (A.W.), Stanford School of Medicine, Stanford, California
| | - Arden M Morris
- Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | | | - Rebecca A Aslakson
- Department of Anesthesiology (R.A.A.), University of Vermont, Burlington, Vermont
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (Y.S.), Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott Shreve
- Department of Veterans Affairs (S.S.), VA Palliative Care, Lebanon, Pennsylvania
| | - Karl A Lorenz
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California
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7
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Siddiqi A, Monton O, Woods A, Masroor T, Fuller S, Owczarzak J, Yenokyan G, Cooper LA, Freund KM, Smith TJ, Kutner JS, Colborn KL, Joyner R, Elk R, Johnston FM. Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC): a study protocol for a hybrid type 1 randomized controlled trial. BMC Palliat Care 2023; 22:139. [PMID: 37718442 PMCID: PMC10506196 DOI: 10.1186/s12904-023-01250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/24/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND There are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention. METHODS We will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms. DISCUSSION We expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States. TRIAL REGISTRATION Registered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022.
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Affiliation(s)
- Amn Siddiqi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Olivia Monton
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
| | - Alison Woods
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Taleaa Masroor
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Shannon Fuller
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
| | - Jill Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
| | - Lisa A Cooper
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD, 21205, USA
- Johns Hopkins University School of Nursing, 525 N Wolfe Street, Baltimore, MD, 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, 2024 East Monument Street, Suite 2-515, Baltimore, MD, 21287, USA
| | - Karen M Freund
- Department of Medicine, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - Thomas J Smith
- Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, 12401 E 17th Ave, Aurora, CO, 80045, USA
| | - Kathryn L Colborn
- Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Robert Joyner
- Richard A. Henson Research Institute, TidalHealth Peninsula Regional, 100 East Carroll Street, Salisbury, MD, 21801, USA
| | - Ronit Elk
- Department of Medicine, University of Alabama at Birmingham, 933 19th Street S, Birmingham, AL, 35205, USA
| | - Fabian M Johnston
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University, 600 N Wolfe Street, Blalock 606, Baltimore, MD, 21287, USA.
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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Abbas M, Reich AJ, Wang Y, Hu FY, Bollens-Lund E, Kelley AS, Cooper Z. The burden of pre-admission pain, depression, and caregiving on palliative care needs for seriously ill trauma patients. J Am Geriatr Soc 2023; 71:2229-2238. [PMID: 36805543 PMCID: PMC10363197 DOI: 10.1111/jgs.18289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Increasing numbers of individuals admitted to hospitals for trauma are older adults, many of whom also have underlying serious illnesses. Older adults with serious illness benefit from palliative care, but the palliative care needs of seriously ill older adults with trauma have not been elucidated. We hypothesize that older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours before trauma admission. METHODS Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients 66 years or older who met an established definition of serious illness in surgery and were admitted with trauma. Descriptive analyses were performed for baseline patient characteristics, pre-admission pain (dichotomized as none/mild vs. moderate/severe), depression (dichotomized as no, Center for Epidemiologic Studies Depression scale [CES-D] < 3 vs. yes, CES-D ≥ 3), and unpaid caregiving hours (dichotomized as low (<30 h/month), high (≥30 h/month)). RESULTS We identified 1741 patients, 67.4% were female and 86.8% White. Mean age was 83 (SD 7.5), and 60.3% had ≥4 comorbidities. The majority (62.9%) were admitted due to falls, 33.5% had isolated hip fracture. The prevalence of baseline moderate/severe pain and depression were 38.1% and 42.6%, respectively. Among the cohort, 42.2% had unpaid caregiving, of those 27.7% had ≥30 h/week of unpaid caregiving hours. CONCLUSIONS Prior to trauma admission, older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours. These findings may inform targeted palliative care interventions to reduce symptom burden and post-discharge healthcare utilization.
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Affiliation(s)
- Muhammad Abbas
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amanda Jane Reich
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yihan Wang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Frances Y Hu
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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10
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Hu FY, Wang Y, Abbas M, Bollens-Lund E, Reich AJ, Lipsitz SR, Gray TF, Kim D, Ritchie C, Kelley AS, Cooper Z. Prevalence of unpaid caregiving, pain, and depression in older seriously ill patients undergoing elective surgery. J Am Geriatr Soc 2023; 71:2151-2162. [PMID: 36914427 PMCID: PMC10363213 DOI: 10.1111/jgs.18316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/22/2023] [Accepted: 02/07/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Serious illness is a life-limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major surgery annually, and national guidelines recommend that palliative care be available to all seriously ill patients. However, the palliative care needs of elective surgical patients are incompletely described. Understanding baseline caregiving needs and symptom burden among seriously ill older surgical patients could inform interventions to improve outcomes. METHODS Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients ≥66 years who met an established serious illness definition from administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality (AHRQ) criteria. Descriptive analyses were performed for preoperative patient characteristics, including: unpaid caregiving (no or yes); pain (none/mild or moderate/severe); and depression (no, CES-D < 3, or yes, CES-D ≥ 3). Multivariable regression was performed to examine the association between unpaid caregiving, pain, depression, and in-hospital outcomes, including hospital days (days admitted between discharge date and one-year post-discharge), in-hospital complications (no or yes), and discharge destination (home or non-home). RESULTS Of the 1343 patients, 55.0% were female and 81.6% were non-Hispanic White. Mean age was 78.0 (SD 6.8); 86.9% had ≥2 comorbidities. Before admission, 27.3% of patients received unpaid caregiving. Pre-admission pain and depression were 42.6% and 32.8%, respectively. Baseline depression was significantly associated with non-home discharge (OR 1.6, 95% CI 1.2-2.1, p = 0.003), while baseline pain and unpaid caregiving needs were not associated with in-hospital or post-acute outcomes in multivariable analysis. CONCLUSIONS Prior to elective surgery, older adults with serious illnesses have high unpaid caregiving needs and a prevalence of pain and depression. Baseline depression alone was associated with discharge destinations. These findings highlight opportunities for targeted palliative care interventions throughout the surgical encounter.
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Affiliation(s)
- Frances Y Hu
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Yihan Wang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Abbas
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Dae Kim
- Department of Medicine, Brigham and Woman's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
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11
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Christensen M, Liang M. Critical care: A concept analysis. Int J Nurs Sci 2023; 10:403-413. [PMID: 37545780 PMCID: PMC10401358 DOI: 10.1016/j.ijnss.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/08/2023] [Accepted: 06/24/2023] [Indexed: 08/08/2023] Open
Abstract
Objective The terms critical care and the Intensive Care Unit (ICU) are often used interchangeably to describe a place of care. Defining critical care becomes challenging because of the colloquial use of the term. Using concept analysis allows for the development of definition and meaning. The aim of this concept analysis is to distinguish the use of the term critical care to develop an operational definition which describes what constitutes critical care. Method Walker and Avant's eight-step approach to concept analysis guided this study. Five databases (CINAHL, Scopus, PubMed, ProQuest Dissertation Abstracts and Medline in EBSCO) were searched for studies related to critical care. The search included both qualitative and quantitative studies written in English and published between 1990 and 2022. Results Of the 439 papers retrieved, 47 met the inclusion criteria. The defining attributes of critical care included 1) a maladaptive response to illness/injury, 2) admission modelling criteria, 3) advanced medical technologies, and 4) specialised health professionals. Antecedents were associated with illness/injury that progressed to a level of criticality with a significant decline in both physical and psychological functioning. Consequences were identified as either death or survival with/without experiencing post-ICU syndrome. Conclusion Describing critical care is often challenging because of the highly technical nature of the environment. This conceptual understanding and operational definition will inform future research as to the scope of critical care and allow for the design of robust evaluative instruments to better understand the nature of care in the intensive care environment.
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Affiliation(s)
- Martin Christensen
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China
- The Interdisciplinary Centre for Qualitative Research, The Hong Kong Polytechnic University, Hong Kong, China
| | - Mining Liang
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China
- The Interdisciplinary Centre for Qualitative Research, The Hong Kong Polytechnic University, Hong Kong, China
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12
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Katlic MR. All Surgeons Should Be Palliative Care Surgeons. JAMA Surg 2022; 157:1132-1133. [PMID: 36260364 DOI: 10.1001/jamasurg.2022.4725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Mark R Katlic
- Sinai Center for Geriatric Surgery, LifeBridge Health System, Baltimore, Maryland
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13
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Pierce JG, Ricon R, Rukmangadhan S, Kim M, Rajasekar G, Nuño M, Curtis E, Humphries M. Adherence to the TQIP Palliative Care Guidelines Among Patients With Serious Illness at a Level I Trauma Center in the US. JAMA Surg 2022; 157:1125-1132. [PMID: 36260298 PMCID: PMC9582969 DOI: 10.1001/jamasurg.2022.4718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/17/2022] [Indexed: 01/11/2023]
Abstract
Importance The American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines encourage trauma service clinicians to deliver palliative care in parallel with life-sustaining treatment and recommend goals of care (GOC) discussions within 72 hours of admission for patients with serious illness. Objective To measure adherence to TQIP guidelines-recommended GOC discussions for trauma patients with serious illness, treated at a level I trauma center in the US. Design, Setting, and Participants This retrospective cohort study included 674 adults admitted to a trauma service center for 3 or more days between December 2019 and June 2020. The medical records of 486 patients who met the criteria for serious illness using a consensus definition adapted to the National Trauma Data Bank were reviewed for the presence of a GOC discussion. Patients were divided into 2 cohorts based on admission before or after the guidelines were incorporated into the institutional practice guidelines on March 1, 2020. Main Outcomes and Measures The primary outcomes were GOC completion within 72 hours of admission and during the overall hospitalization. Patient and clinical factors associated with GOC completion were assessed. Other palliative care processes measured included palliative care consultation, prior advance care planning document, and do-not-resuscitate code status. Additional end-of-life processes (ie, comfort care and inpatient hospice) were measured in a subset with inpatient mortality. Results Of 674 patients meeting the review criteria, 486 (72.1%) met at least 1 definition of serious illness (mean [SD] age, 60.9 [21.3] years; mean [SD] Injury Severity Score, 16.9 [12.3]). Of these patients, 328 (67.5%) were male and 266 (54.7%) were White. Among the seriously ill patients, 92 (18.9%) had evidence of GOC completion within 72 hours of admission and 124 (25.5%) during the overall hospitalization. No differences were observed between patients admitted before and after institutional guideline publication in GOC completion within 72 hours (19.0% [47 of 248 patients] vs 18.9% [45 of 238]; P = .99) or during the overall hospitalization (26.2% [65 of 248 patients] vs 24.8% [59 of 238]; P = .72). After adjusting for age, GOC completion was found to be associated with the presence of mechanical ventilation (odds ratio [OR], 6.42; 95% CI, 3.49-11.81) and meeting multiple serious illness criteria (OR, 4.07; 95% CI, 2.25-7.38). Conclusions and Relevance The findings of this cohort study suggest that, despite the presence of national guidelines, GOC discussions for patients with serious illness were documented infrequently. This study suggests a need for system-level interventions to ensure best practices and may inform strategies to measure and improve trauma service quality in palliative care.
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Affiliation(s)
| | | | | | | | - Ganesh Rajasekar
- Department of Surgery, University of California, Davis Medical Center, Sacramento
| | - Miriam Nuño
- Department of Public Health Sciences, University of California, Davis
| | - Eleanor Curtis
- Department of Surgery, University of California, Davis Medical Center, Sacramento
| | - Misty Humphries
- Department of Surgery, University of California, Davis Medical Center, Sacramento
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14
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Du W, Liu P, Xu W. Effects of decreasing the out-of-pocket expenses for outpatient care on health-seeking behaviors, health outcomes and medical expenses of people with diabetes: evidence from China. Int J Equity Health 2022; 21:162. [DOI: 10.1186/s12939-022-01775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 09/18/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background:
To improve access to outpatient services and provide financial support in outpatient expenses for the insured, China has been establishing its scheme of decreasing the out-of-pocket expenses for outpatient care in recent years. There are 156 million diabetes patients in China which almost accounts for a quarter of diabetes population worldwide. Outpatient services plays an important role in diabetes treatment. The study aims to clarify the effects of decreasing the out-of-pocket expenses for outpatient care on health-seeking behaviors, health outcomes and medical expenses of people with diabetes.
Methods:
This study constructed a two-way fixed effect model, utilized 5,996 diabetes patients’ medical visits records from 2019 to 2021, to ascertain the influence of decreasing the out-of-pocket expenses for outpatient care on diabetes patients. The dependent variables were diabetes patients’ health-seeking behaviors, health outcomes, medical expenses and expenditure of the basic medical insurance funds for them; the core explanatory variable was the out-of-pocket expenses for outpatient care expressed by the annual outpatient reimbursement ratio.
Results:
With each increase of 1% in the annual outpatient reimbursement ratio: (1) for health-seeking behaviors, a diabetes patient’s annual number of outpatient visits and annual number of medical visits increased by 0.021 and 0.014, while the annual number of hospitalizations decreased by 0.006; (2) for health outcomes, a diabetes patient’s annual length of hospital stays and average length of a hospital stay decreased by 1.2% and 1.1% respectively, and the number of diabetes complications and Diabetes Complications Severity Index (DCSI) score both decreased by 0.001; (3) for medical expenses, a diabetes patient’s annual outpatient expenses, annual inpatient expenses, annual medical expenses and annual out-of-pocket expenses decreased by 2.2%, 4.6%, 2.6% and 4.0%; (4) for expenditure of the basic medical insurance funds for a diabetes patient, the annual expenditure on outpatient services increased by 1.1%, and on inpatient services decreased by 4.4%, but on healthcare services didn’t change.
Conclusion:
Decreasing the out-of-pocket expenses for outpatient care appropriately among people with diabetes could make patients have a more rational health-seeking behaviors, a better health status and a more reasonable medical expenses while the expenditure of the basic medical insurance funds is stable totally.
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15
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Guttmann K, Kelley A, Weintraub A, Boss R. Defining Neonatal Serious Illness. J Palliat Med 2022; 25:1655-1660. [PMID: 35486825 PMCID: PMC9836668 DOI: 10.1089/jpm.2022.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 01/22/2023] Open
Abstract
Background: One major challenge to the conduct of rigorous neonatal palliative care research is the lack of robust universally agreed upon definitions of key concepts central to pediatric and neonatal palliative care. Objective: We sought to define neonatal serious illness as a foundational concept for neonatal palliative care. Design: Survey study. Setting/Subjects: Practitioners in the United States with expertise in neonatal serious illness. Measurements: Participants ranked 15 components according to how important each would be to include in a conceptual definition of neonatal serious illness. Based on rankings and free text responses, a working definition was created and a follow-up survey was circulated. Participants then ranked the extent to which the proposed definition comprehensively defines neonatal serious illness. The definition was further refined based on responses to the second survey. Results: Eighty experts responded to our first survey. Definition components ranked as most important included "high risk of short term mortality" and "results in shortened lifespan." Analysis of free text responses revealed additional components viewed as important. We developed the following conceptual definition: "Neonatal serious illness 1) carries a high risk of short term mortality OR lifelong medical complexity with probable shortened lifespan, 2) may involve substantial prognostic uncertainty (especially in regard to neurodevelopment) that complicates medical decision-making, and 3) significantly impacts the patient and family's life now or in the future with strain related to treatments and care." Conclusion: We believe our definition of neonatal serious illness will facilitate future study essential to the advancement of care for this population.
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Affiliation(s)
- Katherine Guttmann
- Division of Newborn Medicine, Department of Pediatrics, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy Kelley
- Department of Geriatrics and Palliative Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrea Weintraub
- Division of Newborn Medicine, Department of Pediatrics, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Renee Boss
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Berman Institute of Bioethics, Baltimore, Maryland, USA
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Lee KC, Walling AM, Senglaub SS, Bernacki R, Fleisher LA, Russell MM, Wenger NS, Cooper Z. Improving Serious Illness Care for Surgical Patients: Quality Indicators for Surgical Palliative Care. Ann Surg 2022; 275:196-202. [PMID: 32502076 DOI: 10.1097/sla.0000000000003894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients. SUMMARY OF BACKGROUND DATA PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery. METHODS We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion. RESULTS After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care. CONCLUSIONS This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode.
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Affiliation(s)
- Katherine C Lee
- Department of Surgery, University of California, San Diego, La Jolla, CA
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA
- Affiliated Adjunct Staff, RAND Health, Santa Monica, CA
| | - Steven S Senglaub
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Lee A Fleisher
- Department of Anesthesiology and Medicine, Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Philadelphia, PA
| | - Marcia M Russell
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
- Department of Surgery, Dave Geffen School of Medicine, University of California, Los Angeles, CA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA
- Affiliated Adjunct Staff, RAND Health, Santa Monica, CA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
- Hebrew SeniorLife Marcus Institute for Aging Research, Boston, MA
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Lee KC, Sokas CM, Streid J, Senglaub SS, Coogan K, Walling AM, Cooper Z. Quality Indicators in Surgical Palliative Care: A Systematic Review. J Pain Symptom Manage 2021; 62:545-558. [PMID: 33524478 DOI: 10.1016/j.jpainsymman.2021.01.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/09/2021] [Accepted: 01/19/2021] [Indexed: 02/05/2023]
Abstract
CONTEXT Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs. OBJECTIVES To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality. METHODS A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality. RESULTS There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators. CONCLUSION This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.
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Affiliation(s)
- Katherine C Lee
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, California, USA
| | - Claire M Sokas
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jocelyn Streid
- Department of Anesthesiology and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven S Senglaub
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Coogan
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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18
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Weissman JS, Reich AJ, Prigerson HG, Gazarian P, Tjia J, Kim D, Rodgers P, Manful A. Association of Advance Care Planning Visits With Intensity of Health Care for Medicare Beneficiaries With Serious Illness at the End of Life. JAMA HEALTH FORUM 2021; 2:e211829. [PMID: 35977213 PMCID: PMC8796875 DOI: 10.1001/jamahealthforum.2021.1829] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/04/2021] [Indexed: 12/31/2022] Open
Abstract
Question What is the association of a billed advance care planning (ACP) visit with intensive use of health care services at the end of life (EOL) for Medicare beneficiaries with serious illness? Findings In this cohort study of claims data of 955 777 Medicare beneficiaries with serious illness who died in 2017 and 2018, billed ACP visits that occurred during the decedents’ EOL course but before the last month of life were relatively uncommon. However, their occurrence was associated with less intensive use of EOL health care services. Meaning The findings of this cohort study suggest that ACP is associated with less intensive use of EOL health care services. Importance Advance care planning (ACP) is intended to maximize the concordance of preferences with end-of-life (EOL) care and is assumed to lead to less intensive use of health care services. The Centers for Medicare & Medicaid Services began reimbursing clinicians for ACP discussions with patients in 2016. Objective To determine whether billed ACP visits are associated with intensive use of health care services at EOL. Design, Setting, and Participants This prospective patient-level cohort analysis of seriously ill patients included Medicare fee-for-service beneficiaries who met criteria for serious illness from January 1 to December 31, 2016, and died from January 1, 2017, to December 31, 2018. Analyses were completed from November 1, 2020, to March 31, 2021. Main Outcomes and Measures Five measures of EOL health care services used (inpatient admission, emergency department visit, and/or intensive care unit stay within 30 days of death; in-hospital death; and timing of first hospice bill) and a measure of EOL expenditures. Analyses were adjusted for age, race and ethnicity, sex, Charlson Comorbidity Index, Medicare-Medicaid dual eligibility, and expenditure by hospital referral region (high, medium, or low). The primary exposure was receipt of a billed ACP service classified as none, timely (>1 month before death), or late (first ACP visit ≤1 month before death). Results Of the 955 777 Medicare beneficiaries who met criteria for serious illness in 2016 and died in 2017 or 2018, 522 737 (54.7%) were women, 764 666 (80.0%) were 75 years or older, and 822 684 (86.1%) were non-Hispanic White individuals. Among the study population, 81 131 (8.5%) had a timely ACP visit, and an additional 22 804 (2.4%) had a late ACP visit. After multivariable adjustment, compared with patients without any billed ACP visit, patients with a timely ACP visit experienced significantly less intensive EOL care on 4 of 5 measures, including in-hospital death (adjusted odds ratio [aOR], 0.85; 95% CI, 0.84-0.87), hospital admission (aOR, 0.84; 95% CI, 0.83-0.85), intensive care unit admission (aOR, 0.87; 95% CI, 0.85-0.88), and emergency department visit (OR, 0.83; 95% CI, 0.82-0.84). Only small or insignificant differences in late hospice use or mean total EOL expenditures were noted. Compared with patients without ACP, patients with late ACP experienced more intensive EOL care, including in-hospital death (aOR, 1.22; 95% CI, 1.19-1.26), hospital admission (aOR, 5.28; 95% CI, 5.07-5.50), intensive care unit admission (aOR, 1.57; 95% CI, 1.53-1.62), and emergency department visit (aOR, 3.87; 95% CI, 3.72-4.02). Conclusions and Relevance In this cohort study of US Medicare beneficiaries, billed ACP services during the EOL course of patients with serious illness were relatively uncommon, but if they occurred before the last month of life, they were associated with less intensive use of EOL services. Further research on the variables affecting hospice use and expenditures in the EOL period and the differential effect of late ACP is recommended to understand the relative role of ACP in achieving goal-concordant care.
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Affiliation(s)
- Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Amanda J. Reich
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Holly G. Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
| | - Priscilla Gazarian
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer Tjia
- Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Dae Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Phil Rodgers
- Department of Family Medicine, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Adoma Manful
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
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Robbins AJ, Beilman GJ, Ditta T, Benner A, Rosielle D, Chipman J, Lusczek E. Mortality After Elective Surgery: The Potential Role for Preoperative Palliative Care. J Surg Res 2021; 266:44-53. [PMID: 33984730 DOI: 10.1016/j.jss.2021.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Preoperative optimization is increasingly emphasized for high-risk surgical patients. One critical component of this includes preoperative advanced care planning to promote goal-concordant care. We aimed to define a subset of patients that might benefit from preoperative palliative care consult for advanced care planning. MATERIALS AND METHODS We examined adult patients admitted from January 2016 to December 2018 to a university health system for elective surgery. Multivariate logistic regression was used to identify variables associated with death within 1 y, and presence of palliative care consults preoperatively. Chi-square analysis evaluated the impact of a palliative care consult on advanced care planning variables. RESULTS Of the 29,132 inpatient elective procedures performed, there was a 2.0% mortality rate at 6 mo and 3.5% at 1 y. Those who died were more likely to be older, male, underweight (BMI <18), or have undergone an otolaryngology, neurosurgery or thoracic procedure type (all P-values < 0.05). At the time of admission, 29% had an advance directive, 90% had a documented code status, and 0.3% had a preoperative palliative care consult. Patients were more likely to have an advanced directive, a power of attorney, a documented code status, and have a do not resuscitate order if they had a palliative care consult (all P-values <0.05). The mortality rates and preoperative palliative care rates per procedure type did not follow similar trends. CONCLUSIONS Preoperative palliative care consultation before elective admissions for surgery had a significant impact on advanced care planning.
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Affiliation(s)
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | | | - Ashley Benner
- Clinical & Translational Science Institute, University of Minnesota Medical School, Minneapolis, MN
| | - Drew Rosielle
- Department of Family Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Jeffrey Chipman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Elizabeth Lusczek
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
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Improving quality in colon and rectal surgery through palliative care. SEMINARS IN COLON AND RECTAL SURGERY 2020; 31:100783. [PMID: 33041605 PMCID: PMC7531922 DOI: 10.1016/j.scrs.2020.100783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Palliative care is a medical discipline that emphasizes quality of life and can be provided in parallel with recovery-directed treatments in colon and rectal surgery. Palliative care is receiving increasing attention and investigation for its potential to improve quality and outcomes for a wide spectrum of patients by benefiting symptom management, supporting complex health care decision making and facilitating care transitions. Primary palliative care refers to the application of palliative care principles by clinicians of all disciplines whereas specialty palliative care is a multidisciplinary approach and includes a clinician with advanced training and experience.
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Kelly MT, Sturgeon D, Harlow AF, Jarman M, Weissman JS, Cooper Z. Using Medicare Data to Identify Serious Illness in Older Surgical Patients. J Pain Symptom Manage 2020; 60:e101-e103. [PMID: 32304711 DOI: 10.1016/j.jpainsymman.2020.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 11/22/2022]
Affiliation(s)
| | - Daniel Sturgeon
- Center for Surgery and Public Health, Brigham and Women's Hospita, Boston, Massachusetts, USA
| | - Alyssa F Harlow
- Center for Surgery and Public Health, Brigham and Women's Hospita, Boston, Massachusetts, USA
| | - Molly Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospita, Boston, Massachusetts, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospita, Boston, Massachusetts, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospita, Boston, Massachusetts, USA.
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