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Smith AGC, Yarrington ME, Baker AW, Cox GM, Dicks KV, Engemann JJ, Kohler P, Mourad A, Raslan R, Santivasi WL, Turner NA, Wrenn RH, Zavala S, Stout JE. Beyond Infection: Mortality and End-of-Life Care Associated With Infectious Disease Consultation in an Academic Health System. Clin Infect Dis 2024; 79:864-870. [PMID: 38867715 DOI: 10.1093/cid/ciae325] [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: 04/02/2024] [Revised: 05/28/2024] [Accepted: 06/11/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Infectious diseases (ID) physicians are increasingly faced with the challenge of caring for patients with terminal illnesses or incurable infections. METHODS This was a retrospective cohort of all patients with an ID consult within an academic health system from 1 January 2014 through 31 December 2023, including community, general, and transplant ID consult services. RESULTS There were 60 820 inpatient ID consults (17 235 community, 29 999 general, and 13 586 transplant) involving 37 848 unique patients. The number of consults increased by 94% and the rate rose from 5.0 to 9.9 consults per 100 inpatients (P < .001). In total, 7.5% of patients receiving an ID consult died during admission and 1006 (2.6%) of patients were discharged to hospice. In-hospital mortality was 5.2% for community ID, 7.8% for general ID, and 10.7% for transplant ID patients (P < .001). Six-month mortality was 9% for all nonobstetric admissions versus 19% for community ID, 20.9% for general ID, and 22.3% for transplant ID. In total 2866 (7.6%) of all patients receiving ID consultation also received palliative care consultation during the same hospitalization. The index ID consult preceded any palliative consult in the majority (69.5%) of cases. A total of 16.3% of patients had a do-not-resuscitate order during the index hospitalization; 12.2% of all patients with a do-not-resuscitate order had this placed on the same day as the ID consult. CONCLUSIONS Patients receiving ID consultation were increasingly complex and more likely to die soon after consultation. These results provide a framework for ID clinicians to consider their role in end-of-life care.
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Affiliation(s)
- Alison G C Smith
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael E Yarrington
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Arthur W Baker
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gary M Cox
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kristen V Dicks
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - John J Engemann
- Department of Medicine, WakeMed, Raleigh, North Carolina, USA
| | - Patricia Kohler
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ahmad Mourad
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rasha Raslan
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wil L Santivasi
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nicholas A Turner
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Sofia Zavala
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jason E Stout
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Crowley PD, Whalen FX, Siegel LR, Challener DW. Antibiotics at End of Life: Where Are We Now and Where Are We Going? A Narrative Review. Am J Hosp Palliat Care 2024:10499091241282627. [PMID: 39250304 DOI: 10.1177/10499091241282627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Antibiotics are frequently prescribed at the end of life, though the benefits and harms are not well understood. METHODS We abstracted relevant findings from articles published in English in the past 25 years to answer questions generated by discussion among the authors and with stakeholders in Palliative Care and Infectious Diseases. FINDINGS Prescribing practices vary based on individual situation and geographic location. Patients with cancer and those hospitalized receive more antibiotics than those enrolled in outpatient hospice. Urinary tract infections and pulmonary infections are the most common conditions treated with antibiotics at the end of life -most often with penicillin derivatives and vancomycin in the hospital, fluoroquinolones in outpatient, and cephalosporins in both settings. When asked, patients most often prefer limiting antibiotics to symptom management at the end of life. Physicians' over-estimation of patient preference for antibiotics and the increased probability of misdiagnosis increases antibiotic prescription rates. Antibiotics can improve symptoms when used for specific diseases at the cost of drug reactions, resistant organisms, and delayed discharge. Antibiotic use has variable results on survival duration. Antimicrobial stewardship exists in hospital and long-term care facilities, but not outpatient hospice groups. Stewardship interventions could increase proper use of antibiotics, but more information is needed to apply these interventions to hospice groups. CONCLUSIONS Antibiotics at the end of life are impactful and efforts to educate patients and providers will be invaluable in optimizing care.
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Affiliation(s)
- Patrick D Crowley
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francis X Whalen
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
- Department of Palliative and Supportive Care, Mayo Clinic, Rochester, MN, USA
| | - Leslie R Siegel
- Department of Palliative and Supportive Care, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
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3
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Kang M, Wang WS, Chang Z. Antibiotic Use at the End of Life: Current Practice and Ways to Optimize. Am J Hosp Palliat Care 2024:10499091241266986. [PMID: 39030663 DOI: 10.1177/10499091241266986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
Infections are common complications in end of life (EOL). However, clinicians have minimal guidance regarding antibiotic decision-making in EOL care, leading to the overuse of antibiotics. While symptom relief is frequently cited as a major reason for antibiotic use in EOL, antibiotics have not been shown to provide significant improvement in symptoms outside of urinary tract infections. In addition, when prognosis is expected to be in the range of days to weeks, antibiotics have not been shown to provide significant survival benefit. Antibiotics can be beneficial in EOL care in appropriate scenarios, but the current widespread use of antibiotics in EOL requires reevaluation. There needs to be broader efforts to think about antibiotics like other invasive medical procedures in which benefits and risks are weighed, recognizing that not all patients in EOL who receive antibiotics will benefit. In addition, during care planning process, discussing and documenting antibiotic preferences will be beneficial. Non-antibiotic symptom management should be incorporated to plan of care when infection is suspected. Ultimately, the use of antibiotics at EOL should be for the clear benefit for the recipient and should be guided by the type of infection and its clinical course, patients' primary disease and its prognosis, and the preferences of patients or surrogate decision makers.
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Affiliation(s)
- Minji Kang
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Winnie S Wang
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Zieanna Chang
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Karlin D, Pham C, Furukawa D, Kaur I, Martin E, Kates O, Vijayan T. State-of-the-Art Review: Use of Antimicrobials at the End of Life. Clin Infect Dis 2024; 78:e27-e36. [PMID: 38301076 DOI: 10.1093/cid/ciad735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Indexed: 02/03/2024] Open
Abstract
Navigating antibiotics at the end of life is a challenge for infectious disease (ID) physicians who remain deeply committed to providing patient-centered care and engaging in shared decision making. ID physicians, who often see patients in both inpatient and outpatient settings and maintain continuity of care for patients with refractory or recurrent infections, are ideally situated to provide guidance that aligns with patients' goals and values. Complex communication skills, including navigating difficult emotions around end-of-life care, can be used to better direct shared decision making and assist with antibiotic stewardship.
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Affiliation(s)
- Daniel Karlin
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California, USA
| | - Christine Pham
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, USA
- Department of Pharmaceutical Services, University of California, Los Angeles, California, USA
| | - Daisuke Furukawa
- Division of Infectious Diseases, Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Ishminder Kaur
- Division of Infectious Diseases, Department of Pediatrics, University of California, Los Angeles, California, USA
| | - Emily Martin
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California, USA
| | - Olivia Kates
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tara Vijayan
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, USA
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Kwon MK, Jung KH, Choi S, Kim H, Woo CY, Lee M, Ji JG, Son HJ. Antibiotics use patterns in end-of-life cancer patients and medical staff's perception of antimicrobial stewardship programs. Korean J Intern Med 2023; 38:758-768. [PMID: 37586810 PMCID: PMC10493437 DOI: 10.3904/kjim.2023.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 06/05/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND/AIMS While most cancer patients with end-of-life (EOL) care receive antibiotic treatments, antibiotic use should be decided appropriately considering the benefits, side effects, resistance, and cost effects. Antimicrobial stewardship programs (ASP) are important for patients with EOL care, but there is limited study analyzing actual antibiotic use in EOL care and the perceptions of Korean medical staff. METHODS Electronic medical records of 149 deceased cancer patients hospitalized in the medical hospitalist units at Asan Medical Center in Seoul from May 2019 to September 2021 were reviewed. Basic information, antibiotic use, duration, and changes were investigated. We surveyed medical staff's perceptions of antibiotics in cancer patients with EOL. RESULTS Of the 149 cancer patients with EOL care, 146 (98.0%) agreed with physician orders for life-sustaining treatment (POLST). In total, 143 (95.9%) received antibiotics, 110 (76.9%) received combination antibiotic treatment, and 116 (81.1%) were given antibiotics until the day of death. In a survey of 60 medical staff, 42 (70.0%) did not know about ASP, and 24 (40.0%) thought ASP was important in EOL care. Nineteen doctors (31.7%) discussed the use or discontinuation of antibiotics with patients or caregivers when writing POLST, but only 8 patients (5.6%) stopped antibiotics after POLST. CONCLUSION Most cancer patients with EOL care continue to receive antibiotics until just before their death. A careful approach is needed, considering the benefits and side effects of antibiotic use, and the patient's right to self-decision. It is necessary to actively improve awareness of ASP and its importance for medical staff.
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Affiliation(s)
- Min Kwan Kwon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Kyung Hwa Jung
- Department of Infectious Diseases, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu,
Korea
| | - Sungim Choi
- Division of Infectious Diseases, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang,
Korea
| | - Hyeonjeong Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Chang-Yun Woo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Mingee Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jeong Geun Ji
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Hyo-Ju Son
- Department of Infectious Diseases, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu,
Korea
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Wi YM, Kwon KT, Hwang S, Bae S, Kim Y, Chang HH, Kim SW, Cheong HS, Lee S, Jung DS, Sohn KM, Moon C, Heo ST, Kim B, Lee MS, Hur J, Kim J, Yoon YK. Use of Antibiotics Within the Last 14 Days of Life in Korean Patients: A Nationwide Study. J Korean Med Sci 2023; 38:e66. [PMID: 36880107 PMCID: PMC9988432 DOI: 10.3346/jkms.2023.38.e66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/06/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Antimicrobial prescriptions for serious chronic or acute illness nearing its end stages raise concerns about the potential for futile use, adverse events, increased multidrug-resistant organisms, and significant patient and social cost burdens. This study investigated the nationwide situation of how antibiotics are prescribed to patients during the last 14 days of life to guide future actions. METHODS This nationwide multicenter retrospective cohort study was conducted at 13 hospitals in South Korea from November 1 to December 31, 2018. All decedents were included in the study. Antibiotic use during the last two weeks of their lives was investigated. RESULTS A total of 1,201 (88.9%) patients received a median of two antimicrobial agents during the last two weeks of their lives. Carbapenems were prescribed to approximately half of the patients (44.4%) in the highest amount (301.2 days of therapy per 1,000 patient-days). Among the patients receiving antimicrobial agents, 63.6% were inappropriate and only 327 patients (27.2%) were referred by infectious disease specialists. The use of carbapenem (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.13-2.03; P = 0.006), underlying cancer (OR, 1.56; 95% CI, 1.20-2.01, P = 0.047), underlying cerebrovascular disease (OR, 1.88; 95% CI, 1.23-2.89, P = 0.004), and no microbiological testing (OR, 1.79; 95% CI, 1.15-2.73; P = 0.010) were independent predictors for inappropriate antibiotic prescribing. CONCLUSION A considerable number of antimicrobial agents are administered to patients with chronic or acute illnesses nearing their end-of-life, a high proportion of which are prescribed inappropriately. Consultation with an infectious disease specialist, in addition to an antimicrobial stewardship program, may be necessary to induce the optimal use of antibiotics.
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Affiliation(s)
- Yu Mi Wi
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dong Sik Jung
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Kyung Mok Sohn
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Sang Taek Heo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Jeju National University, Jeju, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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7
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Larnard J, Stead W, Branch-Elliman W. Considering Patient, Family, and Provider Goals and Expectations in a Rapidly Changing Clinical Context: A Framework for Antimicrobial Stewardship at the End of Life. Infect Dis Clin North Am 2023; 37:139-151. [PMID: 36805010 DOI: 10.1016/j.idc.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Antibiotic administration is often a part of end-of-life (EOL) care, including among patients who are not critically ill. Guideline-issuing bodies recommend that antimicrobial stewardship providers (ASPs) provide support to prescribers making decisions about whether or not to treat infections in this population. Relatively little is known about the rationale for antimicrobial prescribing during the EOL period in noncritical care settings, although patient and family preferences are often an influencing factor. The effectiveness of antimicrobials in improving quantity or quality of life in this population is unclear and likely context-specific.
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Affiliation(s)
- Jeffrey Larnard
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Suite GB, Boston, MA 02215, USA.
| | - Wendy Stead
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Suite GB, Boston, MA 02215, USA
| | - Westyn Branch-Elliman
- Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA; Department of Medicine, Harvard Medical School
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Marra AR, Clore GS, Balkenende E, Goedken CC, Livorsi DJ, Goto M, Vaughan-Sarrazin MS, Broderick A, Perencevich EN. Association of entry into hospice or palliative care consultation during acute care hospitalization with subsequent antibiotic utilization. Clin Microbiol Infect 2023; 29:107.e1-107.e7. [PMID: 35931374 DOI: 10.1016/j.cmi.2022.07.018] [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: 05/09/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We aimed to estimate antibiotic use during the last 6 months of life for hospitalized patients under hospice or palliative care and identify potential targets (i.e. time points) for antibiotic stewardship during the end-of-life period. METHODS We conducted a retrospective cohort study of nationwide Veterans Affairs (VA) patients who died between January 1, 2014 and December 31, 2019 and who had been hospitalized within 6 months prior to death. Data from the VA's integrated electronic medical record were collected, including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity score-matched cohort analysis was conducted to compare antibiotic use between hospitalized patients placed into palliative care or hospice matched to hospitalized patients not receiving palliative care or hospice. RESULTS There were 9808 and 40 796 propensity score-matched patient pairs in the hospice and palliative care groups, respectively. Within 14 days of placement or consultation, 41% (4040/9808) of hospice patients and 48% (19 735/40 796) of palliative care patients received at least one antibiotic, while 25% (2420/9808) matched nonhospice and 27% (10 991/40 796) matched nonpalliative care patients received antibiotics. Entry into hospice was independently associated with a 12% absolute increase in antibiotic prescribing, and entry into palliative care was associated with a 17% absolute increase during the 14 days post-entry vs. pre-entry period. DISCUSSION We observed that patients receiving end-of-life care had high levels of antibiotic exposure across this VA population, particularly during admissions when they received hospice or palliative care consultation.
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Affiliation(s)
- Alexandre R Marra
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA; Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Gosia S Clore
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Erin Balkenende
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Cassie Cunningham Goedken
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Daniel J Livorsi
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Mary S Vaughan-Sarrazin
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Ann Broderick
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
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