1
|
Otite FO, Morris N. Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke. Crit Care Clin 2024; 40:709-740. [PMID: 39218482 DOI: 10.1016/j.ccc.2024.05.006] [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] [Indexed: 09/04/2024]
Abstract
Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.
Collapse
Affiliation(s)
- Fadar Oliver Otite
- Cerebrovascular Division, Upstate Neurological Institute, Syracuse, NY, USA.
| | - Nicholas Morris
- Neurocritical Care Division, Department of Neurology, University of Maryland, Baltimore, MD, USA
| |
Collapse
|
2
|
Elkaryoni A, Darki A, Bunte M, Mamas MA, Weinberg I, Elgendy IY. Palliative Care Penetration Among Hospitalizations with Acute Pulmonary Embolism: A Nationwide Analysis. J Palliat Care 2024; 39:129-137. [PMID: 35138196 DOI: 10.1177/08258597221078389] [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] [Indexed: 11/15/2022]
Abstract
Background: Integration of palliative care in the management of critical illnesses has been linked with a better quality of life for patients and their families. Yet, there is a paucity of data regarding the role of palliative care for acute pulmonary embolism (PE) hospitalizations which is a leading cause of cardiovascular death in the United States. Methods: Using the Nationwide Inpatient Sample years 2005-2015, acute PE hospitalizations were identified by using ICD-9-codes. The primary outcome was the trends of palliative care penetration during acute PE hospitalizations and the main secondary outcome was the factors associated with palliative care utilization. Results: Among 505,485 acute PE hospitalizations, 15,522 (3.1%) had a palliative care encounter. Hospitalizations with high-risk PE versus non-high-risk PE showed a higher utilization for palliative care (7.6% vs. 2.7%, P < 0.001). The annual trends of palliative care penetration among hospitalizations with PE showed a rising pattern (0.6% in 2005 vs. 5.6% in 2015, Ptrend<0.001). A similar trend was observed among those with high-risk PE (0.8% in 2005 vs. 12.8% in 2015, Ptrend<0.001). The trends of palliative care utilization among cancer and non-cancer admissions increased over time (1.3%in 2005 to 15.5% in 2015 vs. 0.5% in 2005 to 3.9% in 2015, both P-trends<0.001). Some racial and regional disparities were identified among the predictors of palliative care utilization. Conclusions: Palliative care penetration among acute PE hospitalizations remains suboptimal even among high-risk PE, and cancer hospitalizations, but has been increasing in recent years. Future studies are needed to investigate the barriers for palliative care utilization and narrowing this gap among admissions with acute PE.
Collapse
Affiliation(s)
| | - Amir Darki
- Loyola Stritch School of Medicine, Maywood, IL, USA
| | - Matthew Bunte
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas, MO, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, UK
| | | | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| |
Collapse
|
3
|
Oud L. Disparities in Palliative Care Among Critically Ill Patients With and Without COVID-19 at the End of Life: A Population-Based Analysis. J Clin Med Res 2023; 15:438-445. [PMID: 38189035 PMCID: PMC10769605 DOI: 10.14740/jocmr5027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/02/2023] [Indexed: 01/09/2024] Open
Abstract
Background The surge in critical illness and associated mortality brought by the coronavirus virus disease 2019 (COVID-19) pandemic, coupled with staff shortages and restrictions of family visitation, may have adversely affected delivery of palliative measures, including at the end of life of affected patients. However, the population-level patterns of palliative care (PC) utilization among septic critically ill patients with and without COVID-19 during end-of-life hospitalizations are unknown. Methods A statewide dataset was used to identify patients aged ≥ 18 years with intensive care unit (ICU) admission and a diagnosis of sepsis in Texas, who died during hospital stay during April 1 to December 31, 2020. COVID-19 was defined by the International Classification of Diseases, 10th Revision (ICD-10) code U07.1, and PC was identified by ICD-10 code Z51.5. Multivariable logistic models were fitted to estimate the association of COVID-19 with use of PC among ICU admissions. A similar approach was used for sensitivity analyses of strata with previously reported lower and higher than reference use of PC. Results There were 20,244 patients with sepsis admitted to ICU during terminal hospitalization, and 9,206 (45.5%) had COVID-19. The frequency of PC among patients with and without COVID-19 was 32.0% vs. 37.1%, respectively. On adjusted analysis, the odds of PC use remained lower among patients with COVID-19 (adjusted odds ratio (aOR): 0.84, 95% confidence interval (CI): 0.78 - 0.90), with similar findings on sensitivity analyses. Conclusions PC was markedly less common among critically ill septic patients with COVID-19 during terminal hospitalization, compared to those without COVID-19. Further studies are needed to determine the factors underlying these findings in order to reduce disparities in use of PC.
Collapse
Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX, USA.
| |
Collapse
|
4
|
Kalasapudi L, Williamson S, Shipper AG, Motta M, Esenwa C, Otite FO, Chaturvedi S, Morris NA. Scoping Review of Racial, Ethnic, and Sex Disparities in the Diagnosis and Management of Hemorrhagic Stroke. Neurology 2023; 101:e267-e276. [PMID: 37202159 PMCID: PMC10382273 DOI: 10.1212/wnl.0000000000207406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/28/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the United States, Black, Hispanic, and Asian Americans experience excessively high incidence rates of hemorrhagic stroke compared with White Americans. Women experience higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity. METHODS We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients aged 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke. RESULTS After reviewing 6,161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control after intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care. DISCUSSION Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke.
Collapse
Affiliation(s)
- Lakshman Kalasapudi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Stacey Williamson
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Andrea G Shipper
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Melissa Motta
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Charles Esenwa
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Fadar Oliver Otite
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Seemant Chaturvedi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Nicholas A Morris
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse.
| |
Collapse
|
5
|
Daniel D, Santos D, Maillie L, Dhamoon MS. Variability in intensive care utilization for intracerebral hemorrhage in the United States: Retrospective cohort study. J Stroke Cerebrovasc Dis 2022; 31:106619. [PMID: 35780718 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106619] [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: 05/08/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES There are urban-rural geographic health disparities in intracerebral hemorrhage (ICH) outcomes. However, there is limited data regarding the relationship between intensive care (ICU) availability and ICH outcomes. We examined whether ICU availability was a significant contributor to ICH outcomes by US geographic region. MATERIALS AND METHODS We used de-identified Medicare inpatient datasets from January 2016 to December 2019 and identified all index ICH admissions, stratifying by ICU care received during the hospitalization. Distributions of teaching hospital status, quartile of ICH volume, hospital urban-rural designation, and ICU availability were obtained using chi-square test. Propensity-score matching was utilized to compare outcomes of more favorable outcome, inpatient mortality, and 30-day all-cause readmissions by ICU availability at each hospital. RESULTS Out of a total of 119,891 hospitalizations for ICH, 66,306 (55.3%) received ICU-level care. Of hospitals that treated at least one ICH, 42.6% did not provide ICU level care for any ICH admission during the study period. Teaching hospitals (48.0% vs 7.0%; p<0.0001), hospitals with higher ICH case volumes (p<0.0001) and in larger metropolitan areas (p<0.0001) were more likely to have an ICU available. Propensity score-matched models showed that hospital ICU availability was associated with a lower likelihood of inpatient mortality (29.4% vs 33.7%; p=0.0016) CONCLUSIONS: Rural-urban disparities in ICH outcomes are likely multifactorial, but ICU availability likely contributes to the disparity. Additional studies are necessary to elucidate other contributing mechanisms.
Collapse
Affiliation(s)
- David Daniel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Daniel Santos
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Luke Maillie
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| |
Collapse
|
6
|
Williamson TL, Adil SM, Shalita C, Charalambous LT, Mitchell T, Yang Z, Parente BA, Lee HJ, Ubel PA, Lemmon ME, Galanos AN, Lad SP, Komisarow JM. Palliative Care Consultations in Patients with Severe Traumatic Brain Injury: Who Receives Palliative Care Consultations and What Does that Mean for Utilization? Neurocrit Care 2022; 36:781-790. [PMID: 34988887 PMCID: PMC9117411 DOI: 10.1007/s12028-021-01366-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Palliative care has the potential to improve goal-concordant care in severe traumatic brain injury (sTBI). Our primary objective was to illuminate the demographic profiles of patients with sTBI who receive palliative care encounters (PCEs), with an emphasis on the role of race. Secondary objectives were to analyze PCE usage over time and compare health care resource utilization between patients with or without PCEs. METHODS The National Inpatient Sample database was queried for patients age ≥ 18 who had a diagnosis of sTBI, defined by using International Classification of Diseases, 9th Revision codes. PCEs were defined by using International Classification of Diseases, 9th Revision code V66.7 and trended from 2001 to 2015. To assess factors associated with PCE in patients with sTBI, we performed unweighted generalized estimating equations regression. PCE association with decision making was modeled via its effect on rate of percutaneous endoscopic gastrostomy (PEG) tube placement. To quantify differences in PCE-related decisions by race, race was modeled as an effect modifier. RESULTS From 2001 to 2015, the proportion of palliative care usage in patients with sTBI increased from 1.5 to 36.3%, with 41.6% White, 22.3% Black, and 25% Hispanic patients with sTBI having a palliative care consultation in 2015, respectively. From 2008 to 2015, we identified 17,673 sTBI admissions. White and affluent patients were more likely to have a PCE than Black, Hispanic, and low socioeconomic status patients. Across all races, patients receiving a PCE resulted in a lower rate of PEG tube placement; however, White patients exhibited a larger reduction of PEG tube placement than Black patients. Patients using palliative care had lower total hospital costs (median $16,368 vs. $26,442, respectively). CONCLUSIONS Palliative care usage for sTBI has increased dramatically this century and it reduces resource utilization. This is true across races, however, its usage rate and associated effect on decision making are race-dependent, with White patients receiving more PCE and being more likely to decline the use of a PEG tube if they have had a PCE.
Collapse
Affiliation(s)
- Theresa L Williamson
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA.
| | - Syed M Adil
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Chidyaonga Shalita
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Lefko T Charalambous
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Taylor Mitchell
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Beth A Parente
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Peter A Ubel
- Fuqua School of Business, Duke University, Durham, NC, 27710, USA
| | - Monica E Lemmon
- Department of Pediatrics, Duke University Medical Center, Durham, NC, 27710, USA
| | - Anthony N Galanos
- Division of Palliative Care, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| | - Jordan M Komisarow
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC, 27710, USA
| |
Collapse
|
7
|
Thomas SM, Reindorp Y, Christophe BR, Connolly ES. Systematic Review of Resource Use and Costs in the Hospital Management of Intracerebral Hemorrhage. World Neurosurg 2022; 164:41-63. [PMID: 35489599 DOI: 10.1016/j.wneu.2022.04.055] [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: 12/10/2021] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND While clinical guidelines provide a framework for hospital management of spontaneous intracerebral hemorrhage (ICH), variation in the resource use and costs of these services exists. We sought to perform a systematic literature review to assess the evidence on hospital resource use and costs associated with management of adult patients with ICH, as well as identify factors that impact variation in such hospital resource use and costs, regarding clinical characteristics and delivery of services. METHODS A systematic literature review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Ovid MEDLINE(R) 1946 to present. Articles were assessed against inclusion and exclusion criteria. Study design, ICH sample size, population, setting, objective, hospital characteristics, hospital resource use and cost data, and main study findings were abstracted. RESULTS In total, 43 studies met the inclusion criteria. Pertinent clinical characteristics that increased hospital resource use included presence of comorbidities and baseline ICH severity. Aspects of service delivery that greatly impacted hospital resource consumption included intensive care unit length of stay and performance of surgical procedures and intensive care procedures. CONCLUSIONS Hospital resource use and costs for patients with ICH were high and differed widely across studies. Making concrete conclusions on hospital resources and costs for ICH care was constrained, given methodologic and patient variation in the studies. Future research should evaluate the long-term cost-effectiveness of ICH treatment interventions and use specific economic evaluation guidelines and common data elements to mitigate study variation.
Collapse
Affiliation(s)
- Steven Mulackal Thomas
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York, USA.
| | - Yarin Reindorp
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Brandon R Christophe
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Edward Sander Connolly
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
8
|
Cobert J, Cook AC, Lin JA, O'Riordan DL, Pantilat SZ. Trends in Palliative Care Consultations in Critically Ill Patient Populations, 2013-2019. J Pain Symptom Manage 2022; 63:e176-e181. [PMID: 34348177 DOI: 10.1016/j.jpainsymman.2021.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/19/2021] [Accepted: 07/26/2021] [Indexed: 11/15/2022]
Abstract
CONTEXT Critically ill patients have important palliative care (PC) needs in the intensive care unit (ICU), but specialty PC is often underutilized. OBJECTIVE To evaluate changes in utilization and reasons for PC consultation over time. METHODS Data from a national multi-site network of inpatient PC visits were used to identify patients age ≥18 years admitted to an ICU between 2013 and 2019. Year of ICU admission was the exposure. Primary diagnosis and reason for referral were identified by standardized process measures within the dataset at the time of referral. Trends in primary diagnosis and reason for referral were modeled as a function of year of ICU admission. RESULTS Across 39,515 ICU patients seen by a PC team, overall numbers of consultations from the ICU increased each year. Referrals for patients with cancer decreased from 17.6% (95% CI 13.7%-21.5%) to 14.3% (95% CI 13.2%-14.7%) and for patients with cardiovascular disease increased from 16.8% in (95% CI 16.8%-16.9%) to 18.8% (95% CI 18.8%-18.9%). Reasons for referrals were primarily for goals of care and advance care planning and increased from 74.0% (95% CI 70.0%-78.0%) in 2013 to 80.0% (95% CI 79.4%-80.0%) in 2019 (P < 0.0001 for all trends). CONCLUSION PC referrals in ICU patients with cancer are decreasing, while those for cardiovascular disease are increasing. Reasons for referrals in the ICU are commonly for goals of care; other reasons, like pain control are uncommon. Early goals of care conversations and further training in advance care planning should be emphasized in the ICU setting.
Collapse
Affiliation(s)
- Julien Cobert
- Anesthesia Service (J.C.), San Francisco VA Health Care System, San Francisco, CA, USA; Department of Anesthesiology (J.C.), University of California San Francisco, San Francisco, CA, USA.
| | - Allyson C Cook
- Division of Palliative Medicine (A.C.C., J.A.L., D.L.O., S.Z.P.), Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Surgery (A.C.C., J.A.L.), University of California San Francisco, San Francisco, CA, USA; Critical Care Medicine (A.C.C.), Department of Anesthesia, University of California San Francisco
| | - Joseph A Lin
- Division of Palliative Medicine (A.C.C., J.A.L., D.L.O., S.Z.P.), Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Surgery (A.C.C., J.A.L.), University of California San Francisco, San Francisco, CA, USA
| | - David L O'Riordan
- Division of Palliative Medicine (A.C.C., J.A.L., D.L.O., S.Z.P.), Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine (A.C.C., J.A.L., D.L.O., S.Z.P.), Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
9
|
Garg A, Soto AL, Knies AK, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Predictors of Surrogate Decision Makers Selecting Life-Sustaining Therapy for Severe Acute Brain Injury Patients: An Analysis of US Population Survey Data. Neurocrit Care 2021; 35:468-479. [PMID: 33619667 PMCID: PMC8380750 DOI: 10.1007/s12028-021-01200-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with a severe acute brain injury admitted to the intensive care unit often have a poor neurological prognosis. In these situations, a clinician is responsible for conducting a goals-of-care conversation with the patient's surrogate decision makers. The diversity in thought and background of surrogate decision makers can present challenges during these conversations. For this reason, our study aimed to identify predictive characteristics of US surrogate decision makers' favoring life-sustaining treatment (LST) over comfort measures only for patients with severe acute brain injury. METHODS We analyzed data from a cross-sectional survey study that had recruited 1588 subjects from an online probability-based US population sample. Seven hundred and ninety-two subjects had randomly received a hypothetical scenario regarding a relative intubated with severe acute brain injury with a prognosis of severe disability but with the potential to regain some consciousness. Seven hundred and ninety-six subjects had been randomized to a similar scenario in which the relative was projected to remain vegetative. For each scenario, we conducted univariate analyses and binary logistic regressions to determine predictors of LST selection among available respondent characteristics. RESULTS 15.0% of subjects selected LST for the severe disability scenario compared to 11.4% for the vegetative state scenario (p = 0.07), with those selecting LST in both groups expressing less decisional certainty. For the severe disability scenario, independent predictors of LST included having less than a high school education (adjusted OR = 2.87, 95% CI = 1.23-6.76), concern regarding prognostic accuracy (7.64, 3.61-16.15), and concern regarding the cost of care (4.07, 1.80-9.18). For the vegetative scenario, predictors included the youngest age group (30-44 years, 3.33, 1.02-10.86), male gender (3.26, 1.75-6.06), English as a second language (2.94, 1.09-7.89), Evangelical Protestant (3.72, 1.28-10.84) and Catholic (4.01, 1.72-9.36) affiliations, and low income (< $25 K). CONCLUSION Several demographic and decisional characteristics of US surrogate decision makers predict LST selection for patients with severe brain injury with varying degrees of poor prognosis. Surrogates concerned about the cost of medical care may nevertheless be inclined to select LST, albeit with high levels of decisional uncertainty, for patients projected to have severe disabilities.
Collapse
Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Alexandria L Soto
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
| | - Andrea K Knies
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
| | - Liana Fraenkel
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA.
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW Nontraumatic intracerebral hemorrhage (ICH) is the second most common type of stroke. This article summarizes the basic pathophysiology, classification, and management of ICH and discusses the available evidence on therapy for hematoma, hematoma expansion, and perihematomal edema. RECENT FINDINGS Current available data on potential therapeutic options for ICH are promising, although none of the trials have shown improvement in mortality rate. The literature available on reversal of anticoagulation and antiplatelet agents after an ICH and resumption of these medications is also increasing. SUMMARY ICH continues to have high morbidity and mortality. Advances in therapeutic options to target secondary brain injury from the hematoma, hematoma expansion, and perihematomal edema are increasing. Data on reversal therapy for anticoagulant-associated or antiplatelet-associated ICH and resumption of these medications are evolving.
Collapse
|
11
|
Mehta AK, Wright SM, Wu DS, Harris CM. Palliative Care Involvement in Patients Hospitalized in the United States with Aneurysmal Subarachnoid Hemorrhage. J Palliat Med 2021; 24:1555-1560. [PMID: 34166123 DOI: 10.1089/jpm.2021.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Aneurysmal subarachnoid hemorrhage (aSAH) has a high mortality rate and significantly impacts survivors' quality of life. Objective: To assess impact of specialty palliative care services (sPCS) among patients hospitalized with aSAH. Design: A retrospective cohort study using the National Inpatient Sample (2017-2018). Setting/Subjects: U.S. adult patients hospitalized for aSAH with and without sPCS involvement. Measurements: Mortality and health care utilization variables. Results: Among 48,050 patients with aSAH, 12.7% received sPCS input. aSAH patients with sPCS were more likely to be sicker (higher National Inpatient Sample-subarachnoid hemorrhage [NIS-SAH] severity score, p < 0.01). Patients with sPCS had a 70% in-hospital mortality rate, whereas only 9% of the rest of this cohort died during the incident hospitalization (p < 0.01). Those with sPCS involvement had shorter lengths of stay (p < 0.05) and nonsignificantly lower hospital charges. Conclusion: sPCS involvement, inferred by International Classification of Diseases, 10th Revision (ICD-10) code Z51.5, was associated with shorter length of stay and lower hospital charges among survivors, but this did not meet prespecified statistical significance. There may be significant benefits to consulting sPCS for patients hospitalized with aSAH.
Collapse
Affiliation(s)
- Ambereen Kurwa Mehta
- Palliative Care Program, Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.,Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Scott Mitchell Wright
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - David Shih Wu
- Palliative Care Program, Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.,Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Ché Matthew Harris
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| |
Collapse
|
12
|
Rural-Urban Disparities in Intracerebral Hemorrhage Mortality in the USA: Preliminary Findings from the National Inpatient Sample. Neurocrit Care 2021; 32:715-724. [PMID: 32232726 PMCID: PMC7223184 DOI: 10.1007/s12028-020-00950-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives To compare in-hospital mortality between intracerebral hemorrhage (ICH) patients in rural hospitals to those in urban hospitals of the USA. Methods We used the National Inpatient Sample to retrospectively identify all cases of ICH in the USA over the period 2004–2014. We used multivariable-adjusted models to compare odds of mortality between rural and urban hospitals. Joinpoint regression was used to evaluate trends in age- and sex-adjusted mortality in rural and urban hospitals over time. Results From 2004 to 2014, 5.8% of ICH patients were admitted in rural hospitals. Rural patients were older (mean [SE] 76.0 [0.44] years vs. 68.8 [0.11] years in urban), more likely to be white and have Medicare insurance. Age- and sex-adjusted mortality was greater in rural hospitals (32.2%) compared to urban patients (26.5%) (p value < 0.001). After multivariable adjustment, patients hospitalized in rural hospitals had two times the odds of in-hospital death compared to patients in urban hospitals (OR 2.07, 95% CI 1.77–2.41. p value < 0.001). After joinpoint regression, mortality declined in urban hospitals by an average of 2.8% per year (average annual percentage change, [AAPC] − 2.8%, 95% CI − 3.7 to − 1.8%), but rates in rural hospitals remained unchanged (AAPC − 0.54%, 95% CI − 1.66 to 0.58%). Conclusions Despite current efforts to reduce disparity in stroke care, ICH patients hospitalized in rural hospitals had two times the odds of dying compared to those in urban hospitals. In addition, the ICH mortality gap between rural and urban centers is increasing. Further studies are needed to identify and reverse the causes of this disparity. Electronic supplementary material The online version of this article (10.1007/s12028-020-00950-2) contains supplementary material, which is available to authorized users.
Collapse
|
13
|
Chu KM, Jones EM, Meeks JR, Pan AP, Agarwal KL, Taffet GE, Vahidy FS. Decade-Long Nationwide Trends and Disparities in Use of Comfort Care Interventions for Patients With Ischemic Stroke. J Am Heart Assoc 2021; 10:e019785. [PMID: 33823605 PMCID: PMC8174182 DOI: 10.1161/jaha.120.019785] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Stroke remains one of the leading causes of disability and death in the United States. We characterized 10-year nationwide trends in use of comfort care interventions (CCIs) among patients with ischemic stroke, particularly pertaining to acute thrombolytic therapy with intravenous tissue-type plasminogen activator and endovascular thrombectomy, and describe in-hospital outcomes and costs. Methods and Results We analyzed the National Inpatient Sample from 2006 to 2015 and identified adult patients with ischemic stroke with or without thrombolytic therapy and CCIs using validated International Classification of Diseases, Ninth Revision (ICD-9) codes. We report adjusted odds ratios (ORs) and 95% CI of CCI usage across five 2-year periods. Of 4 249 201 ischemic stroke encounters, 3.8% had CCI use. CCI use increased over time (adjusted OR, 4.80; 95% CI, 4.15-5.55) regardless of acute treatment type. Advanced age, female sex, White race, non-Medicare insurance, higher income, disease severity, comorbidity burden, and discharge from non-northeastern teaching hospitals were independently associated with receiving CCIs. In the fully adjusted model, thrombolytic therapy and endovascular thrombectomy, respectively, conferred a 6% and 10% greater likelihood of receiving CCIs. Among CCI users, there was a significant decline in in-hospital mortality compared with all other dispositions over time (adjusted OR, 0.46; 95% CI, 0.38-0.56). Despite longer length of stay, CCI hospitalizations incurred 16% lower adjusted costs. Conclusions CCI use among patients with ischemic stroke has increased regardless of acute treatment type. Nonetheless, considerable disparities persist. Closing the disparities gap and optimizing access, outcomes, and costs for CCIs among patients with stroke are important avenues for further research.
Collapse
Affiliation(s)
- Kristie M Chu
- Department of Neurology McGovern Medical School University of Texas Health Science Center at Houston TX
| | - Erica M Jones
- Department of Neurology McGovern Medical School University of Texas Health Science Center at Houston TX
| | | | - Alan P Pan
- Center for Outcomes Research Houston Methodist Houston TX
| | - Kathryn L Agarwal
- Department of Geriatric Medicine Baylor College of Medicine Houston TX
| | - George E Taffet
- Department of Geriatric Medicine Baylor College of Medicine Houston TX
| | - Farhaan S Vahidy
- Center for Outcomes Research Houston Methodist Houston TX.,The Houston Methodist Neurological Institute Houston Methodist Houston TX
| |
Collapse
|
14
|
Kobayashi T, Salinas JL, Ten Eyck P, Chen B, Ando T, Inagaki K, Alsuhaibani M, Auwaerter PG, Molano I, Diekema DJ. Palliative care consultation in patients with Staphylococcus aureus bacteremia. Palliat Med 2021; 35:785-792. [PMID: 33757367 PMCID: PMC8436633 DOI: 10.1177/0269216321999574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Palliative care consultation has shown benefits across a wide spectrum of diseases, but the utility in patients with Staphylococcus aureus bacteremia remains unclear despite its high mortality. AIM To examine the frequency of palliative care consultation and factors associated with palliative care consult in Staphylococcus aureus bacteremia patients in the United States. DESIGN A population-based retrospective analysis using the Nationwide Inpatient Sample database in 2014, compiled by the Healthcare Costs and Utilization Project of the Agency for Healthcare Research and Quality. SETTING/SUBJECTS All inpatients with a discharge diagnosis of Staphylococcus aureus bacteremia (ICD-9-CM codes; 038.11 and 038.12). MEASUREMENTS Palliative care consultation was identified using ICD-9-CM code V66.7. Patients' baseline characteristics and outcomes were compared between those with and without palliative care consult. RESULTS A total of 111,320 Staphylococcus aureus bacteremia admissions were identified in 2014. Palliative care consult was observed in 8140 admissions (7.3%). Palliative care consultation was associated with advanced age, white race, comorbidities, higher income, teaching/urban hospitals, Midwest region, Methicillin-resistant Staphylococcus aureus bacteremia and the lack of echocardiogram. Palliative care consult was also associated with shorter but more expensive hospitalizations. Crude mortality was 53% (4314/8140) among admissions with palliative care consult and 8% (8357/10,3180) among those without palliative care consult (p < 0.001). CONCLUSIONS Palliative care consultation was infrequent during the management of Staphylococcus aureus bacteremia, and a substantial number of patients died during their hospitalizations without palliative care consult. Given the reported benefit in other medical conditions, palliative care consultation may have a role in Staphylococcus aureus bacteremia. Selecting patients who may benefit the most should be explored.
Collapse
Affiliation(s)
- Takaaki Kobayashi
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Jorge L Salinas
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
| | - Benjamin Chen
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Tomo Ando
- Division of Cardiology, Columbia University, New York, NY, USA
| | - Kengo Inagaki
- Division of Infectious Diseases, Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mohammed Alsuhaibani
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.,Department of Pediatrics, College of Medicine, Qassim University, Qassim, Saudi Arabia
| | - Paul G Auwaerter
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ilonka Molano
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.,Division of Supportive and Palliative Care, University of Iowa, Iowa City, IA, USA
| | - Daniel J Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
15
|
Wright J, Gerges C, Shammassian B, Zhou X, Huang Wright C, Duan Y, Cabrera CI, Rosenfeld K, D'Anza B, Pronovost P, Sajatovic M, Bambakidis N. Use of Telemedicine to Improve Interfacility Communication and Aid in Triage of Patients with Intracerebral Hemorrhage: A Pilot Study. World Neurosurg 2020; 147:e189-e199. [PMID: 33309640 DOI: 10.1016/j.wneu.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Over the past several years there has been a dramatic increase in the implementation of telemedicine technology to aid in the delivery of care across community, inpatient, and emergency settings. This technology has proved valuable for acute life-threatening clinical scenarios. We aimed to pilot a novel neurosurgical telemedicine program within an academic tertiary care center to assist in consultation of patients with high-grade intracranial hemorrhage (ICH) (ICH score 4, 5). METHODS A quality improvement conceptual framework was developed. Subsequently, a process map and improvement interventions were created. Patients in community hospitals with high-grade ICH or pre-existing Do Not Resuscitate/Do Not Intubate orders with an admitting diagnosis of ICH triggered a TeleNeurosurgery consultation. Patients who met the inclusion criteria, with consent of their decision makers, were enrolled in the study. Post-encounter physician surveys were used to evaluate overall satisfaction with the implementation. RESULTS This 18-month pilot study proved feasible, with an enrollment of 63.6% (n = 14 of 22) of patients who met criteria. All patients who were enrolled in the study and participated in TeleNeurosurgery consultation remained at the presenting facility for end-of-life care and palliative medicine consultation. Both community emergency physicians and subspecialists who performed the consultations reported satisfaction with the TeleNeurosurgery consultation process and a perceived benefit both to patients, families, and emergency medicine physicians. CONCLUSIONS The program proved feasible and several areas in need of improvement within the health system were identified. Emergency physicians reported comfort with the process, program effectiveness, and improved access to care by implementation of this program.
Collapse
Affiliation(s)
- James Wright
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
| | - Christina Gerges
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Berje Shammassian
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Xiaofei Zhou
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Christina Huang Wright
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Yifei Duan
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Claudia I Cabrera
- Ear, Nose, and Throat Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Kenneth Rosenfeld
- Department of Medicine, Division of Geriatrics and Palliative Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Brian D'Anza
- Medical Director, Telehealth, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Peter Pronovost
- Chief Clinical Transformation Officer, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nicholas Bambakidis
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
16
|
Chatterjee K, Harrington S, Sexton K, Goyal A, Robertson RD, Corwin HL. Impact of Palliative Care Utilization for Surgical Patients Receiving Prolonged Mechanical Ventilation: National Trends (2009-2013). Jt Comm J Qual Patient Saf 2020; 46:493-500. [PMID: 32414575 DOI: 10.1016/j.jcjq.2020.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (≥ 96 consecutive hours). METHODS National Inpatient Sample (NIS) data 2009-2013 was used to identify adults (age ≥ 18) who had a surgical procedure and required prolonged MV (≥ 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS. RESULTS Utilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization. CONCLUSIONS Among surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.
Collapse
|
17
|
Anand V, Vallabhajosyula S, Cheungpasitporn W, Frantz RP, Cajigas HR, Strand JJ, DuBrock HM. Inpatient Palliative Care Use in Patients With Pulmonary Arterial Hypertension: Temporal Trends, Predictors, and Outcomes. Chest 2020; 158:2568-2578. [PMID: 32800817 DOI: 10.1016/j.chest.2020.07.079] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive disease associated with significant morbidity and mortality. Despite the negative impact of PAH on quality of life and survival, data on use of specialty palliative care services (PCS) is scarce. RESEARCH QUESTION We sought to evaluate the inpatient use of PCS in patients with PAH. STUDY DESIGN AND METHODS Using the National (Nationwide) Inpatient Sample, 30,495 admissions with a primary diagnosis of PAH were identified from 2001 through 2017. The primary outcome of interest was temporal trends and predictors of inpatient PCS use in patients with PAH. RESULTS The inpatient use of PCS was low (2.2%), but increased during the study period from 0.5% in 2001 to 7.6% in 2017, with a significant increase starting in 2009. White race, private insurance, higher socioeconomic status, hospital-specific factors, higher comorbidity burden (Charlson Comorbidity Index), cardiac and noncardiac organ failure, and use of extracorporeal membrane oxygenation and noninvasive mechanical ventilation were independent predictors of increased PCS use. PCS use was associated with a higher prevalence of do-not-resuscitate status, a longer length of stay, higher hospitalization costs, and increased in-hospital mortality with less frequent discharges to home, likely because these patients were also sicker (higher comorbidity index and illness acuity). INTERPRETATION The inpatient use of PCS in patients with PAH is low, but has been increasing over recent years. Despite increased PCS use over time, patient- and hospital-specific disparities in PCS use continue. Further studies evaluating these disparities and the role of PCS in the comprehensive care of PAH patients are warranted.
Collapse
Affiliation(s)
- Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson, MS
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Hector R Cajigas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jacob J Strand
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
18
|
Han H, Yu F, Wu C, Dai L, Ruan Y, Cao Y, He J. Trends and Utilization of Inpatient Palliative Care Among Patients With Metastatic Bladder Cancer. J Palliat Care 2020; 36:105-112. [PMID: 32406315 DOI: 10.1177/0825859720924936] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To explore the trends and utilization of palliative care (PC) service among inpatients with metastatic bladder cancer (MBC). METHODS A retrospective, cross-sectional analysis was performed using data from the 2003 to 2014 National Inpatient Sample. Palliative care was identified through International Classification of Diseases, Ninth Revision code V66.7. Demographics, comorbidities, hospital characteristics, tumor-related, and treatment-related factors were compared between patients with and without PC. Multivariable logistic regression was used to explore predictors of PC use. RESULTS Among 131 852 patients with MBC, 13 224 (10.03%) received PC. Rate of PC increased from 2.49% in 2003 to 28.39% in 2014 (P < .0001). Similarly, rate of PC in decedents increased from 7.02% in 2003 to 54.86% in 2014 (P < .0001). Patients receiving PC were older, tendered to be white, had more comorbidities, and higher all-patient refined diagnosis-related group mortality risk. Predictors of PC included age (odds ratio [OR]: 1.02; 95% CI: 1.01-1.02; P < .0001), Medicaid (OR: 1.87; 95%.CI: 1.54-2.26; P < .0001), and private (OR: 1.61; 95% CI: 1.40-1.84; P < .0001) insurance, hospitals in the West (OR: 1.33; 95% CI: 1.10-1.61; P = .0032), and Mid-west (OR: 1.46; 95% CI: 1.22-1.75; P = .0032), major (OR: 1.32; 95% CI: 1.11-1.49; P < .0001), and extreme (OR: 2.37; 95% CI: 2.04-2.76; P < .0001) mortality risk. Chemotherapy and mechanical ventilation were related with lower odds of PC use. Palliative care predictors in the decedents were similar to those in overall patients with bladder cancer. CONCLUSIONS Palliative care encounter in MBC shows an increasing trend. However, it still remains very low. Disparities in PC use covered age, insurance, and hospital characteristics among metastatic bladder cancer in the United States.
Collapse
Affiliation(s)
- Hedong Han
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Feifei Yu
- Medical Service Research Division, Naval Medical Center of PLA, Shanghai, China
| | - Cheng Wu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Lihe Dai
- Department of Urology, Changhai Hospital, 12521Second Military Medical University, Shanghai, China
| | - Yiming Ruan
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, 6233Örebro University, Örebro, Sweden
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China.,Tongji University School of Medicine, Shanghai, China
| |
Collapse
|
19
|
Ando T, Adegbala O, Uemura T, Ashraf S, Akintoye E, Pahuja M, Afonso L, Briasoulis A, Takagi H. Palliative Care in Ruptured Aortic Aneurysm in the United States: A Retrospective Analysis of Nationwide Inpatient Sample Database. Angiology 2020; 71:633-640. [DOI: 10.1177/0003319720917239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We assessed the trend of palliative care (PC) referrals and its effect on hospitalization cost and length of stay (LOS) in ruptured aortic aneurysm (rAA). The Nationwide Inpatient Sample from 2005 to 2014 was used to identify admissions with age ≥50 and rAA. A total of 54 134 rAA admissions were identified and 5019 (9.3%) had PC referrals. During the study period, PC referral rate increased from 0.97% to 15.3% ( P trend < .0001). Length of stay (1.7 vs 2.8 days, adjusted mean ratio [aMR] = 0.62, 95% confidence interval [CI]: 0.58-0.66), and cost (US$7778 vs US$13 575, aMR = 0.57, 95% CI: 0.52-0.63) were significantly lower in rAA admissions that did not undergo interventions. In the percutaneous repair group, LOS was similar but the cost was higher (US$61 759 vs US$52 260, aMR = 1.18, 95% CI: 1.05-1.30), whereas in surgical repair group, LOS was shorter (4.6 vs 5.9 days, aMR = 0.77, 95% CI: 0.73-0.82) but the cost was higher (US$59 755 vs US$52 523, aMR = 1.14, 95% CI: 1.02-1.28). Palliative care could shorten LOS and save hospitalization cost in rAA admissions not a candidate for repair. Further studies are required to investigate the variable effects of PC on rAA.
Collapse
Affiliation(s)
- Tomo Ando
- Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Oluwole Adegbala
- Englewood Hospital and Medical Center, Seton Hall University-Hackensack Meridian School of Medicine, Englewood, NJ, USA
| | - Takeshi Uemura
- University Health Partners of Hawaii, John A Burns School of Medicine, Honolulu, HI, USA
| | - Said Ashraf
- Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | | | - Mohit Pahuja
- Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Luis Afonso
- Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | | | | |
Collapse
|
20
|
Older Patients With Severe Traumatic Brain Injury: National Variability in Palliative Care. J Surg Res 2020; 246:224-230. [DOI: 10.1016/j.jss.2019.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/18/2019] [Accepted: 09/03/2019] [Indexed: 01/24/2023]
|
21
|
Poblete RA, Zheng L, Arenas M, Vazquez A, Yu D, Emanuel BA, Kim-Tenser MA, Sanossian N, Mack W. Older Age Is Not Associated with Worse Outcomes Following Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:104320. [PMID: 31395424 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is commonly offered after large spontaneous intracerebral hemorrhage (ICH) as a life-saving measure. Based on limited available evidence, surgery is sometimes avoided in the elderly. The association between age and outcomes following DHC in spontaneous ICH remains largely understudied. OBJECTIVE The goal of this study is to investigate the influence of older age on outcomes of patients who undergo DHC for spontaneous ICH. METHODS In this retrospective cohort study, inpatient data were obtained from the United States Nationwide Inpatient Sample from 2000 to 2011. Using International Classification of Diseases, ninth revision designations, patients with a primary diagnosis of nontraumatic ICH who underwent DHC were identified. The primary outcome of interest was the association of age to inpatient mortality and poor outcome. Subjects were grouped by age: 18-50, 51-60, 61-70, and more than 70 years. Sample characteristics were compared across age groups using χ2 testing, and univariate and multivariate Poisson Regression was performed using a generalized equation to estimate rate ratios for primary and secondary outcomes. RESULTS One thousand one hundred and forty four patient cases were isolated. Death occurred in an estimated 28.9% and poor outcome in 86.4%. In multivariate Poisson regression models, there was no difference in hospital mortality or poor outcome by age group. Although younger patients were more likely to be diagnosed with herniation, total complication rate was similar between age groups. CONCLUSIONS Our study results do not provide evidence that age independently predicts in-hospital mortality or poor outcomes. The true influence of age on outcomes is unclear, and further study is needed to determine which factors may be best in selecting candidates for DHC following spontaneous ICH.
Collapse
Affiliation(s)
- Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Ling Zheng
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Marcela Arenas
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alejandro Vazquez
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Derek Yu
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Benjamin A Emanuel
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - May A Kim-Tenser
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nerses Sanossian
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| |
Collapse
|
22
|
Adejumo AC, Kim D, Iqbal U, Yoo ER, Boursiquot BC, Cholankeril G, Wong RJ, Kwo PY, Ahmed A. Suboptimal Use of Inpatient Palliative Care Consultation May Lead to Higher Readmissions and Costs in End-Stage Liver Disease. J Palliat Med 2019; 23:97-106. [PMID: 31397615 DOI: 10.1089/jpm.2019.0100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background/Aims: Patients with end-stage liver disease (ESLD) have a high risk for readmission. We studied the role of palliative care consultation (PCC) in ESLD-related readmissions with a focus on health care resource utilization in the United States. Methods: We performed a retrospective longitudinal analysis on patients surviving hospitalizations with ESLD from January 2010 to September 2014 utilizing the Nationwide Readmissions Database with a 90-day follow-up after discharge. We analyzed annual trends in PCC among patients with ESLD. We matched PCC to no-PCC (1:1) using propensity scores to create a pseudorandomized clinical study. We estimated the impact of PCC on readmission rates (30- and 90-day), and length of stay (LOS) and cost during subsequent readmissions. Results: Of the 67,480 hospitalizations with ESLD, 3485 (5.3%) received PCC, with an annual increase from 3.6% to 6.7% (p for trend <0.01). The average 30- and 90-day annual readmission rates were 36.2% and 54.6%, respectively. PCC resulted in a lower risk for 30- and 90-day readmissions (hazard ratio: 0.42, 95% confidence interval [CI]: 0.38-0.47 and 0.38, 95% CI: 0.34-0.42, respectively). On subsequent 30- and 90-day readmissions, PCC was associated with decreased LOS (5.6- vs. 7.4 days and 5.7- vs. 6.9 days, p < 0.01) and cost (US $48,752 vs. US $75,810 and US $48,582 vs. US $69,035, p < 0.01). Conclusion: Inpatient utilization of PCC for ESLD is increasing annually, yet still remains low in the United States. More importantly, PCC was associated with a decline in readmission rates resulting in a lower burden on health care resource utilization and improvement in cost savings during subsequent readmissions.
Collapse
Affiliation(s)
- Adeyinka Charles Adejumo
- Department of Medicine, North Shore Medical Center, Salem, Massachusetts.,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Umair Iqbal
- Department of Medicine, Geisinger Medical Center, Danville, Pennsylvania
| | - Eric R Yoo
- Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, California
| | - Brian C Boursiquot
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital, Oakland, California
| | - Paul Y Kwo
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
23
|
Wen Y, Jiang C, Koncicki HM, Horowitz CR, Cooper RS, Saha A, Coca SG, Nadkarni GN, Chan L. Trends and Racial Disparities of Palliative Care Use among Hospitalized Patients with ESKD on Dialysis. J Am Soc Nephrol 2019; 30:1687-1696. [PMID: 31387926 DOI: 10.1681/asn.2018121256] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/16/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Study findings show that although palliative care decreases symptom burden, it is still underused in patients with ESKD. Little is known about disparity in use of palliative care services in such patients in the inpatient setting. METHODS To investigate the use of palliative care consultation in patients with ESKD in the inpatient setting, we conducted a retrospective cohort study using the National Inpatient Sample from 2006 to 2014 to identify admitted patients with ESKD requiring maintenance dialysis. We compared palliative care use among minority groups (black, Hispanic, and Asian) and white patients, adjusting for patient and hospital variables. RESULTS We identified 5,230,865 hospitalizations of such patients from 2006 through 2014, of which 76,659 (1.5%) involved palliative care. The palliative care referral rate increased significantly, from 0.24% in 2006 to 2.70% in 2014 (P<0.01). Black and Hispanic patients were significantly less likely than white patients to receive palliative care services (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.61 to 0.84, P<0.01 for blacks and aOR, 0.46; 95% CI, 0.30 to 0.68, P<0.01 for Hispanics). These disparities spanned across all hospital subtypes, including those with higher proportions of minorities. Minority patients with lower socioeconomic status (lower level of income and nonprivate health insurance) were also less likely to receive palliative care. CONCLUSIONS Despite a clear increase during the study period in provision of palliative care for inpatients with ESKD, significant racial disparities occurred and persisted across all hospital subtypes. Further investigation into causes of racial and ethnic disparities is necessary to improve access to palliative care services for the vulnerable ESKD population.
Collapse
Affiliation(s)
- Yumeng Wen
- Department of Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, New York
| | - Changchuan Jiang
- Department of Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, New York
| | - Holly M Koncicki
- Division of Nephrology and.,Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Carol R Horowitz
- Department of Medicine, Mount Sinai Hospital, New York, New York.,Department of Population Health Science and Policy and
| | - Richard S Cooper
- Department of Public Health Sciences, Loyola University, Maywood, Illinois
| | - Aparna Saha
- Department of Public Health Sciences, Loyola University, Maywood, Illinois
| | - Steven G Coca
- Division of Nephrology and.,Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Girish N Nadkarni
- Division of Nephrology and .,Department of Medicine, Mount Sinai Hospital, New York, New York.,Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Lili Chan
- Division of Nephrology and .,Department of Medicine, Mount Sinai Hospital, New York, New York
| |
Collapse
|
24
|
Vallabhajosyula S, Prasad A, Dunlay SM, Murphree DH, Ingram C, Mueller PS, Gersh BJ, Holmes DR, Barsness GW. Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15-Year National Perspective on Trends, Disparities, Predictors, and Outcomes. J Am Heart Assoc 2019; 8:e011954. [PMID: 31315497 PMCID: PMC6761657 DOI: 10.1161/jaha.119.011954] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background This study sought to evaluate the 15‐year national utilization, trends, predictors, disparities, and outcomes of palliative care services (PCS) use in cardiogenic shock complicating acute myocardial infarction. Methods and Results A retrospective cohort from January 1, 2000 through December 31, 2014 was analyzed using the National Inpatient Sample database. Administrative codes for acute myocardial infarction–cardiogenic shock and PCS were used to identify eligible admissions. The primary outcomes were the frequency, utilization trends, and predictors of PCS. Secondary outcomes included in‐hospital mortality and resources utilization. Multivariable regression and propensity‐matching analyses were used to control for confounding. In this 15‐year period, there were 444 253 acute myocardial infarction–cardiogenic shock admissions, of which 4.5% received PCS. The cohort receiving PCS was older, of white race, female sex, and with higher comorbidity and acute organ failure. The PCS cohort received fewer cardiac procedures, but more noncardiac organ support therapies. Older age, female sex, white race, higher comorbidity, higher socioeconomic status, admission to a larger hospital, and admission after 2008 were independent predictors of PCS use. Use of PCS was independently associated with higher in‐hospital mortality (odds ratio 6.59 [95% CI 6.37–6.83]; P<0.001). The cohort with PCS use had >2‐fold higher in‐hospital mortality, 12‐fold higher use of do‐not‐resuscitate status, lesser in‐hospital resource utilization, and fewer discharges to home. Similar findings were observed in the propensity‐matched cohort. Conclusions PCS use in patients with acute myocardial infarction–cardiogenic shock is low, though there is a trend towards increased adoption. There are significant patient and hospital‐specific disparities in the utilization of PCS.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Division of Pulmonary and Critical Care Medicine Department of Medicine Mayo Clinic Rochester MN
| | - Abhiram Prasad
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Department of Health Science Research Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Dennis H Murphree
- Department of Health Science Research Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
| | - Cory Ingram
- Division of General Internal Medicine Department of Medicine Mayo Clinic Rochester MN
| | - Paul S Mueller
- Division of General Internal Medicine Department of Medicine Mayo Clinic Rochester MN
| | - Bernard J Gersh
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - David R Holmes
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | |
Collapse
|
25
|
Faigle R, Gottesman RF. Variability in Palliative Care Use after Intracerebral Hemorrhage at US Hospitals: A Multilevel Analysis. Neuroepidemiology 2019; 53:84-92. [PMID: 31238305 DOI: 10.1159/000500276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/09/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Palliative care (PC) is an essential component of comprehensive care of patients with intracerebral hemorrhage (ICH). In the present study, we sought to characterize the variability of PC use after ICH among US hospitals. METHODS ICH admissions from hospitals with at least 12 annual ICH cases were identified in the Nationwide Inpatient Sample between 2008 and 2011. We used multilevel logistic regression modeling to estimate between-hospital variance in PC use. We calculated the intraclass correlation coefficient (ICC), proportional variance change, and median OR after accounting for individual-level and hospital-level covariates. RESULTS Among 26,791 ICH admissions, 12.5% received PC (95% CI 11.5-13.5). Among the 629 included hospitals, the median rate of PC use was 9.1 (interquartile range 1.5-19.3) per 100 ICH admissions, and 150 (23.9%) hospitals had no recorded PC use. The ICC of the random intercept (null) model was 0.274, suggesting that 27.4% of the overall variability in PC use was due to between-hospital variability. Adding hospital-level covariates to the model accounted for 25.8% of the between-hospital variance observed in the null model, with 74.2% of between-hospital variance remaining unexplained. The median OR of the fully adjusted model was 2.62 (95% CI 2.41-2.89), indicating that a patient moving from 1 hospital to another with a higher intrinsic propensity of PC use had a 2.63-fold median increase in the odds of receiving PC, independent of patient and hospital factors. CONCLUSIONS Substantial variation in PC use after ICH exists among US hospitals. A substantial proportion of this between-hospital variability remains unexplained even after accounting for patient and hospital characteristics.
Collapse
Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
26
|
Han H, Liu Y, Qin Y, Guo W, Ruan Y, Wu C, Cao Y, He J. Utilization of Palliative Care for Patients Undergoing Hematopoietic Stem Cell Transplantation During Hospitalization: A Population-Based National Study. Am J Hosp Palliat Care 2019; 36:900-906. [PMID: 30922064 DOI: 10.1177/1049909119838975] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Patients undergoing hematopoietic stem cell transplantation (HSCT) have substantial physical and psychological symptoms. This study aimed to investigate the utilization of palliative care (PC) in patients undergoing HSCT during hospitalization. METHODS The 2008-2014 National Inpatient Sample was queried for eligible participants. Demographics, hospital characteristics, comorbidities, posttransplantation complications, and inpatient procedures were compared between patients with and without PC. Multivariate logistic regression was performed to identify predictors associated with PC use. RESULTS Among 21 458 patients undergoing HSCT during hospitalization, 278 (1.30%) received PC. The rate of PC use has significantly increased from 0.64% in 2008 to 1.95% in 2014. Patients receiving PC had more co-comorbidities, posttransplantation complications, inpatient procedures, and were more likely to carry a diagnosis of leukemia. In allogeneic HSCT, large bed size (odds ratio [OR] =2.80; 95% confidence interval [CI]: 1.17-6.70), stem cell source from cord blood (OR = 1.93; 95% CI: 1.15-3.24), and graft-versus-host disease (OR = 2.04; 95% CI: 1.36-3.06) were predictors of PC use. In a subset analysis of 783 patients who died during hospitalization, 166 (21.20%) received PC. Among the decedents, Hispanic race had lower odds of PC use (OR = 0.20; 95% CI: 0.05-0.82) in allogeneic HSCT and women had higher odds of PC (OR = 2.70; 95% CI: 1.35-5.41) in autologous HSCT. CONCLUSIONS The rate of PC use has significantly increased among patients undergoing HSCT during hospitalization from 2008 to 2014 but still remains very low. Further investigation is warranted to verify and better understand the barriers toward PC use for HSCT patients.
Collapse
Affiliation(s)
- Hedong Han
- 1 Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yuzhou Liu
- 2 Mount Sinai St Luke's and West Medical Center, New York, NY, USA
| | - Yuchen Qin
- 1 Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Wei Guo
- 1 Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yiming Ruan
- 1 Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Cheng Wu
- 1 Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yang Cao
- 3 Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Jia He
- 1 Department of Health Statistics, Second Military Medical University, Shanghai, China.,4 Tongji University School of Medicine, Shanghai, China
| |
Collapse
|
27
|
Cruz-Flores S, Rodriguez GJ, Chaudhry MRA, Qureshi IA, Qureshi MA, Piriyawat P, Vellipuram AR, Khatri R, Kassar D, Maud A. Racial/ethnic disparities in hospital utilization in intracerebral hemorrhage. Int J Stroke 2019; 14:686-695. [DOI: 10.1177/1747493019835335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and purpose There is evidence that racial and ethnic differences among intracerebral hemorrhage (ICH) patients exist. We sought to establish the occurrence of disparities in hospital utilization in the United States. Methods We identified ICH patients from United States Nationwide Inpatient Sample database for years 2006–2014 using codes (DX1 = 431, 432.0) from the International Classification of Diseases, 9th edition. We compared five race/ethnic categories: White, Black, Hispanic, Asian or Pacific Islander, and Others ( Native American and other) with regard to demographics, comorbidities, disease severity, in-hospital complications, in-hospital procedures, length of stay (LOS), total hospital charges, in-hospital mortality, palliative care, (PC) and do not resuscitate (DNR). We categorized procedures as lifesaving (i.e. ventriculostomy, craniotomy, craniectomy, and ventriculoperitoneal (VP) shunt), life sustaining (i.e. mechanical ventilation, tracheostomy, transfusions, and gastrostomy). White race/ethnicity was set as the reference group. Results Out of 710,293 hospitalized patients with ICH 470,539 (66.2%), 114,821 (16.2%), 66,451 (9.3%), 30,297 (4.3%) and 28,185 (3.9%) were White, Black, Hispanic, Asian or Pacific Islander, and Others, respectively. Minorities (Black, Hispanic, Asian or Pacific Islander, and Others) had a higher rate of in-hospital complications, in-hospital procedures, mean LOS, and hospital charges compared to Whites. In contrast, Whites had a higher rate of in-hospital mortality, PC, and DNR. In multivariable analysis, all minorities had higher rate of MV, tracheostomy, transfusions, and gastrostomy compared to Whites, while Hispanics had higher rate of craniectomy and VP shunt; and Asian or Pacific Islander and Others had higher rate of craniectomy. Whites had a higher rate of in-hospital mortality, palliative care, and DNR compared to minorities. In mediation analysis, in-hospital mortality for whites remained high after adjusting with PC and DNR. Conclusion Minorities had greater utilization of lifesaving and life sustaining procedures, and longer LOS. Whites had greater utilization of palliative care, hospice, and higher in-hospital mortality. These results may reflect differences in culture or access to care and deserve further study.
Collapse
Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohammad Rauf A Chaudhry
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Ihtesham A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohtashim A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Paisith Piriyawat
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Anantha R Vellipuram
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Darine Kassar
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| |
Collapse
|
28
|
Assareh H, Stubbs JM, Trinh LTT, Greenaway S, Agar M, Achat HM. Variations in hospital inpatient palliative care service use: a retrospective cohort study. BMJ Support Palliat Care 2018; 10:e27. [PMID: 30409775 DOI: 10.1136/bmjspcare-2018-001578] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/26/2018] [Accepted: 10/03/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Use of palliative care in hospitals for people at end of life varies. We examined rate and time of in-hospital palliative care use and associated interhospital variations. METHODS We used admissions from all hospitals in New South Wales, Australia, within a 12-month period, for a cohort of adults who died in 73 public acute care hospitals between July 2010 and June 2014. Receiving palliative care and its timing were based on recorded use. RESULTS Among 90 696 adults who died, 27% received palliative care, and the care was initiated 7.6 days (mean; SD: 3.3 days) before death. Over the 5-year period, the palliative care rate rose by 58%, varying extent across chronic conditions. The duration of palliative care before death declined by 7%. Patient (demographics, morbidities and service use) and hospital factors (size, location and availability of palliative care unit) explained half of the interhospital variation in outcomes: adjusted IQR in rate and duration of palliative care among hospitals were 23%-39% and 5.2-8.7 days, respectively. Hospitals with higher rates often initiated palliative care earlier (correlation: 0.39; p<0.01). CONCLUSION Despite an increase over time in the palliative care rate, its initiation was late and of brief duration. Palliative care use was associated with patient and hospital characteristics; however, half of the between hospital variation remained unexplained. The observed suboptimal practices and variability indicate the need for expanded and standardised use of palliative care supported by assessment tools, service enhancement and protocols.
Collapse
Affiliation(s)
- Hassan Assareh
- Epidemiology and Health Analytics, Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| | - Joanne M Stubbs
- Epidemiology and Health Analytics, Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| | - Lieu T T Trinh
- Epidemiology and Health Analytics, Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| | - Sally Greenaway
- Western Sydney Local Health District, Westmead Hospital, Westmead, New South Wales, Australia
| | - Meera Agar
- South Western Sydney Local Health District, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.,Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Helen M Achat
- Epidemiology and Health Analytics, Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| |
Collapse
|
29
|
Mrad C, Abougergi MS, Daly B. One Step Forward, Two Steps Back: Trends in Aggressive Inpatient Care at the End of Life for Patients With Stage IV Lung Cancer. J Oncol Pract 2018; 14:e746-e757. [PMID: 30265173 DOI: 10.1200/jop.18.00515] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patients with metastatic lung cancer are treated with palliative intent. Aggressive care at the end of life is a marker of poor-quality care. National trends and factors related to aggressive inpatient care at the end of life for these patients have not been evaluated. METHODS Patients with stage IV lung cancer and a terminal hospitalization were identified in the National Inpatient Sample database between 1998 and 2014. Longitudinal analysis was conducted to determine trends in aggressive inpatient care at the end of life and multivariate logistic regression was performed to determine associations with patient and hospital characteristics. RESULTS A total of 412,946 patients met the inclusion criteria. From 1998 to 2014, the proportion of patients admitted to the intensive care unit (ICU) during the terminal hospitalization increased from 13.3% to 27.9% (P < .001). The ICU stay translated into a higher mean total cost of care (+$18,461; 95% CI, $17,460 to $19,463). Promisingly, palliative care encounters for terminal hospitalizations also increased during this period from 8.7% to 53.0% (P < .01) and were correlated with a decrease in aggressive care at the end of life. However, this did not offset the trend in increased ICU use; mean total costs for a terminal hospitalization increased from $14,000 to $19,500, adjusted for inflation. A multivariable model demonstrates variation by patient and hospital characteristics in aggressive care use. CONCLUSIONS Among patients with metastatic lung cancer there has been a substantial increase in ICU use during terminal hospitalizations, resulting in high cost for the health care system.
Collapse
Affiliation(s)
- Chebli Mrad
- Roswell Park Comprehensive Cancer Center, Buffalo; Memorial Sloan Kettering Cancer Center, New York, NY; University of South Carolina, Greenville, SC
| | - Marwan S Abougergi
- Roswell Park Comprehensive Cancer Center, Buffalo; Memorial Sloan Kettering Cancer Center, New York, NY; University of South Carolina, Greenville, SC
| | - Bobby Daly
- Roswell Park Comprehensive Cancer Center, Buffalo; Memorial Sloan Kettering Cancer Center, New York, NY; University of South Carolina, Greenville, SC
| |
Collapse
|
30
|
Oud L. Patterns of palliative care utilization among patients with end stage liver disease during end-of-life hospitalizations: A population-level analysis. J Crit Care 2018; 48:290-295. [PMID: 30269008 DOI: 10.1016/j.jcrc.2018.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/08/2018] [Accepted: 09/10/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE To investigate the patterns and predictors of palliative care (PC) utilization across ICU- and non ICU-managed patients with end-stage liver disease (ESLD) during end-of-life hospitalization. MATERIALS AND METHODS The Texas Inpatient Public Use Data File was used to perform a retrospective, population-based cohort study of patients with ESLD and end-of-life hospitalization during 2005-2014. PC use among ICU- and non ICU-managed patients was examined. Logistic regression modeling was used to identify predictors of PC. RESULTS We studied 30,301 patients, of which 5484 (18.1%) had reported PC and 24,174 (79.8%) were admitted to ICU. Between 2005 and 2014 PC use among ICU- and non ICU-managed patients increased from 0.5% to 32.9% and 7.1% to 47.0%, respectively, while ICU admission rate rose from 76.5% to 82.9%. PC use was reduced with rising APR-DRG illness severity (adjusted odds ratio, "extreme" vs. "minor" 0.36 [95% confidence interval, 0.24-0.54]), ICU admission (0.60 [0.55-0.65]), and use of mechanical ventilation (0.75 [0.70-0.81]). CONCLUSIONS There was persistent gap in use of PC among ICU-managed patients with ESLD during end-of-life hospitalization. ICU utilization rose, unexpectedly, despite the increasing use of PC in this cohort, and PC utilization was, paradoxically, lower among patients with the highest need.
Collapse
Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX 79763, USA.
| |
Collapse
|
31
|
Chauhan N, Ali SF, Hannawi Y, Hinduja A. Utilization of Hospice Care in Patients With Acute Ischemic Stroke. Am J Hosp Palliat Care 2018; 36:28-32. [DOI: 10.1177/1049909118796796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: A significant percentage of terminally ill patients are discharged to hospice care following a devastating stroke. Objective: We sought to determine the factors associated with hospital discharge to hospice care in a large cohort of patients with stroke. Methods: Using the institutional Get With The Guidelines-Stroke database, all consecutive patients with acute ischemic stroke (AIS) who were alive at discharge, from January 2009 until July 2015, were analyzed. Univariate and multivariable statistical analyses were performed to determine the factors associated with discharge to hospice care. Results: Of 2446 patients with AIS, 3.4% died and were excluded of remaining 2363 patients, and 4.2% were discharged to hospice care. Univariate analysis identified patients who were discharged to hospice care to be older, caucasian, Medicare or private insurance, have atrial fibrillation, heart failure and less often had diabetes mellitus or smoked. Altered mentation at presentation and urinary tract infection were more common in patients discharged to hospice. On multivariable analysis, patients transferred to hospice care were older (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.01-1.07; P < .001), had a high National Institute of Health Stroke Scale (NIHSS; OR: 1.15, 95% CI: 1.10-1.20; P < .001), and altered mental status at presentation (OR: 2.42, 95% CI: 1.29-4.55; P < .001). Conclusion: In our study, elderly patients with high NIHSS and altered mental status were identified as factors associated with transition to hospice care following AIS. Prospective studies on the optimal timing of initiation of these consults are needed.
Collapse
Affiliation(s)
- Nabeel Chauhan
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Syed F. Ali
- Department of Neurology, University of Arkansas or Medical Sciences, Little Rock, AR, USA
| | - Yousef Hannawi
- Division of Cerebrovascular and Neurocritical Care, Department of Neurology, Ohio State University, Columbus, OH, USA
| | - Archana Hinduja
- Division of Cerebrovascular and Neurocritical Care, Department of Neurology, Ohio State University, Columbus, OH, USA
| |
Collapse
|
32
|
National Trends (2009–2013) for Palliative Care Utilization for Patients Receiving Prolonged Mechanical Ventilation*. Crit Care Med 2018; 46:1230-1237. [DOI: 10.1097/ccm.0000000000003182] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
33
|
Palliative care in heart failure. Trends Cardiovasc Med 2018; 28:445-450. [PMID: 29735287 DOI: 10.1016/j.tcm.2018.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/04/2018] [Accepted: 02/15/2018] [Indexed: 12/31/2022]
Abstract
Palliative care (PC) is now recommended by all major cardiovascular societies for advanced heart failure (HF). PC is a philosophy of care that uses a holistic approach to address physical, psychosocial, and spiritual needs in patients with a terminal disease process. In HF, PC has been shown to improve symptoms and quality of life, facilitate advanced care planning, decrease hospital readmissions, and decrease hospital-associated healthcare costs. Although PC is still underutilized in HF, uptake is increasing. Specific strategies for successfully implementing PC in HF include early PC involvement, multidisciplinary collaboration, exploring patient values for end-of-life care, medical therapy (including both the addition of symptom-directed medications, as well as the removal of life-prolonging medications), and considerations regarding device therapy and mechanical support. Barriers to PC in HF include difficulties predicting the disease trajectory, patient and physician misconceptions, and lack of PC-trained physicians. Moving forward, PC will continue to be a key part of advanced HF care as our knowledge of this area grows.
Collapse
|
34
|
Albaeni A, Chandra-Strobos N, Eid SM. Palliative care utilization following out-of-hospital cardiac arrest in the United States. Resuscitation 2018; 124:112-117. [PMID: 29337174 DOI: 10.1016/j.resuscitation.2018.01.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/06/2018] [Accepted: 01/10/2018] [Indexed: 01/08/2023]
Abstract
AIMS Palliative care (PC) has become an integral component of comprehensive care provided to critically ill patients. Little is known about the utilization of palliative care following Out-of-Hospital Cardiac Arrest (OHCA) in the United States. METHODS We used the 2002-2013 National Inpatient Sample database to identify adults ≥18 years old with an ICD-9-CM principal diagnosis code of cardio-respiratory arrest or ventricular fibrillation (VF). Patients were categorized into two groups based on the presence of PC, then compared using Pearson χ2 test for categorical variables and linear regression for continuous variables. Multiple linear and logistic regression models were conducted to identify factors associated with PC, and temporal trends in PC utilization. RESULTS Of the 154,177 patients hospitalized with OHCA in the U.S, 11,260 (7.3%) had PC consultations during hospitalization. PC Utilization increased from 1.5% in 2002 to 16.7% in 2013 (P-trend < 0.001). Patients who received Palliative care were older (mean age 70.7 ± 0.3 vs 65.9 ± 0.1), more likely to be female (45.8% vs 40.5%), and had higher Charlson comorbidity index ≥2 (55.8% vs 46.8%). In adjusted analyses, older age, female gender, Caucasian race, higher Charlson comorbidity index, multiorgan failure, metastatic cancer, non-shockable rhythm, admission to larger, urban and teaching hospitals were all associated with higher PC utilization. CONCLUSION We observed significant increase in the utilization of palliative care consultations following OHCA over the study period. This was influenced by multiple patient and hospital factors. Further investigations are needed to identify the appropriate cost-effective use of palliative care following cardiac arrest.
Collapse
Affiliation(s)
- Aiham Albaeni
- Department of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555-0570, USA.
| | | | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| |
Collapse
|
35
|
Feder SL, Redeker NS, Jeon S, Schulman-Green D, Womack JA, Tate JP, Bedimo RJ, Budoff MJ, Butt AA, Crothers K, Akgün KM. Validation of the ICD-9 Diagnostic Code for Palliative Care in Patients Hospitalized With Heart Failure Within the Veterans Health Administration. Am J Hosp Palliat Care 2017; 35:959-965. [PMID: 29254358 DOI: 10.1177/1049909117747519] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patients with heart failure (HF) are at increased risk of unmet palliative care needs. The International Classification of Diseases, Ninth Revision ( ICD-9) code, V66.7, can identify palliative care services. However, code validity for specialist palliative care in the Veterans Health Administration (VHA) has not been determined. OBJECTIVE To validate the ICD-9 code for specialist palliative care and determine common reasons for specialist palliative care consultation among VHA patients hospitalized with HF. DESIGN Electronic health record review of data from the Veterans Aging Cohort Study. SETTING/PARTICIPANTS The sample included 100 patients hospitalized with HF from 2003 to 2012. MEASUREMENTS Data from 50 patients with V66.7 were matched by age, race, site of care, hospital length of stay, intensive care unit admission, and fiscal year of study discharge to 50 patients with HF without V66.7 who had died within a year of hospitalization. We calculated positive and negative predictive values (PPV, NPV), sensitivity, and specificity. RESULTS All patients included in the sample were male, 66% black ethnicity, and mean age = 65 years (standard deviations [SD] ± 10.5 for cases; SD ± 9.8 for matches). Specialist palliative care was documented for 49 of 50 patients with V66.7 (PPV = 98%, 95% confidence interval [CI]: 88-99) and 9 of 50 patients without the code (NPV = 82%, 95% CI: 68-91). Sensitivity was 84% (95% CI: 72-92), and specificity was 98% (95% CI: 86-99). Establishing goals of care was the most frequent reason for palliative care consultation (43% of the sample). CONCLUSION The ICD-9 code V66.7 identifies specialist palliative care for hospitalized patients with HF in the VHA. Replication of findings in other data sources and populations is needed.
Collapse
Affiliation(s)
- Shelli L Feder
- 1 Yale School of Nursing, Yale University West Campus, West Haven, CT, USA
| | - Nancy S Redeker
- 1 Yale School of Nursing, Yale University West Campus, West Haven, CT, USA
| | - Sangchoon Jeon
- 1 Yale School of Nursing, Yale University West Campus, West Haven, CT, USA
| | | | - Julie A Womack
- 1 Yale School of Nursing, Yale University West Campus, West Haven, CT, USA.,2 VA Connecticut Healthcare System, West Haven, CT, USA
| | - Janet P Tate
- 2 VA Connecticut Healthcare System, West Haven, CT, USA
| | - Roger J Bedimo
- 3 Department of Medicine, Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Matthew J Budoff
- 4 Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
| | - Adeel A Butt
- 5 Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kristina Crothers
- 6 Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Kathleen M Akgün
- 2 VA Connecticut Healthcare System, West Haven, CT, USA.,7 Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
36
|
Faigle R, Ziai WC, Urrutia VC, Cooper LA, Gottesman RF. Racial Differences in Palliative Care Use After Stroke in Majority-White, Minority-Serving, and Racially Integrated U.S. Hospitals. Crit Care Med 2017; 45:2046-2054. [PMID: 29040110 PMCID: PMC5693642 DOI: 10.1097/ccm.0000000000002762] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Racial/ethnic differences in palliative care resource use after stroke have been recognized, but it is unclear whether patient or hospital characteristics drive this disparity. We sought to determine whether palliative care use after intracerebral hemorrhage and ischemic stroke differs between hospitals serving varying proportions of minority patients. DESIGN Population-based cross-sectional study. SETTING Inpatient hospital admissions from the Nationwide Inpatient Sample between 2007 and 2011. PATIENTS A total of 46,735 intracerebral hemorrhage and 331,521 ischemic stroke cases. INTERVENTIONS Palliative care use. MEASUREMENTS AND MAIN RESULTS Intracerebral hemorrhage and ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic minority stroke patients (< 25% minorities ["white hospitals"], 25-50% minorities ["mixed hospitals"], or > 50% minorities ["minority hospitals"]). Logistic regression was used to evaluate the association between race/ethnicity and palliative care use within and between the different hospital strata. Stroke patients receiving care in minority hospitals had lower odds of palliative care compared with those treated in white hospitals, regardless of individual patient race/ethnicity (adjusted odds ratio, 0.65; 95% CI, 0.50-0.84 for intracerebral hemorrhage and odds ratio, 0.62; 95% CI, 0.50-0.77 for ischemic stroke). Ethnic minorities had a lower likelihood of receiving palliative care compared with whites in any hospital stratum, but the odds of palliative care for both white and minority intracerebral hemorrhage patients was lower in minority compared with white hospitals (odds ratio, 0.66; 95% CI, 0.50-0.87 for white and odds ratio, 0.64; 95% CI, 0.46-0.88 for minority patients). Similar results were observed in ischemic stroke. CONCLUSIONS The odds of receiving palliative care for both white and minority stroke patients is lower in minority compared with white hospitals, suggesting system-level factors as a major contributor to explain race disparities in palliative care use after stroke.
Collapse
Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Wendy C. Ziai
- Department of Neurology, Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Victor C. Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lisa A. Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Rebecca F. Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| |
Collapse
|
37
|
Rosenfeld EB, Chan JK, Gardner AB, Curry N, Delic L, Kapp DS. Disparities Associated With Inpatient Palliative Care Utilization by Patients With Metastatic Gynecologic Cancers: A Study of 3337 Women. Am J Hosp Palliat Care 2017; 35:697-703. [DOI: 10.1177/1049909117736750] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Emily B. Rosenfeld
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
- Division of Gynecologic Oncology, New York Medical College, Valhalla, NY, USA
| | - John K. Chan
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Austin B. Gardner
- Division of Gynecologic Oncology, Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
- Division of Gynecologic Oncology, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Natasha Curry
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Lejla Delic
- Division of Gynecologic Oncology, California Pacific Palo Alto Medical Foundation, Sutter Research Institute, San Francisco, CA, USA
| | - Daniel S. Kapp
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
38
|
Chong K, Silver SA, Long J, Zheng Y, Pankratz VS, Unruh ML, Chertow GM. Infrequent Provision of Palliative Care to Patients with Dialysis-Requiring AKI. Clin J Am Soc Nephrol 2017; 12:1744-1752. [PMID: 29042462 PMCID: PMC5672958 DOI: 10.2215/cjn.00270117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 07/05/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The use of palliative care in AKI is not well described. We sought to better understand palliative care practice patterns for hospitalized patients with AKI requiring dialysis in the United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the 2012 National Inpatient Sample, we identified patients with AKI and palliative care encounters using validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared palliative care encounters in patients with AKI requiring dialysis, patients with AKI not requiring dialysis, and patients without AKI. We described the provision of palliative care in patients with AKI requiring dialysis and compared the frequency of palliative care encounters for patients with AKI requiring dialysis with that for patients with other illnesses with similarly poor prognoses. We used logistic regression to determine factors associated with the provision of palliative care, adjusting for demographics, hospital-level variables, and patient comorbidities. RESULTS We identified 3,031,036 patients with AKI, of whom 91,850 (3%) received dialysis. We observed significant patient- and hospital-level differences in the provision of palliative care for patients with AKI requiring dialysis; adjusted odds were 26% (95% confidence interval, 12% to 38%) lower in blacks and 23% (95% confidence interval, 3% to 39%) lower in Hispanics relative to whites. Lower provision of palliative care was observed for rural and urban nonteaching hospitals relative to urban teaching hospitals, small and medium hospitals relative to large hospitals, and hospitals in the Northeast compared with the South. After adjusting for age and sex, there was low utilization of palliative care services for patients with AKI requiring dialysis (8%)-comparable with rates of utilization by patients with other illnesses with poor prognosis, including cardiogenic shock (9%), intracranial hemorrhage (10%), and acute respiratory distress syndrome (10%). CONCLUSIONS The provision of palliative care varied widely by patient and facility characteristics. Palliative care was infrequently used in hospitalized patients with AKI requiring dialysis, despite its poor prognosis and the regular application of life-sustaining therapy.
Collapse
Affiliation(s)
- Kelly Chong
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Samuel A. Silver
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Jin Long
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Yuanchao Zheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - V. Shane Pankratz
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Mark L. Unruh
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| |
Collapse
|
39
|
Widger K, Vadeboncoeur C, Zelcer S, Liu Y, Kassam A, Sutradhar R, Rapoport A, Nelson K, Wolfe J, Earle C, Pole JD, Gupta S. The Validity of Using Health Administrative Data To Identify the Involvement of Specialized Pediatric Palliative Care Teams in Children with Cancer in Ontario, Canada. J Palliat Med 2017; 20:1210-1216. [DOI: 10.1089/jpm.2017.0028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kimberley Widger
- Paediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Christina Vadeboncoeur
- Palliative Care Team, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Roger Neilson House Children's Hospice, Ottawa, Ontario, Canada
| | - Shayna Zelcer
- Hematology and Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Ying Liu
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Alisha Kassam
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Southlake Regional Health Centre, Newmarket, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Adam Rapoport
- Paediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Emily's House Children's Hospice, Toronto, Ontario, Canada
| | - Katherine Nelson
- Paediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Craig Earle
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jason D. Pole
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Pediatric Oncology Group of Ontario, Toronto, Ontario, Canada
| | - Sumit Gupta
- Cancer Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
40
|
Rush B, Walley KR, Celi LA, Rajoriya N, Brahmania M. Palliative care access for hospitalized patients with end-stage liver disease across the United States. Hepatology 2017; 66:1585-1591. [PMID: 28660622 DOI: 10.1002/hep.29297] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 02/28/2017] [Accepted: 05/20/2017] [Indexed: 12/12/2022]
Abstract
UNLABELLED Patients with end-stage liver disease (ESLD) often have a high symptom burden. Historically, palliative care (PC) services have been underused in this population. We investigated the use of PC services in patients with ESLD hospitalized across the United States. We used the Nationwide Inpatient Sample to conduct a retrospective nationwide cohort analysis. All patients >18 years of age admitted with ESLD, defined as those with at least two liver decompensation events, were included in the analysis. A multivariate logistic regression model predicting referral to PC was created. We analyzed 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Sample, with 39,349 (0.07%) patients meeting study inclusion. PC consultation was performed in 1,789 (4.5%) ESLD patients. The rate of PC referral in ESLD increased from 0.97% in 2006 to 7.1% in 2012 (P < 0.01). In multivariate analysis, factors associated with lower referral to PC were Hispanic race (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.66-0.89; P < 0.01) and insurance coverage (OR, 0.74; 95% CI, 0.65-0.84; P < 0.01). Factors associated with increased referral to PC were age (per 5-year increase, OR, 1.05; 95% CI, 1.03-1.08; P < 0.01), do-not-resuscitate status (OR, 16.24; 95% CI, 14.20-18.56; P < 0.01), treatment in a teaching hospital (OR, 1.25; 95% CI, 1.12-1.39; P < 0.01), presence of hepatocellular carcinoma (OR, 2.00; 95% CI, 1.71-2.33; P < 0.01), and presence of metastatic cancer (OR, 2.39; 95% CI, 1.80-3.18; P < 0.01). PC referral was most common in west coast hospitals (OR, 1.81; 95% CI, 1.53-2.14; P < 0.01) as well as large-sized hospitals (OR, 1.49; 95% CI, 1.22-1.82; P < 0.01). CONCLUSION From 2006 to 2012 the use of PC in ESLD patients increased substantially; socioeconomic, geographical, and ethnic barriers to accessing PC were observed. (Hepatology 2017;66:1585-1591).
Collapse
Affiliation(s)
- Barret Rush
- Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.,Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA.,Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Keith R Walley
- Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Leo A Celi
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Neil Rajoriya
- Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Mayur Brahmania
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA.,Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
41
|
Wiskar K, Celi LA, Walley KR, Fruhstorfer C, Rush B. Inpatient palliative care referral and 9-month hospital readmission in patients with congestive heart failure: a linked nationwide analysis. J Intern Med 2017; 282:445-451. [PMID: 28741859 DOI: 10.1111/joim.12657] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE End-stage heart failure (HF) is characterized by high symptom burden and frequent hospitalization. Palliative care (PC) is recommended for advanced HF, and there is some evidence in other diseases that this may reduce readmission rates. We attempted examine the association of an inpatient PC visit on hospital readmission for patients admitted with HF. METHODS Retrospective linked nationwide analysis from 2013 with 9-month follow-up for all hospital readmissions for patients admitted with HF exacerbations using the Nationwide Readmission Database (NRD). The NRD gathers all hospital admissions for patients from 22 states and tracks patients throughout the year, allowing for examination of readmission statistics. A propensity score model for PC visit was made, and patients were matched in a 1 : 1 fashion. RESULTS There were 102 746 patients who survived an admission for HF in the first 3 months of 2013. Of these, 2287 (2.2%) patients had a PC visit as inpatients. After matching based on propensity for a PC visit during the index hospitalization, 2282 patients who received a PC visit were matched to 2282 patients who did not. Those receiving a PC visit were less likely to be readmitted for HF (9.3% vs. 22.4%, P < 0.01) or for any cause (29.0% vs. 63.2%, P < 0.01) during the 9-month follow-up period. The average hospital charges during the follow-up period for the non-PC cohort were $77 643 per patient. The average charges for PC patients were $23 200 (P < 0.01). CONCLUSIONS Patients with HF who received an inpatient PC visit had significantly lower rates of all-cause and HF-specific readmission in the subsequent 9 months. Total 9-month hospital charges were also significantly lower for patients who received an inpatient PC visit.
Collapse
Affiliation(s)
- K Wiskar
- Department of Medicine, Division of General Internal Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - L A Celi
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K R Walley
- Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, BC, Canada
| | - C Fruhstorfer
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - B Rush
- Department of Medicine, Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, BC, Canada.,Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| |
Collapse
|
42
|
Murthy SB, Moradiya Y, Shah J, Merkler AE, Mangat HS, Iadacola C, Hanley DF, Kamel H, Ziai WC. Nosocomial Infections and Outcomes after Intracerebral Hemorrhage: A Population-Based Study. Neurocrit Care 2017; 25:178-84. [PMID: 27350549 DOI: 10.1007/s12028-016-0282-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infections after intracerebral hemorrhage (ICH) may be associated with worse outcomes. We aimed to evaluate the association between nosocomial infections (>48 h) and outcomes of ICH at a population level. METHODS We identified patients with ICH using ICD-9-CM codes in the 2002-2011 Nationwide Inpatient Sample. Demographics, comorbidities, surgical procedures, and hospital characteristics were compared between patients with and without concomitant nosocomial infections. Primary outcomes were in-hospital mortality and home discharge. Secondary outcome was permanent cerebrospinal shunt placement. Logistic regression analyses were used to analyze the association between infections and outcomes. RESULTS Among 509,516 ICH patients, infections occurred in 117,636 (23.1 %). Rates of infections gradually increased from 18.7 % in 2002-2003 to 24.1 % in 2010-2011. Pneumonia was the most common nosocomial infection (15.4 %) followed by urinary tract infection (UTI) (7.9 %). Patients with infections were older (p < 0.001), predominantly female (56.9 % vs. 47.9 %, p < 0.001), and more often black (15.0 % vs. 13.4 %, p < 0.001). Nosocomial infection was associated with longer hospital stay (11 vs. 5 days, p < 0.001) and a more than twofold higher cost of care (p < 0.001). In the adjusted regression analysis, patients with infection had higher odds of mortality [odds ratio (OR) 2.11, 95 % CI 2.08-2.14] and cerebrospinal shunt placement (OR 2.19, 95 % CI 2.06-2.33) and lower odds of home discharge (OR 0.49, 95 % CI 0.47-0.51). Similar results were observed in subgroup analyses of individual infections. CONCLUSIONS In a nationally representative cohort of ICH patients, nosocomial infection was associated with worse outcomes and greater resource utilization.
Collapse
Affiliation(s)
- Santosh B Murthy
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA. .,Clinical and Translational Neuroscience Unit, Feil Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.
| | - Yogesh Moradiya
- Department of Neurosurgery, Northwell Long Island Jewish School of Medicine, New York, NY, USA
| | - Jharna Shah
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander E Merkler
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA
| | - Halinder S Mangat
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA
| | - Costantino Iadacola
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA.,Clinical and Translational Neuroscience Unit, Feil Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hooman Kamel
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA.,Clinical and Translational Neuroscience Unit, Feil Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
43
|
Patel AA, Walling AM, May FP, Saab S, Wenger N, Wenger N. Palliative Care and Health Care Utilization for Patients With End-Stage Liver Disease at the End of Life. Clin Gastroenterol Hepatol 2017; 15:1612-1619.e4. [PMID: 28179192 PMCID: PMC5544588 DOI: 10.1016/j.cgh.2017.01.030] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 01/21/2017] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There has been increased attention on ways to improve the quality of end-of-life care for patients with end-stage liver disease; however, there have been few reports of care experiences for patients during terminal hospitalizations. We analyzed data from a large national database to increase our understanding of palliative care for and health care utilization by patients with end-stage liver disease. METHODS We performed a cross-sectional, observational study to examine terminal hospitalizations of adults with decompensated cirrhosis using data from the National Inpatient Sample from 2009 through 2013. We collected data on palliative care consultation and total hospital costs, and performed multivariate regression analyses to identify factors associated with palliative care consultation. We also investigated whether consultation was associated with lower costs. RESULTS Among hospitalized adults with terminal decompensated cirrhosis, 30.3% received palliative care; the mean cost per hospitalization was $48,551 ± $1142. Palliative care consultation increased annually, and was provided to 18.0% of patients in 2009 and to 36.6% of patients in 2013 (P < .05). The mean cost for the terminal hospitalization did not increase significantly ($47,969 in 2009 to $48,956 in 2013, P = .77). African Americans, Hispanics, Asians, and liver transplant candidates were less likely to receive palliative care, whereas care in large urban teaching hospitals was associated with a higher odds of receiving consultation. Palliative care was associated with lower procedure burden-after adjusting for other factors, palliative care was associated with a cost reduction of $10,062. CONCLUSIONS Palliative care consultation for patients with end-stage liver disease increased from 2009 through 2013. Palliative care consultation during terminal hospitalizations is associated with lower costs and procedure burden. Future research should evaluate timing and effects of palliative care on quality of end-of-life care in this population.
Collapse
Affiliation(s)
- Arpan A. Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, CA,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Anne M. Walling
- Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, CA,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Folasade P. May
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, CA,Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Sammy Saab
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, CA,Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Neil Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Neil Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California
| |
Collapse
|
44
|
Singh T, Peters SR, Tirschwell DL, Creutzfeldt CJ. Palliative Care for Hospitalized Patients With Stroke: Results From the 2010 to 2012 National Inpatient Sample. Stroke 2017; 48:2534-2540. [PMID: 28818864 PMCID: PMC5571885 DOI: 10.1161/strokeaha.117.016893] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Substantial variability exists in the use of life-prolonging treatments for patients with stroke, especially near the end of life. This study explores patterns of palliative care utilization and death in hospitalized patients with stroke across the United States. METHODS Using the 2010 to 2012 nationwide inpatient sample databases, we included all patients discharged with stroke identified by International Classification of Diseases-Ninth Revision codes. Strokes were subclassified as ischemic, intracerebral, and subarachnoid hemorrhage. We compared demographics, comorbidities, procedures, and outcomes between patients with and without a palliative care encounter (PCE) as defined by the International Classification of Diseases-Ninth Revision code V66.7. Pearson χ2 test was used for categorical variables. Multivariate logistic regression was used to account for hospital, regional, payer, and medical severity factors to predict PCE use and death. RESULTS Among 395 411 patients with stroke, PCE was used in 6.2% with an increasing trend over time (P<0.05). We found a wide range in PCE use with higher rates in patients with older age, hemorrhagic stroke types, women, and white race (all P<0.001). Smaller and for-profit hospitals saw lower rates. Overall, 9.2% of hospitalized patients with stroke died, and PCE was significantly associated with death. Length of stay in decedents was shorter for patients who received PCE. CONCLUSIONS Palliative care use is increasing nationally for patients with stroke, especially in larger hospitals. Persistent disparities in PCE use and mortality exist in regards to age, sex, race, region, and hospital characteristics. Given the variations in PCE use, especially at the end of life, the use of mortality rates as a hospital quality measure is questioned.
Collapse
Affiliation(s)
- Tarvinder Singh
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle.
| | - Steven R Peters
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - David L Tirschwell
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - Claire J Creutzfeldt
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| |
Collapse
|
45
|
Wiskar KJ, Celi LA, McDermid RC, Walley KR, Russell JA, Boyd JH, Rush B. Patterns of Palliative Care Referral in Patients Admitted With Heart Failure Requiring Mechanical Ventilation. Am J Hosp Palliat Care 2017; 35:620-626. [DOI: 10.1177/1049909117727455] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Katie J. Wiskar
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Robert C. McDermid
- Department of Critical Care Medicine, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Keith R. Walley
- Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, British Columbia, Canada
- Division of Critical Care Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - James A. Russell
- Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, British Columbia, Canada
- Division of Critical Care Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - John H. Boyd
- Centre for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, British Columbia, Canada
- Division of Critical Care Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Barret Rush
- Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Critical Care Medicine, Surrey Memorial Hospital, Surrey, British Columbia, Canada
- Division of Critical Care Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| |
Collapse
|
46
|
Witjes M, Kotsopoulos A, Herold IHF, Otterspoor L, Simons KS, van Vliet J, de Blauw M, Festen B, Eijkenboom JJA, Jansen NE, van der Hoeven JG, Abdo WF. The Influence of End-of-Life Care on Organ Donor Potential. Am J Transplant 2017; 17:1922-1927. [PMID: 28371278 DOI: 10.1111/ajt.14286] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/16/2017] [Accepted: 03/18/2017] [Indexed: 01/25/2023]
Abstract
Many patients with acute devastating brain injury die outside intensive care units and could go unrecognized as potential organ donors. We conducted a prospective observational study in seven hospitals in the Netherlands to define the number of unrecognized potential organ donors outside intensive care units, and to identify the effect that end-of-life care has on organ donor potential. Records of all patients who died between January 2013 and March 2014 were reviewed. Patients were included if they died within 72 h after hospital admission outside the intensive care unit due to devastating brain injury, and fulfilled the criteria for organ donation. Physicians of included patients were interviewed using a standardized questionnaire regarding logistics and medical decisions related to end-of-life care. Of the 5170 patients screened, we found 72 additional potential organ donors outside intensive care units. Initiation of end-of-life care in acute settings and lack of knowledge and experience in organ donation practices outside intensive care units can result in under-recognition of potential donors equivalent to 11-34% of the total pool of organ donors. Collaboration with the intensive care unit and adjusting the end-of-life path in these patients is required to increase the likelihood of organ donation.
Collapse
Affiliation(s)
- M Witjes
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands.,Dutch Transplant Foundation, Leiden, The Netherlands
| | - A Kotsopoulos
- Department of Intensive Care, St. Elisabeth hospital, Tilburg, The Netherlands
| | - I H F Herold
- Department of Intensive Care, Catharina hospital, Eindhoven, The Netherlands
| | - L Otterspoor
- Department of Intensive Care, Catharina hospital, Eindhoven, The Netherlands
| | - K S Simons
- Department of Intensive Care, Jeroen Bosch hospital, Den Bosch, The Netherlands
| | - J van Vliet
- Department of Intensive Care, Rijnstate hospital, Arnhem, The Netherlands
| | - M de Blauw
- Department of Intensive Care, Rijnstate hospital, Arnhem, The Netherlands
| | - B Festen
- Department of Intensive Care, Gelderse Vallei hospital, Ede, The Netherlands
| | - J J A Eijkenboom
- Department of Intensive Care, Maxima medical center, Veldhoven, The Netherlands
| | - N E Jansen
- Dutch Transplant Foundation, Leiden, The Netherlands
| | - J G van der Hoeven
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - W F Abdo
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands
| |
Collapse
|
47
|
Rush B, Berger L, Anthony Celi L. Access to Palliative Care for Patients Undergoing Mechanical Ventilation With Idiopathic Pulmonary Fibrosis in the United States. Am J Hosp Palliat Care 2017; 35:492-496. [PMID: 28602096 DOI: 10.1177/1049909117713990] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The utilization of palliative care (PC) in patients with end-stage idiopathic pulmonary fibrosis (IPF) is not well understood. METHODS The Nationwide Inpatient Sample (NIS) was utilized to examine the use of PC in mechanically ventilated (MV) patients with IPF. The NIS captures 20% of all US inpatient hospitalizations and is weighted to estimate 95% of all inpatient care. RESULTS A total of 55 208 382 hospital admissions from the 2006 to 2012 NIS samples were examined. There were 21 808 patients identified with pulmonary fibrosis, of which 3166 underwent mechanical ventilation and were included in the analysis. Of the 3166 patients in the main cohort, 408 (12.9%) had an encounter with PC, whereas 2758 (87.1%) did not. After multivariate logistic regression modeling, variables associated with increased access to PC referral were age (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01-1.03, P < .01), treatment in an urban teaching hospital (OR: 1.49, 95% CI: 1.27-3.58, P < .01), and do-not-resuscitate status (OR: 9.86, 95% CI: 7.48-13.00, P < .01). Factors associated with less access to PC were Hispanic race (OR: 0.64, 95% CI: 0.41-0.99, P = .04) and missing race (OR: 0.52, 95% CI: 0.34-0.79, P < .01), with white race serving as the reference. The use of PC has increased almost 10-fold from 2.3% in 2006 to 21.6% in 2012 ( P < .01). CONCLUSION The utilization of PC in patients with IPF who undergo MV has increased dramatically between 2006 and 2012.
Collapse
Affiliation(s)
- Barret Rush
- 1 Division of Critical Care Medicine, St Pauls Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,2 Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Landon Berger
- 1 Division of Critical Care Medicine, St Pauls Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,3 Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | | |
Collapse
|
48
|
Murthy SB, Merkler AE, Omran SS, Gialdini G, Gusdon A, Hartley B, Roh D, Mangat HS, Iadecola C, Navi BB, Kamel H. Outcomes after intracerebral hemorrhage from arteriovenous malformations. Neurology 2017; 88:1882-1888. [PMID: 28424275 DOI: 10.1212/wnl.0000000000003935] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare outcomes after intracerebral hemorrhage (ICH) from cerebral arteriovenous malformation (AVM) rupture and other causes of ICH. METHODS We performed a retrospective population-based study using data from the Nationwide Inpatient Sample. We used standard diagnosis codes to identify ICH cases from 2002 to 2011. Our predictor variable was cerebral AVM. Our primary outcomes were inpatient mortality and home discharge. We used logistic regression to compare outcomes between patients with ICH with and without AVM while adjusting for demographics, comorbidities, and hospital characteristics. In a confirmatory analysis using a prospective cohort of patients hospitalized with ICH at our institution, we additionally adjusted for hematoma characteristics and the Glasgow Coma Scale score. RESULTS Among 619,167 ICH hospitalizations, the 4,485 patients (0.7%, 95% confidence interval [CI] 0.6-0.8) with an AVM were younger and had fewer medical comorbidities than patients without AVM. After adjustment for confounders, patients with AVM had lower odds of death (odds ratio [OR] 0.5, 95% CI 0.4-0.7) and higher odds of home discharge (OR 2.0, 95% CI 1.4-3.0) than patients without AVM. In a confirmatory analysis of 342 patients with ICH at our institution, the 34 patients (9.9%, 95% CI 7.2-13.6) with a ruptured AVM had higher odds of ambulatory independence at discharge (OR 4.4, 95% CI 1.4-13.1) compared to patients without AVM. CONCLUSIONS Patients with ICH due to ruptured AVM have more favorable outcomes than patients with ICH from other causes.
Collapse
Affiliation(s)
- Santosh B Murthy
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY.
| | - Alexander E Merkler
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Setareh Salehi Omran
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Gino Gialdini
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Aaron Gusdon
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Benjamin Hartley
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - David Roh
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Halinder S Mangat
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Costantino Iadecola
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Babak B Navi
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Hooman Kamel
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| |
Collapse
|
49
|
Howell ML, Schwab K, Ayres AM, Shapley D, Anderson CD, Gurol ME, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN. Chaplaincy Visitation and Spiritual Care after Intracerebral Hemorrhage. J Health Care Chaplain 2017; 23:156-166. [PMID: 28394726 DOI: 10.1080/08854726.2017.1304726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
To better understand factors influencing spiritual care during critical illness, we examined the use of spiritual care in patients hospitalized with intracerebral hemorrhage (ICH), a frequently disabling and fatal disease. Specifically, the study was designed to examine which demographic and clinical characteristics were associated with chaplain visits to critically ill patients. The charts of consecutive adults (>18) with spontaneous ICH presenting to a single academic medical center between January 2014 and September 2015 were reviewed. Chaplains visited 86 (32%) of the 266 patients. Family requests initiated the majority of visits (57%). Visits were disproportionately to Catholic patients and those with more severe injury. Even among Catholics, 28% of those who died had no chaplaincy visit. Standardized chaplaincy screening methods and note templates may help maximize access to spiritual care and delineate the religious and spiritual preferences of patients and families.
Collapse
Affiliation(s)
- Melissa L Howell
- a Department of Emergency Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Kristin Schwab
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Alison M Ayres
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Dean Shapley
- c Department of Chaplaincy , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Christopher D Anderson
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - M Edip Gurol
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Anand Viswanathan
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Steven M Greenberg
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Jonathan Rosand
- b Department of Neurology, J. Philip Kistler Stroke Research Center , Massachusetts General Hospital , Boston , Massachusetts , USA
| | - Joshua N Goldstein
- a Department of Emergency Medicine , Massachusetts General Hospital , Boston , Massachusetts , USA
| |
Collapse
|
50
|
Hua M, Li G, Clancy C, Morrison RS, Wunsch H. Validation of the V66.7 Code for Palliative Care Consultation in a Single Academic Medical Center. J Palliat Med 2016; 20:372-377. [PMID: 27925839 DOI: 10.1089/jpm.2016.0363] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Use of administrative data to study the effectiveness of specialized palliative care is limited by the lack of a reliable method to identify patients receiving palliative care consultation. The International Classification of Diseases, Ninth Revision (ICD-9) code V66.7 has been used, but its validity for this purpose is unknown. OBJECTIVE To examine the validity of the ICD-9 code V66.7 for identifying whether hospitalized patients received palliative care consultation. DESIGN Retrospective cohort study. SETTING/SUBJECTS All patients of age ≥18 years admitted to a single academic medical center between August 2013 and August 2015. MEASUREMENTS Sensitivity and specificity of the V66.7 code for palliative care consultation for all patients and several a priori identified subgroups. The reference standard was the presence of a palliative care consultation note in the electronic medical record. RESULTS Of 100,910 admissions, 1999 received a palliative care consultation (2.0%) and 1846 (1.8%) had usage of the V66.7 code. Sensitivity and specificity for the V66.7 code were 49.9% and 99.1%, respectively. Sensitivity was considerably higher for certain subgroups, such as patients with dementia (76.3%) and metastatic cancer (66.3%); addition of age restrictions further improved sensitivity while maintaining high specificity. Specificity was substantially lower for patients who died during hospitalization (sensitivity 53.9%, specificity 75.1%). CONCLUSIONS In a single center, the ICD-9 code V66.7 had poor sensitivity and high specificity for identifying hospitalized patients who received a palliative care consultation. Appropriate use of this code for this purpose should take these characteristics into consideration.
Collapse
Affiliation(s)
- May Hua
- 1 Department of Anesthesiology, Columbia University , New York, New York.,2 Department of Epidemiology, Columbia University Mailman School of Public Health , New York, New York
| | - Guohua Li
- 2 Department of Epidemiology, Columbia University Mailman School of Public Health , New York, New York.,3 Department of Anesthesiology, Center for Health Policy and Outcomes in Anesthesia and Critical Care, Columbia University College of Physicians and Surgeons
| | - Caitlin Clancy
- 1 Department of Anesthesiology, Columbia University , New York, New York
| | - R Sean Morrison
- 4 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Hannah Wunsch
- 1 Department of Anesthesiology, Columbia University , New York, New York.,5 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre , Toronto, Ontario, Canada .,6 Department of Anesthesia, University of Toronto , Toronto, Ontario, Canada
| |
Collapse
|