Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT

Equity evaluation of intensive care unit admission based on comorbidity in hospitalized patients with COVID-19: a cross-sectional analysis

Background

Intensive care unit (ICU) beds played a crucial role in reducing mortality rates of patients with severe COVID-19. The surge in the number of patients led to a shortage of ICU beds, which may have exacerbated inequity of healthcare utilization. However, most attention has been focused on the horizontal equity in healthcare utilization, where individuals with the same needs receive the same services. Vertical equity, where individuals with higher needs receive more healthcare is often neglected, which might overestimate the equity. This study analyzes the vertical equity of ICU utilization among hospitalized patients with COVID-19.

Methods

In total, 18,547 hospitalized patients with COVID-19 in Maryland in 2020 were enrolled in this cross-sectional study. Logistic regression analysis was conducted to determine the independent factors affecting ICU utilization, and the Shapley value decomposition approach was implemented to assess the contribution of the independent variables to disparities in ICU admission. A concentration curve and concentration index were used to assess the vertical equity in healthcare utilization.

Results

ICU utilization by patients with COVID-19 was significantly affected by Charlson Comorbidity Index (CCI), with odds ratios (OR) 1.09 [95% confidence intervals (CI): 1.07-1.10; p < 0.001] in univariable analysis and 1.11 (95% CI: 1.09-1.13; p < 0.001) in multivariable regression analysis. The most important contributors were household income (32.27%) and the CCI (22.89%) in the Shapley value decomposition analysis. The concentration curve was below the line of equity, and the concentration index was 0.094 (95% CI: 0.076-0.111; p < 0.001), indicating that ICU utilization was concentrated among patients with a high CCI. These results were robust for all subgroup analyses.

Conclusion

Among 18,547 hospitalized patients with COVID-19 in Maryland in 2020, ICU utilization was significantly affected by comorbid conditions. The concentration curve and concentration index also indicated that ICU utilization was more concentrated in patients with a higher CCI. The results was consistent with the principle of vertical equity, whereby healthcare resources are more concentrated on COVID-19 patients with higher health needs.

Patient and Hospital Characteristics Associated With the Interhospital Transfer of Adult Patients With Sepsis

IMPORTANCE

The interhospital transfer (IHT) of patients with sepsis to higher-capability hospitals may improve outcomes. Little is known about patient and hospital factors associated with sepsis IHT.

OBJECTIVES

We evaluated patterns of hospitalization and IHT and determined patient and hospital factors associated with the IHT of adult patients with sepsis.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

A total of 349,938 adult patients with sepsis at 329 nonfederal hospitals in California, 2018-2019.

MAIN OUTCOMES AND MEASURES

We evaluated patterns of admission and outward IHT between low sepsis-, intermediate sepsis-, and high sepsis-capability hospitals. We estimated odds of IHT using generalized estimating equations logistic regression with bootstrap stepwise variable selection.

RESULTS

Among the cohort, 223,202 (66.4%) were initially hospitalized at high-capability hospitals and 10,870 (3.1%) underwent IHT. Nearly all transfers (98.2%) from low-capability hospitals were received at higher-capability hospitals. Younger age (< 65 yr) (adjusted odds ratio [aOR] 1.54; 95% CI, 1.40-1.69) and increasing organ dysfunction (aOR 1.22; 95% CI, 1.19-1.25) were associated with higher IHT odds, as were admission to low-capability (aOR 2.79; 95% CI, 2.33-3.35) or public hospitals (aOR 1.35; 95% CI, 1.09-1.66). Female sex (aOR 0.88; 95% CI, 0.84-0.91), Medicaid insurance (aOR 0.59; 95% CI, 0.53-0.66), home to admitting hospital distance less than or equal to 10 miles (aOR 0.92; 95% CI, 0.87-0.97) and do-not-resuscitate orders (aOR 0.48; 95% CI, 0.45-0.52) were associated with lower IHT odds, as was admission to a teaching hospital (aOR 0.83; 95% CI, 0.72-0.96).

CONCLUSIONS AND RELEVANCE

Most patients with sepsis are initially hospitalized at high-capability hospitals. The IHT rate for sepsis is low and more likely to originate from low-capability and public hospitals than from high-capability and for-profit hospitals. Transferred patients with sepsis are more likely to be younger, male, sicker, with private medical insurance, and less likely to have care limitation orders. Future studies should evaluate the comparative benefits of IHT from low-capability hospitals.

Endocrine treatment near the end of life among older women with metastatic breast cancer: a nationwide cohort study

Background

The appropriate time to discontinue chemotherapy at the end of life has been widely discussed. In contrast, few studies have investigated the patterns of endocrine treatment near death. In this study, we aimed to investigate the end-of-life endocrine treatment patterns of older women with metastatic breast cancer and explore characteristics associated with treatment.

Methods

A retrospective cohort study of all older women (age ≥65 years) with hormone receptor-positive breast cancer who died in Sweden, 2016 - 2020. We used routinely collected administrative and health data with national coverage. Treatment initiation was defined as dispensing during the last three months of life with a nine-month washout period, while continuation and discontinuation were assessed by previous use during the same period. We used log-binomial models to explore factors associated with the continuation and initiation of endocrine treatments.

Results

We included 3098 deceased older women with hormone receptor-positive breast cancer (median age 78). Overall, endocrine treatment was continued by 39% and initiated by 5% and of women during their last three months of life, while 31% discontinued and 24% did not use endocrine treatment during their last year of life. Endocrine treatment continuation was more likely among older and less educated women, and among women who had multi-dose drug dispensing, chemotherapy, and CDK4/6 use. Only treatment-related factors were associated with treatment initiation.

Conclusion

More than a third of women with metastatic breast cancer continue endocrine treatments potentially past the point of benefit, whereas late initiation is less frequent. Further research is warranted to determine whether our results reflect overtreatment at the end of life once patients' preferences and survival prognosis are considered.

Trends in Obesity Prevalence among US Older Adults in the Last Two Years of Life, 1998-2018

CONTEXT

The prevalence of obesity has grown in the US over the decades. The temporal trends of body mass index categories in the last two years of life are poorly understood.

OBJECTIVES

To describe the trends in body mass categories in the last two years of life over the past two decades controlling for other demographic changes.

METHODS

We performed a cross-sectional study of prospectively collected survey data from the nationally representative Health and Retirement Study (HRS) among decedents who died between 1998 and 2018. We categorized BMI into five categories and calculated the proportion of decedents with each BMI category during each four epochs (1998-2003, 2004-2008, 2009-2013, 2014-2018). We examined trends in regression models with survey wave groupings modeled as an orthogonal polynomial and adjusted for factors commonly associated with BMI: sex, age, race, ethnicity, education, and tobacco use.

RESULTS

The analytic cohort included 14,797 decedents. From 1998-2003 to 2014-2018 time periods, those categorized as having mild-to-moderate obesity in the last two years of life increased from 12.4% to 14.8% (linear trend P < 0.001), a 19% increase. Severe obesity increased from 1.9% to 4.3%, a 126% increase (linear trend P < 0.001). Underweight decreased from 9.9% to 5.9%, a 40% decrease (linear trend P < 0.001), adjusted for demographic factors. Adjusted quadratic temporal trends for BMI category were nonsignificant, except for in mild-to-moderate obesity.

CONCLUSION

Severe obesity has increased greatly while underweight has decreased. As obesity increases in the final years of life, it is critical to assess how the existing and future palliative services and end of life care system address body size and weight.

Geriatric Cardiology: Coming of Age

Older adults with cardiovascular disease (CVD) contend with deficits across multiple domains of health due to age-related physiological changes and the impact of CVD. Multimorbidity, polypharmacy, cognitive changes, and diminished functional capacity, along with changes in the social environment, result in complexity that makes provision of CVD care to older adults challenging. In this review, we first describe the history of geriatric cardiology, an orientation that acknowledges the unique needs of older adults with CVD. Then, we introduce 5 essential principles for meeting the needs of older adults with CVD: 1) recognize and consider the potential impact of multicomplexity; 2) evaluate and integrate constructs of cognition into decision-making; 3) evaluate and integrate physical function into decision-making; 4) incorporate social environmental factors into management decisions; and 5) elicit patient priorities and health goals and align with care plan. Finally, we review future steps to maximize care provision to this growing population.

Advance directives completion and hospital out-of-pocket expenditures

INTRODUCTION

Health care costs remain high at the end of life. It is not known if there is a relationship between advance directive (AD) completion and hospital out-of-pocket costs. This analysis investigated whether AD completion was associated with lower hospital out-of-pocket costs at end of life.

METHODS

We used Health and Retirement Study participants who died between 2000 and 2014 (N = 9228) to examine the association between AD completion status and hospital out-of-pocket spending in the last 2 years of life through the use of a two-part model controlling for socioeconomic status, death-related characteristics and health insurance coverage.

RESULTS

About 44% of decedents had completed ADs. Having an AD was significantly associated with $673 lower hospital out-of-pocket costs, with a higher magnitude of savings among younger decedents. Decedents who completed ADs 3 months or less before death had higher out-of-pocket costs ($1854 on average) than those who completed ADs more than 3 months before death ($1176 on average).

CONCLUSIONS

AD completion was significantly associated with lower hospital out-of-pocket costs, with greater out-of-pocket savings among younger decedents. Early AD completers experienced lower costs than decedents who completed ADs closer to death.

Disparity in prehospital scene time for geriatric trauma patients

BACKGROUND

Geriatric patients face disparities in prehospital trauma care. We hypothesized that geriatric trauma patients are more likely to experience prolonged prehospital scene time than younger adults.

METHODS

Retrospective analysis of the 2017 National Emergency Medical Services Information System. Patients who met anatomic or physiologic trauma criteria based on national triage guidelines were included (n = 16,356). Geriatric patients (age≥65, n = 3594) were compared to younger adults (age 18-64). The primary outcome was prolonged scene time (>10 min). Multivariable logistic regression was performed, controlling for patient demographics, on-scene treatments, and injury severity.

RESULTS

Geriatric patients were more likely to experience prolonged scene time than younger adults after controlling for other factors (OR 1.78, 95% CI 1.57-2.04, p < 0.001). The likelihood of prolonged scene time reached OR 2.29 (95% CI 1.85-2.84) for patients age 70-79 and OR 2.66 (95% CI 2.07-3.42) for patients age 80-89, relative to age 18-29.

CONCLUSIONS

Geriatric trauma patients are more likely than younger adults to have prolonged prehospital scene time. This disparity may be caused by delayed recognition of injury severity or age-related cognitive biases.

Patient Characteristics and Costs Associated With COVID-19-Related Medical Care Among Medicare Fee-for-Service Beneficiaries

BACKGROUND

New cases of COVID-19 continue to occur daily in the United States, and the need for medical treatments continues to grow. Knowledge of the direct medical costs of COVID-19 treatments is limited.

OBJECTIVE

To examine the characteristics of older adults with COVID-19 and their costs for COVID-19-related medical care.

DESIGN

Retrospective observational study.

SETTING

Medical claims for Medicare fee-for-service (FFS) beneficiaries.

PATIENTS

Medicare FFS beneficiaries aged 65 years or older who had a COVID-19-related medical encounter during April through December 2020.

MEASUREMENTS

Patient characteristics and direct medical costs of COVID-19-related hospitalizations and outpatient visits.

RESULTS

Among 28.1 million Medicare FFS beneficiaries, 1 181 127 (4.2%) sought COVID-19-related medical care. Among these patients, 23.0% had an inpatient stay and 4.2% died during hospitalization. The majority of the patients were female (57.0%), non-Hispanic White (79.6%), and residents of an urban county (77.2%). Medicare FFS costs for COVID-19-related medical care were $6.3 billion; 92.6% of costs were for hospitalizations. The mean hospitalization cost was $21 752, and the mean length of stay was 9.2 days; hospitalization cost and length of stay were higher if the patient needed a ventilator ($49 441 and 17.1 days) or died ($32 015 and 11.3 days). The mean cost per outpatient visit was $164. Patients aged 75 years or older were more likely to be hospitalized, but their hospitalizations were associated with lower costs than for younger patients. Male sex and non-White race/ethnicity were associated with higher probability of being hospitalized and higher medical costs.

LIMITATION

Results are based on Medicare FFS patients.

CONCLUSION

The COVID-19 pandemic has resulted in substantial disease and economic burden among older Americans, particularly those of non-White race/ethnicity.

PRIMARY FUNDING SOURCE

None.

Supportive Care Interventions to Promote Health-Related Quality of Life in Patients Living With Heart Failure: A Systematic Review and Meta-Analysis

Supportive care (physical, psychosocial, and spiritual) may be beneficial as a coping resource in the care of patients with heart failure (HF). Nurses may provide individualised supportive care to offer positive emotional support, enhance the patients' knowledge of self-management, and meet the physical and psychosocial needs of patients with HF. The aim of this study was to examine the potential effectiveness of supportive care interventions in improving the health- related quality of life (HRQoL) of patients with HF. Related outcomes of depression and anxiety were also examined. A systematic search of PubMed, CINAHL, and the Cochrane Library was performed to locate randomised controlled trials (RCTs) that implemented any supportive care interventions in patients with HF published in the English language. Identified articles were further screened for additional studies. Ten (10) RCTs were selected for the meta-analysis. Effect sizes were estimated between the comparison groups over the overall follow-up period, and presented along with confidence intervals (CIs). Statistical heterogeneity for each comparison was estimated using Q (chi square test) and I² statistics with 95% CIs. Statistical heterogeneity was observed in all study variables (i.e., HRQoL and dimensions). There was a positive, but not statistically significant, effect of social support on HRQoL (mean difference [MD], 5.31; 95% CI, -8.93 to 19.55 [p=0.46]). The results of the two dimensions suggested a positive and statistically significant effect of the supportive care interventions (physical: MD, 7.90; 95% CI, 11.31-4.50 [p=0.00]; emotional dimension: MD, 4.10; 95% CI, 6.14-2.06; [p=0.00]). The findings of the current study highlight the need to incorporate supportive care to meet the needs of patients with HF. Patients with HF have care needs that change continuously and rapidly, and there is a need of a continuous process in order to address the holistic needs of patients with HF at all times and not just in a cardiology department or an acute care setting. Patients with HF have multiple needs, which remain unmet. Supportive care is a holistic, ongoing approach that may be effective in identifying and meeting the care needs of patients with HF along with the patient. This review includes all interventions provided in individuals with HF, giving clinicians the opportunity to choose the most suitable ones in improving the clinical outcomes of their patients with HF.

Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage

Background

We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage.

Methods

We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status.

Results

Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity.

Conclusions

Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.

Surgery for the Very Old: Are Nonagenarians Different?

Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007–2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30–1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.

Health-related preferences of older patients with multimorbidity: an evidence map

OBJECTIVES

To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.

DESIGN

Evidence map (systematic review variant).

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.

STUDY SELECTION

Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).

DATA EXTRACTION

Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.

RESULTS

The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.

CONCLUSION

Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.

TRIAL REGISTRATION NUMBER

Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.

Who Are High Users of Hospitals in Canada? Findings From a Population-Based Study

Background

Dying people and older people have often been thought of as high users of hospitals, but current population-based evidence is needed to confirm or refute this claim.

Purpose

Quantitative population-based study designed to identify and describe hospital patients who are high users.

Methods

Data for all 2014–2015 Canadian hospital patients (excluding Quebec) were analyzed to identify and describe high users through descriptive-comparative and regression analysis tests.

Results

Only a small proportion of patients are high users in relation to multiple admissions or 30+ inpatient days of care, and with considerable diversity among them and relatively few of these advanced in age or dying in hospital.

Conclusions

Relatively few patients are high users of hospitals. These people are most often under age 65, so they have the potential to be ill and high users for many years. Flagging would enable individualized care planning to reduce illness exacerbations or slow disease progression and address other risk factors for long or repeat hospitalizations.

Retrospective cohort analysis of real-life decisions about end-of-life care preferences in a Southeast Asian country

OBJECTIVE

To describe the end-of-life care preferences of individuals, and to examine the influence of age and gender on these preferences.

DESIGN, SETTING AND PARTICIPANTS

A retrospective cohort study was conducted. Participants included all adults (≥21 years old) (n=3380) who had completed a statement of their preferences as part of a national Advance Care Planning (ACP) programme in Singapore. Data were extracted from the national and Tan Tock Seng Hospital ACP database.

MAIN MEASURES

End-of-life care preferences were obtained from the ACP document and differentiated by health status (healthy, chronically ill or diagnosed with advanced illnesses). To analyse the data, descriptive statistics and logistic regression analysis were used.

RESULTS

Across healthy and chronically ill patients, the majority did not opt for cardiopulmonary resuscitation (CPR) or other life-sustaining measures. Among individuals with advanced illnesses, 94% preferred not to attempt CPR but 69% still preferred to receive some form of active medical treatment. Approximately 40% chose to be cared for, and to die at home. Age and sex significantly predict preferences in those with advanced illnesses. Older age (>=75 years) showed higher odds for home as preferred place of care (OR 1.52; 95% CI 1.23 to 1.89) and place of death (OR 1.29; 95% CI 1.03 to 1.61) and lower odds for CPR (OR 0.31; 95% CI 0.18 to 0.54) and full treatment (OR 0.32; 95% CI 0.17 to 0.62). Being female was associated with lower odds for home as preferred place of care (OR 0.69; 95% CI 0.57 to 0.84) and place of death (OR 0.70; 95% CI 0.57 to 0.85) and higher odds for full treatment (OR 2.35; 95% CI 1.18 to 4.68).

CONCLUSION

The majority preferred to not proceed with life-sustaining treatments, but there was still a strong preference to receive some form of limited treatment. Better understanding of end-of-life care preferences through ACP can better guide end-of-life care programme planning, and resource allocation decisions.

What Matters at the End of Life: A Qualitative Study of Older Peoples Perspectives in Southern Denmark

What matters at the end of life (EOL) among the older population in Denmark is poorly investigated. We used focus groups and in-depth interviews, to identify perspectives within the EOL, along with what influences resuscitation, decision making, and other treatment preferences. We included eligible participants aged ≥65 years in the Region of Southern Denmark. Five focus groups and nine in-depth interviews were conducted, in total 31 participants. We found a general willingness to discuss EOL, and experiences of the process of dying were present among all participants. Three themes emerged during the analysis: (a) Being independent is crucial for the future, (b) Handling and talking about the EOL, and (c) Conditions in Everyday Life are Significant. Life experiences seemed to affect the degree of reflection of EOL and the decision-making process. Knowing your population of interest is crucial, when developing an approach or using an advance care plan from another setting.

Emergency department mortality: Fair and square

OBJECTIVE

This study explored the therapeutic approaches used for end-of-life (EOL) patients admitted to the emergency department (ED) and examined whether the decision to perform life-extending treatment (LET) or to allow natural death (AND) depends on patient characteristics, medical staff variables, and ED setting.

METHODS

A retrospective archive study was conducted from January 2015 to December 2017 in the ED of a tertiary hospital. The study sample were 674 EOL patients who had died in the ED. For each patient, data were collected and measured for dying process (LET vs. AND), patient characteristics, ED-setting variables, and medical-staff characteristics.

RESULTS

The proportion of EOL patients undergoing LET increased from 18.1% in 2015 to 25.9% in 2016 and to 30.3% in 2017 (p = .010), and a quarter of them were treated by emergency medical services. Males tended to receive LET more than females (p < .001). An association was found between Jewish physicians and nurses and AND (p = .001). Heavier workload in the ED and greater severity of the triage classification predicted more LET (OR-1.67, CI = 1.05-1.76, p = .003 and OR = 1.42, CI-0.60-0.81, p < .001, respectively). Receiver operating characteristic analysis showed that patient characteristics contributed most crucially to the therapeutic approaches (C statistic 0.624-0.675, CI-0.62-0.71).

CONCLUSIONS

The therapeutic approach used for EOL patients in the ED depends on variables in all three treatment layers: patient, medical staff, and ED setting. Applicable national programs should be developed to ensure that no external factors influence the dying-process decision.

Advanced imaging and hospice use in end-of-life cancer care

INTRODUCTION

Advanced imaging can inform prognosis and may be a mechanism to de-escalate unnecessary end-of-life care in patients with cancer. Associations between greater use of advanced imaging and less-aggressive end-of-life care in real-world practice has not been examined.

METHODS

We conducted a retrospective analysis of SEER-Medicare data on patients who died from breast, lung, colorectal, or prostate cancer between 2002 and 2007. Hospital referral region (HRR)-level use of computerized tomography (CT), magnetic resonance imaging, and positron emission tomography was categorized by tertile of imaging use and correlated with hospice enrollment overall and late hospice enrollment using multivariable logistic regression.

RESULTS

A total of 55,058 patients met study criteria. Hospice use ranged from 50.8% (colorectal cancer) to 62.1% (prostate cancer). In multivariable analyses, hospital referral regions (HRRs) with high rates of CT imaging were associated with lower odds of hospice enrollment (odds ratio, 0.80; 95% CI, 0.70-0.90) and late enrollment among those who did enroll (odds ratio, 1.49; 95% CI, 1.26-1.76). HRRs with the highest rates of CT use were predominantly located in the Midwest and Northeast and associated with higher percentage population of black patients (14.5 vs 5.6%), greater comorbidity (28.4 vs 23.7%), metropolitan residence (93.9 vs 78.5%), and less than high school education (26.4 vs 19.3%).

CONCLUSION

In this population-based retrospective study, we did not observe evidence that overall and timely hospice are associated with higher rates of imaging near the end of life. An observed association between higher rates of imaging, particularly CT, may be explained in part by HRR-level differences in practice patterns and patient demographic characteristics. Further research is warranted to explore the ability of oncologic imaging to appropriately de-escalate care.

Patient and Hospital Characteristics Associated with Interhospital Transfer for Adults with Ventilator-Dependent Respiratory Failure

RATIONALE

Patients with ventilator-dependent respiratory failure have improved outcomes at centers with greater expertise; yet, most patients are not treated in such facilities. Efforts to align care for respiratory failure and hospital capability would necessarily require interhospital transfer.

OBJECTIVES

To characterize the prevalence and the patient and hospital factors associated with interhospital transfer of adults residing in Florida with ventilator-dependent respiratory failure.

METHODS

We performed a retrospective, observational study using Florida Healthcare Cost and Utilization Project data. We selected patients 18 years of age and older with International Classification of Diseases, Ninth Revision, codes of respiratory failure and mechanical ventilation during 2012 and 2013, and we identified cohorts of patients that did and did not undergo interhospital transfer. We obtained patient sociodemographic and clinical variables and categorized hospitals into subtypes on the basis of patient volume and services provided: large, medium (nonprofit or for-profit), and small.

RESULTS

Interhospital transfer was our primary outcome measure. Patient sociodemographics, clinical variables, and hospital types were used as covariates. We identified 2,580 patients with ventilator-dependent respiratory failure who underwent interhospital transfer. Overall, transfer was uncommon, with only 2.9% of patients being transferred. In a hierarchical model, age less than 65 years (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.77-2.45) and tracheostomy (OR, 3.19; 95% CI, 2.80-3.65) were associated with higher odds of transfer, whereas having Medicaid was associated with lower odds of transfer than having commercial insurance (OR, 0.65; 95% CI, 0.56-0.75). Additionally, care in medium-sized for-profit hospitals was associated with lower odds of transfer (OR, 1.37 vs. 2.70) than care in medium nonprofit hospitals, despite similar hospital characteristics.

CONCLUSIONS

In Florida, interhospital transfer of patients with ventilator-dependent respiratory failure is uncommon and more likely among younger, commercially insured, medically resource-intensive patients. For-profit hospitals are less likely to transfer than nonprofit hospitals. In future studies, researchers should test for geographic variations and examine the clinical implications of selectivity in interhospital transfer of patients with ventilator-dependent respiratory failure.

Risk Factor Assessment of Hospice Patients Readmitted within 7 Days of Acute Care Hospital Discharge

Factors surrounding readmission rates for hospice patients within seven days are still relatively unknown. The present study specifically investigates the seven-day readmission rate of patients newly discharged to hospice, and the predictive factors associated with readmission for this population. In a retrospective case-control study, we seek to identify potential predictors by comparing the characteristics of patients discharged to hospice and readmitted within one week to patients who were not readmitted. Cases (n = 46) were patients discharged to home hospice and readmitted to the hospital within seven days. Controls (n = 117) were patients discharged to home hospice and not readmitted to the hospital within seven days. Significant risk factors for readmission within seven days were found to be: age (p < 0.01), race (p < 0.001), language (p < 0.001), and insurance (p < 0.001). Further study of these predictors may identify opportunities for interventions that address patient and family concerns that may lead to readmission.

Health-Related Decisions for Serious Illness Among Ethnically Diverse Older Adults

We investigated the influence of sociodemographic factors, acculturation, ethnicity, health status, and spirituality on older adults' health-related decisions when confronted with a choice between competing options. The sample included 451 participants: African Americans (15.74%), Afro-Caribbeans (25.5%), European Americans (36.36%), and Hispanic Americans (22.4%). Compared with others, European Americans and Hispanic Americans favored quality of life over a lengthy life. Sociodemographic factors, acculturation, ethnicity, health status, and spirituality accounted for variations of decisions. The variability of decisions calls for multiple care options to explore the value of different trade-offs in order to avoid predetermined clinical practice guidelines, especially in nursing.

Awareness of do-not-resuscitate orders in the outpatient setting in Saudi Arabia. Perception and implications

Objectives:

To determine the level of awareness of outpatients, and their preferences regarding the appropriate time for discussions regarding do-not-resuscitate (DNR) order in Saudi Arabia.

Methods:

This cross-sectional, self-administered survey was conducted at King Fahd Medical City, a tertiary care hospital in Riyadh, Saudi Arabia between December 2012 and January 2013. Demographic parameters of the participants were analyzed by frequency distribution, and the data on their responses by percentage analysis.

Results:

The survey participants constituted 307 randomly selected outpatients/caregivers presenting for outpatient care at primary and tertiary care centers, 70% were female. Three-fourths of the participants had heard of DNR order, of which 50% defined it accurately. Ninety percent preferred a discussion while ill, and 10% while healthy. More than 70% expressed willingness to share the decision with their spouses/family members. Almost one-third believed DNR orders were consistent with Islamic beliefs, almost as many believed they were inconsistent, and almost a third did not take either position. Almost all the participants showed a willingness to learn more about the order.

Conclusion:

A divided opinion exists regarding religious and ethical aspects of the issue among the participants. However, almost all the participants showed a willingness to learn more about the DNR order.

Initial disease severity and quality of care of emergency department sepsis patients who are older or younger than 70 years of age

Objective

Due to atypical symptom presentation older patients are more prone to delayed sepsis recognition. We investigated whether initial disease severity before emergency department (ED) treatment (including treatable acute organ dysfunction), quality of ED sepsis care and the impact on mortality was different between patients older and younger than 70 years. If differences exist, improvements are needed for ED management of older patients at risk for sepsis.

Methods

In this observational multicenter study, ED patients who were hospitalized with a suspected infection were stratified by age <70 and ≥70 years. The presence of treatable and potentially reversible acute organ dysfunction was measured by the RO components of the Predisposition, Infection, Response and Organ dysfunction (PIRO) score, reflecting acute sepsis-related organ dysfunction developed before ED presentation. Quality of care, as assessed by the full compliance with nine quality performance measures and the standardized mortality ratio (SMR: observed/expected in-hospital mortality), was compared between older and younger patients.

Results

The RO-components of the PIRO score were 8 (interquartile range; 4–9) in the 833 older patients, twice as high as the 4 (2–8; P<0.001) in the 1537 younger patients. However, full compliance with all nine quality performance measures was achieved in 34.2 (31.0–37.4)% of the older patients, not higher than the 33.0 (30.7–35.4)% in younger patients (P = 0.640). In-hospital mortality was 9.2% (95%-CI, 7.3–11.2) in patients ≥70, twice as high as the 4.6% (3.6–5.6) in patients <70 years, resulting in an SMR (in study period) of ~0.7 in both groups (P>0.05).

Conclusion

Older sepsis patients are sicker at ED presentation but are not treated more expediently or reliably despite their extra acuity The presence of twice as much treatable acute organ dysfunction before ED treatment suggests that acute organ dysfunction is recognized relatively late by general practitioners or patients in the out of hospital setting.

End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis

With population aging, “do not resuscitate” (DNAR) decisions, pertaining to the appropriateness of attempting resuscitation following a cardiac arrest, are becoming commoner. It is unclear from the literature whether using age to make these decisions represents “ageism.” We undertook a systematic review of the literature using CINAHL, Medline, and the Cochrane database to investigate the relationship between age and DNAR. All 10 studies fulfilling our inclusion criteria found that “do not attempt resuscitation” orders were more prevalent in older patients; eight demonstrated that this was independent of other mediating factors such as illness severity and likely outcome. In studies comparing age groups, the adjusted odds of having a DNAR order were greater in patients aged 75 to 84 and ≥85 years (adjusted odds ratio [AOR] 1.70, 95% confidence interval [CI] = [1.25, 2.33] and 2.96, 95% CI = [2.34, 3.74], respectively), compared with those <65 years. In studies treating age as a continuous variable, there was no significant increase in the use of DNAR with age (AOR 0.98, 95% CI = [0.84, 1.15]). In conclusion, age increases the use of “do not resuscitate” orders, but more research is needed to determine whether this represents “ageism.”

New Evidence on End-of-Life Hospital Utilization for Enhanced Health Policy and Services Planning

BACKGROUND

Long-standing concern exists over hospital use by people near or at the end of life (EOL) related to the appropriateness, quality, and cost of care in hospital. It is widely believed that most people die in hospital after an escalation in hospital use over the last year of life. As most deaths in high-income countries are not sudden or unexpected, opportunities exist for planning compassionate, effective, and evidence-based EOL care.

OBJECTIVE

Gain current population-based evidence for EOL health policy and services planning.

DESIGN

Retrospective study of population-based hospital utilization data.

SETTING/SUBJECTS

All hospital patients in every Canadian province and territory except Quebec. All decedents with hospital separations in 2014-2015.

MEASURES

Descriptive-comparative and logical regression analysis tests.

RESULTS

In 2014-2015, 3.5% of hospital episodes ended in death and 43.7% of all deaths in Canada (excluding Quebec) took place in hospital. 95.2% of those dying in hospital were only admitted once or twice during their last 365 days of life. 3.6% of those dying in hospital had been living in the community and receiving publicly funded home care before the hospital admission that ended in death, while 67.0% had been living at home without home care. 79.0% of hospital deaths followed an unplanned admission through the emergency room, with 70.5% arriving by ambulance. The hospital care provided in the last stay was largely noninterventionist.

CONCLUSIONS

These findings reveal the need for a major reconceptualization of death, dying, and EOL care to ensure sufficient capacity of palliative home care and other services to support dying people and prevent the health and family caregiver crises that lead to hospital-based EOL care and death.

Provider and Patient Gender Influence on Timing of Do-Not-Resuscitate Orders in Hospitalized Patients with Cancer

BACKGROUND

End-of-life decisions and advance directives require timely physician-patient discussions but barriers exist to these discussions.

OBJECTIVE

To evaluate the influence of physician and patient gender on the timing of inpatient do-not-resuscitate (DNR) orders.

DESIGN

Retrospective cohort study.

SETTING/SUBJECTS

All adult patients (≥18 years) with cancer who received inpatient DNR orders at The University of Texas MD Anderson Cancer Center between January 2011 and December 2013.

MEASUREMENTS

Gender interaction between physicians and patients towards timing of the DNR order.

RESULTS

We identified 4,157 unique patients with a cancer diagnosis. These patients were treated by 353 physicians, of whom 123 (34.8%) were females and 230 (65.2%) were males. Multivariate analysis showed female patients were 1.3 times more likely to have early DNR orders written during hospital admission than were male patients (odds ratio [OR] 1.27; 95% confidence interval [CI] 1.07-1.50). When comparing gender interaction between physicians and patients, our results showed that female physicians were 1.5 times more likely to write early DNR orders with their female patients than for their male patients (OR, 1.48; 95% CI, 1.13-1.94). Same gender physician-patient dyads were not found between male physician and their patients (OR, 1.09; 95% CI, 0.91-1.31). Higher age, more comorbid conditions, and progression of diseases were also associated with early DNR orders (all p < 0.01).

CONCLUSION

Female patients are more likely to receive early DNR orders from their female physicians. Gender and gender interaction between physician and patients may potentially influence the timing of receiving DNR order.

Are elderly patients' opinions sought before admission to an intensive care unit? Results of the ICE-CUB study

BACKGROUND

demand for intensive care of the very elderly is growing, but few studies report inclusion of their opinions in the admission decision-making process. Whether or not to refer a very elderly patient to intensive care unit is a difficult decision that should take into account individual wishes, out of respect for the patient's decision-making autonomy.

METHODS

in 15 emergency departments, patients over 80 years old who had a potential indication for admission to intensive care, and that were capable of expressing their opinion were included. Frequency of opinions sought before referral decision and individual and organisational factors associated were recorded and analysed.

RESULTS

a total of 2,115 patients were included. Only 270 (12.7%) of them were asked for their opinion, and there were marked variations between study centres (minimum: 1.1% and maximum: 53.6%). A history of dementia reduced the probability of a patient being asked for his or her opinion (OR 0.47, 95% CI: 0.25-0.83). Patients' opinion was most often sought when their functional autonomy was conserved (OR 2.10, 95% CI: 1.39-3.21) and when a relative had been questioned (OR 5.46, 95% CI: 3.8-7.88). Older attending physicians were less likely to ask for the patient's opinion (older physician versus younger physician, OR 0.48, 95% CI: 0.35-0.66).

CONCLUSIONS

elderly patients are therefore rarely asked for their opinion prior to intensive care admission. Our results indicate that respect of the decision-making autonomy of elderly subjects in the admission process to an intensive care unit should be reinforced.

Risk factors for hospital and long-term mortality of critically ill elderly patients admitted to an intensive care unit

Background. Data on long-term outcomes of elderly (≥65 years) patients in ICU are sparse. Materials and Methods. Adult patients (n = 1563, 45.4% elderly) admitted over 28 months were analyzed by competing risks regression model to determine independent factors related to in-hospital and long-term mortality. Results. 414 (26.5%) and 337 (21.6%) patients died in-hospital and during the 52 months following discharge, respectively; the elderly group had higher mortality during both periods. After discharge, elderly patients had 2.3 times higher mortality compared to the general population of the same age-group. In-hospital mortality was independently associated with mechanical ventilation (subdistribution hazard ratio (SHR) 2.74), vasopressors (SHR 2.56), neurological disease (SHR 1.77), and Mortality Prediction Model II score (SHR 1.01) regardless of age and with malignancy (SHR, hematological 3.65, nonhematological 3.4) and prior renal replacement therapy (RRT, SHR 2.21) only in the elderly. Long-term mortality was associated with low hemoglobin concentration (SHR 0.94), airway disease (SHR 2.23), and malignancy (SHR hematological 1.11, nonhematological 2.31) regardless of age and with comorbidities especially among the nonelderly. Conclusions. Following discharge, elderly ICU patients have higher mortality compared to the nonelderly and general population. In the elderly group, prior RRT and malignancy contribute additionally to in-hospital mortality risk. In the long-term, comorbidities (age-related), anemia, airway disease, and malignancy were significantly associated with mortality.

Considering age when making treatment decisions in the ICU: too little, too much, or just right?

There are a number of studies providing evidence that age is associated with treatment decisions for critically ill adults, although most of these studies have been unable to fully account for both prehospital health status and severity of acute illness. In the previous issue of Critical Care, Turnbull and colleagues present a well-executed study analyzing data from a prospective cohort study of critically ill patients with acute respiratory distress syndrome to investigate the association between age and new limitations in life-sustaining therapy. They report a strong association between age and new limitations in life support in this cohort, even after adjusting for comorbidities, prehospital functional status, and severity of illness including daily organ dysfunction scores. Their results demonstrate that decisions about the goals of care and the ongoing use of life-sustaining treatments should be viewed as dynamic and responsive to events occurring during critical illness. This study raises the important question about the contributors to this association, and the authors raise the possibility that physician or surrogate bias may be contributing to decisions for older patients. While this is unlikely to be the only contributor to the association between age and end-of-life decisions, the mere possibility should prompt reflection on the part of clinicians caring for critically ill patients.

Futility, benefit, and transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a transformative innovation that provides treatment for high or prohibitive surgical risk patients with symptomatic severe aortic stenosis who either were previously not referred for or were denied operative intervention. Trials have demonstrated improvements in survival and symptoms after TAVR versus medical therapy; however, there remains a sizable group of patients who die or lack improvement in quality of life soon after TAVR. This raises important questions about the need to identify and acknowledge the possibility of futility in some patients considered for TAVR. In this very elderly population, a number of factors in addition to traditional risk stratification need to be considered including multimorbidity, disability, frailty, and cognition in order to assess the anticipated benefit of TAVR. Consideration by a multidisciplinary heart valve team with broad areas of expertise is critical for assessing likely benefit from TAVR. Moreover, these complicated decisions should take place with clear communication around desired health outcomes on behalf of the patient and provider. The decision that treatment with TAVR is futile should include alternative plans to optimize the patient's health state or, in some cases, discussions related to end-of-life care. We review issues to be considered when making and communicating these difficult decisions.

Age and decisions to limit life support for patients with acute lung injury: a prospective cohort study

Introduction

The proportion of elderly Americans admitted to the intensive care unit (ICU) in the last month of life is rising. Hence, challenging decisions regarding the appropriate use of life support are increasingly common. The objective of this study was to estimate the association between patient age and the rate of new limitations in the use of life support, independent of daily organ dysfunction status, following acute lung injury (ALI) onset.

Methods

This was a prospective cohort study of 490 consecutive patients without any limitations in life support at the onset of ALI. Patients were recruited from 11 ICUs at three teaching hospitals in Baltimore, Maryland, USA, and monitored for the incidence of six pre-defined limitations in life support, with adjustment for baseline comorbidity and functional status, duration of hospitalization before ALI onset, ICU severity of illness, and daily ICU organ dysfunction score.

Results

The median patient age was 52 (range: 18 to 96), with 192 (39%) having a new limitation in life support in the ICU. Of patients with a new limitation, 113 (59%) had life support withdrawn and died, 53 (28%) died without resuscitation, and 26 (14%) survived to ICU discharge. Each ten-year increase in patient age was independently associated with a 24% increase in the rate of limitations in life support (Relative Hazard 1.24; 95% CI 1.11 to 1.40) after adjusting for daily ICU organ dysfunction score and all other covariates.

Conclusions

Older critically ill patients are more likely to have new limitations in life support independent of their baseline status, ICU-related severity of illness, and daily organ dysfunction status. Future studies are required to determine whether this association is a result of differences in patient preferences by age, or differences in the treatment options discussed with the families of older versus younger patients.

Physician orders for life-sustaining treatment and emergency medicine: ethical considerations, legal issues, and emerging trends

Since its original development in Oregon in 1993, Physician Orders for Life-Sustaining Treatment (POLST) is quickly growing in popularity and prevalence as a method of communicating the end-of-life care preferences for the seriously ill and frail nationwide. Early evidence has suggested significant advantages over advance directives and do-not-resuscitate/do-not-intubate documents both in accuracy and penetration within relevant populations. POLST also may contribute to the quality of end-of-life care administered. Although it was designed to be as clear as possible, unexpected challenges in the interpretation and use of POLST in the emergency department do exist. In this article, we will discuss the history, ethical considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine.

Potentially ineffective care: time for earnest reexamination

The rising costs and suboptimal quality throughout the American health care system continue to invite critical inquiry, and practice in the intensive care unit setting is no exception. Due to their relatively large impact, outcomes and costs in critical care are of significant interest to policymakers and health care administrators. Measurement of potentially ineffective care has been proposed as an outcome measure to evaluate critical care delivery, and the Patient Protection and Affordable Care Act affords the opportunity to reshape the care of the critically ill. Given the impetus of the PPACA, systematic formal measurement of potentially ineffective care and its clinical, economic, and societal impact merits timely reconsideration.

Do not resuscitate orders and aging: impact of multimorbidity on the decision-making process

BACKGROUND

The "Do Not Resuscitate" orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related multimorbidity may influence the DNR decision-making process. Our objective was to perform a systematic review and meta-analysis of published data examining the relationship between DNR orders and multimorbidity in older patients.

METHODS

A systematic Medline and Cochrane literature search limited to human studies published in English and French was conducted on August 2012, with no date limits, using the following Medical Subject Heading terms: "resuscitation orders" OR "do-not-resuscitate" combined with "aged, 80 and over" combined with "comorbidities" OR "chronic diseases".

RESULTS

Of the 65 selected studies, 22 met the selection criteria for inclusion in the qualitative analysis. DNR orders were positively associated with multimorbidity in 21 studies (95%). The meta-analysis included 7 studies with a total of 27,707 participants and 5065 DNR orders. It confirmed that multimorbidity were associated with DNR orders (summary OR = 1.25 [95% CI: 1.19-1.33]). The relationship between DNR orders and multimorbidity differed according to the nature of morbidities; the summary OR for DNR orders was 1.15 (95% CI: 1.07-1.23) for cognitive impairment, OR=2.58 (95% CI: 2.08-3.20) for cancer, OR=1.07 (95% CI: 0.92-1.24) for heart diseases (i.e., coronary heart disease or congestive heart failure), and OR=1.97 (95% CI: 1.61-2.40) for stroke.

CONCLUSIONS

This systematic review and meta-analysis showed that DNR orders are positively associated with multimorbidity, and especially with three morbidities, which are cognitive impairment, cancer and stroke.

Association of age and packed red blood cell transfusion to 1-year survival--an observational study of ICU patients

OBJECTIVES

To compare the 1-year survival for different age strata of intensive care unit (ICU) patients after receipt of packed red blood cell (PRBC) transfusions.

BACKGROUND

Despite guidelines documenting risks of PRBC transfusion and data showing that increasing age is associated with ICU mortality, little data exist on whether age alters the transfusion-related risk of decreased survival.

METHODS

We retrospectively examined data on 2393 consecutive male ICU patients admitted to a tertiary-care hospital from 2003 to 2009 in age strata: 21-50, 51-60, 61-70, 71-80 and >80 years. We calculated Cox regression models to determine the modifying effect of age on the impact of PRBC transfusion on 1-year survival by using interaction terms between receipt of transfusion and age strata, controlling for type of admission and Charlson co-morbidity indices. We also examined the distribution of admission haematocrit and whether transfusion rates differed by age strata.

RESULTS

All age strata experienced statistically similar risks of decreased 1-year survival after receipt of PRBC transfusions. However, patients age >80 were more likely than younger cohorts to have haematocrits of 25-30% at admission and were transfused at approximately twice the rate of each of the younger age strata.

DISCUSSION

We found no significant interaction between receipt of red cell transfusion and age, as variables, and survival at 1 year as an outcome.

Considering the balance: development of a scale to assess patient views on trade-offs in competing health outcomes

OBJECTIVES

To describe the development of a scale assessing participant attitudes regarding two commonly encountered trade-offs: quality versus quantity of life and present versus future health.

DESIGN

Observational cohort study.

SETTING

Community.

PARTICIPANTS

Three hundred and fifty-seven community-dwelling adults aged 65 and older.

MEASUREMENTS

An initial set of 20 items rated on a 5-point Likert scale of agreement was reduced using principal components analysis. Construct validity was evaluated through comparison of the scale with other tools addressing the same trade-offs and analysis of participant characteristics associated with attitudes favoring quality over quantity of life and present over future health. Internal consistency was assessed using Cronbach alpha. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs).

RESULTS

The scale consists of two subscales, each addressing one trade-off, with a total of 10 items. All factor loadings were 0.5 and greater, and subscale scores were significantly different (P ≤ .05) in the expected directions when comparing with other tools and with participant race, education, and religious identity. Internal consistency was good (Cronbach α 0.85 and 0.84), and test-retest reliability was fair (ICCs 0.63 and 0.47). Subscale score medians fell near the middle of each scale, with narrow interquartile ranges, but more than 15% of the sample scored at an extreme of each subscale.

CONCLUSION

This new scale captures views on two common trade-offs in health care. Although test-retest reliability was modest, its high validity suggests that this tool can be used to familiarize people with common trade-offs and further explore influences on attitudes.

Preferences for resuscitation and intubation among patients with do-not-resuscitate/do-not-intubate orders

OBJECTIVE

To determine the accuracy of do-not-resuscitate/do-not-intubate (DNR/DNI) orders in representing patient preferences regarding cardiopulmonary resuscitation (CPR) and intubation.

PATIENTS AND METHODS

We conducted a prospective survey study of patients with documented DNR/DNI code status at an urban academic tertiary care center that serves approximately 250,000 patients per year. From October 1, 2010, to October 1, 2011, research staff enrolled a convenience sample of patients from the inpatient medical service, providing them with a series of emergency scenarios for which they related their treatment preference. We used the Kendall τ rank correlation coefficient to examine correlation between degree of illness reversibility and willingness to be resuscitated. Using bivariate statistical analysis and multivariate logistic regression analysis, we examined predictors of discrepancies between code status and patient preferences. Our main outcome measure was the percentage of patients with DNR/DNI orders wanting CPR and/or intubation in each scenario. We hypothesized that patients with DNR/DNI orders would frequently want CPR and/or intubation.

RESULTS

We enrolled 100 patients (mean ± SD age, 78 ± 13.7 years). A total of 58% (95% CI, 48%-67%) wanted intubation for angioedema, 28% (95% CI, 20%-3.07%) wanted intubation for severe pneumonia, and 20% (95% CI, 13%-29%) wanted a trial resuscitation for cardiac arrest. The desire for intubation decreased as potential reversibility of the acute disease process decreased (Kendall τ correlation coefficient, 0.45; P<.0002).

CONCLUSION

Most patients with DNR/DNI orders want CPR and/or intubation in hypothetical clinical scenarios, directly conflicting with their documented DNR/DNI status. Further research is needed to better understand the discrepancy and limitations of DNR/DNI orders.

Underuse of hospice care by Medicaid-insured patients with stage IV lung cancer in New York and California

PURPOSE

Medicare patients with advanced cancer have low rates of hospice use. We sought to evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare.

PATIENTS AND METHODS

Using linked patient-level data from California (CA) and New York (NY) state cancer registries, state Medicaid programs, NY Medicare, and CA Surveillance, Epidemiology, and End Results-Medicare data, we identified 4,797 CA Medicaid patients and 4,001 NY Medicaid patients ages 21 to 64 years, as well as 27,416 CA Medicare patients and 16,496 NY Medicare patients ages ≥ 65 years who were diagnosed with stage IV lung cancer between 2002 and 2006. We evaluated hospice use, timing of enrollment, and location of death (inpatient hospice; long-term care facility or skilled nursing facility; acute care facility; home with hospice; or home without hospice). We used multiple logistic regressions to evaluate clinical and sociodemographic factors associated with hospice use.

RESULTS

Although 53% (CA) and 44% (NY) of Medicare patients ages ≥ 65 years used hospice, fewer than one third of Medicaid-insured patients ages 21 to 64 years enrolled in hospice after a diagnosis of stage IV lung cancer (CA, 32%; NY, 24%). A minority of Medicaid patient deaths (CA, 19%; NY, 14%) occurred at home with hospice. Most Medicaid patient deaths were either in acute-care facilities (CA, 28%; NY, 36%) or at home without hospice (CA, 39%; NY, 41%). Patient race/ethnicity was not associated with hospice use among Medicaid patients.

CONCLUSION

Given low rates of hospice use among Medicaid enrollees and considerable evidence of suffering at the end of life, opportunities to improve palliative care delivery should be prioritized.

Lack of clinically evident signs of organ failure affects ED treatment of patients with severe sepsis

BACKGROUND

It is not known whether lack of recognition of organ failure explains the low compliance with the "Surviving Sepsis Campaign" (SSC) guidelines. We evaluated whether compliance was higher in emergency department (ED) sepsis patients with clinically recognizable signs of organ failure compared to patients with only laboratory signs of organ failure.

METHODS

Three hundred twenty-three ED patients with severe sepsis and septic shock were prospectively included. Multivariable binary logistic regression was used to assess if clinical and biochemical signs of organ failure were associated with compliance to a SSC-based resuscitation bundle. In addition, two-way analysis of variance was used to investigate the relation between the predisposition, infection, response and organ failure (PIRO) score (3 groups: 1-7, 8-14, 15-24) as a measure of illness severity and time to antibiotics with disposition to ward or ICU as effect modifier.

RESULTS

One hundred twenty-five of 323 included sepsis patients with new-onset organ failure were admitted to the ICU, and in all these patients the SSC resuscitation bundle was started. Respiratory difficulty, hypotension and altered mental status as clinically recognizable signs of organ failure were independent predictors of 100% compliance and not illness severity per se. Corrected ORs (95% CI) were 3.38 (1.08-10.64), 2.37 (1.07-5.23) and 4.18 (1.92-9.09), respectively. Septic ED patients with clinically evident organ failure were more often admitted to the ICU compared to a ward (125 ICU admissions, P < 0.05), which was associated with shorter time to antibiotics [ward: 127 (113-141) min; ICU 94 (80-108) min (P = 0.005)].

CONCLUSIONS

The presence of clinically evident compared to biochemical signs of organ failure was associated with increased compliance with a SSC-based resuscitation bundle and admission to the ICU, suggesting that recognition of severe sepsis is an important barrier for successful implementation of quality improvement programs for septic patients. In septic ED patients admitted to the ICU, the time to antibiotics was shorter compared to patients admitted to a normal ward.

Decision tool to improve the quality of care in rheumatoid arthritis

OBJECTIVE

Despite the importance of achieving tight control, many patients with rheumatoid arthritis (RA) are not effectively treated with disease-modifying antirheumatic drugs. The objective of this study was to develop a decision support tool to inform RA patients with ongoing active disease about the risks and benefits related to biologic therapy.

METHODS

We developed a balanced, web-based, decision support tool. Options, values, and probabilistic information were described using theoretically supported formulations. We conducted a pre-/posttest study to assess preliminary evidence of the tool's efficacy in improving knowledge related to biologics, clarity of values, willingness to take a biologic, and informed choice.

RESULTS

We interviewed 104 subjects (mean age 62 years, 84% women, 87% white, and median duration of RA 8 years). Knowledge (coded on a 0-20 scale) and willingness to take a biologic (coded on a 0-10 scale) significantly increased after viewing the tool (mean differences 2.3 and 1.4, respectively; P < 0.0001 for both). Perceived knowledge and values clarity (coded on 0-100 scales) also significantly improved (mean differences 20.4 and 20.8, respectively; P < 0.0001 for both). The proportion of subjects making an informed value-concordant choice increased substantially from 35% to 64%.

CONCLUSION

A tool designed to effectively communicate the risks and benefits associated with biologic therapy increased knowledge, patient willingness to escalate care, and the likelihood of making an informed choice. The results of this study support the need for a clinical trial to examine the impact of the tool in clinical practice.

Children and terror casualties receive preference in ICU admissions

OBJECTIVE

Trauma casualties caused by terror-related events and children injured as a result of trauma may be given preference in hospital emergency departments (EDs) due to their perceived importance. We investigated whether there are differences in the treatment and hospitalization of terror-related casualties compared to other types of injury events and between children and adults injured in terror-related events.

METHODS

Retrospective study of 121 608 trauma patients from the Israel Trauma Registry during the period of October 2000-December 2005. Of the 10 hospitals included in the registry, 6 were level I trauma centers and 4 were regional trauma centers. Patients who were hospitalized or died in the ED or were transferred between hospitals were included in the registry.

RESULTS

All analyses were controlled for Injury Severity Score (ISS). All patients with ISS 1-24 terror casualties had the highest frequency of intensive care unit (ICU) admissions when compared with patients after road traffic accidents (RTA) and other trauma. Among patients with terror-related casualties, children were admitted to ICU disproportionally to the severity of their injury. Logistic regression adjusted for injury severity and trauma type showed that both terror casualties and children have a higher probability of being admitted to the ICU.

CONCLUSIONS

Injured children are admitted to ICU more often than other age groups. Also, terror-related casualties are more frequently admitted to the ICU compared to those from other types of injury events. These differences were not directly related to a higher proportion of severe injuries among the preferred groups.

Determinants of treatment intensity for patients with serious illness: a new conceptual framework

BACKGROUND

Research during the past few decades has greatly advanced our understanding of the cost, quality, and variability of medical care at the end of life. The current health-care policy debate has focused considerable attention on the unsustainable rate of spending and wide regional variation associated with medical treatments in the last year of life. New initiatives aim to standardize quality and reduce over-utilization at the end of life. We argue, however, that focusing exclusively on medical treatment at the end of life is not likely to lead to effective health-care policy reform or reduce costs. Specifically, end-of-life policy initiatives face the challenges of political feasibility, inaccurate prognostication, and gaps in the existing literature.

OBJECTIVES

With the ultimate aim of improving the quality and efficiency of care, we propose a research and policy agenda guided by a new conceptual framework of factors associated with treatment intensity for patients with serious and complicated medical illness. This model not only expands the population of interest to include all adults with serious illness, but also provides a blueprint for the thorough investigation of the diverse and interconnected determinants of treatment intensity.

CONCLUSIONS

The new conceptual framework presented in this paper can be used to develop future research and policy initiatives designed to improve the quality and efficiency of care for adults with serious illness.

Age still matters: prognosticating short- and long-term mortality for critically ill patients with pneumonia

OBJECTIVE

To determine the association between age and mortality in critically ill patients with pneumonia. We hypothesized that increasing age would be independently associated with both short- and long-term mortality.

DESIGN

Prospective population-based cohort study examining the association between age and 30-day (short-term) and 1-yr (long-term) mortality using Cox proportional hazards regression, adjusting for pneumonia severity, mechanical ventilation, sex, functional status, nursing home residence, and having a living will.

SETTING

Five intensive care units in Edmonton, Alberta, Canada.

PATIENTS

Critically ill adult patients with pneumonia.

MEASUREMENTS AND MAIN RESULTS

The cohort included 351 intensive care unit patients; mean age 61 yrs, 59% male, 16% from nursing homes. Mean Pneumonia Severity Index was 115 (73% Pneumonia Severity Index class IV or V), mean Acute Physiology and Chronic Health Evaluation II score 17, and 83% received invasive mechanical ventilation. Overall, 151 (43%) were < 60 yrs old, 64 (18%) were 60-69 yrs old, 82 (23%) were 70-79 yrs old, and 54 (15%) were ≥ 80 yrs old. By 30 days, 58 of 351 (17%) had died; by 1 yr, 112 of 351 (32%) had died. Mortality increased with age, 28 of 151 (19%) in those < 60 yrs, 14 of 64 (22%) in those 60-69 yrs, 39 of 82 (48%) in those 70-79 yrs, and 31 of 54 (57%) in those ≥ 80 yrs. Independent of pneumonia severity and other factors, age (per 10-yr increase) was associated with 30-day mortality (adjusted hazard ratio 1.24, 95% confidence interval 1.03-1.49, p = .026) and 1-yr mortality (adjusted hazard ratio 1.39, 95% confidence interval 1.21-1.60, p < .001). Having a living will was similarly associated with increased mortality (adjusted hazard ratio 3.08, 95% confidence interval 1.61-5.90, p < .001 at 30 days; adjusted hazard ratio 2.00, 95% confidence interval 1.21-3.32, p = .007 at 1 yr).

CONCLUSIONS

Increasing age was independently associated with risk-adjusted short- and long-term mortality in critically ill patients with pneumonia. These findings may help elderly patients, their families, and physicians better understand what intensive care unit admission can offer and help them to make more informed decisions.

The influence of age on the likelihood of receiving end-of-life care consistent with patient treatment preferences

BACKGROUND

Age differences may help to explain discrepancies in medical care received by cancer patients near death.

OBJECTIVES

Understanding age differences in advanced cancer patients' end-of-life experiences.

DESIGN

NCI and NIMH funded multi-site prospective cohort study.

PARTICIPANTS

396 deceased cancer patients, mean age (58.6 +/- 12.5), in the Coping with Cancer study.

MEASUREMENTS

Baseline interviews (Treatment Preference) and 1 week postmortem chart reviews (Treatment Received).

RESULTS

14.1% of patients were 20-44 years old, 54.0% were 45-64 years old, and 31.8% were > or = 65 years old. Compared to younger patients, middle-aged patients wanted less life-prolonging care (OR 0.32; CI 0.16-0.64). In the last week of life, older patients were less likely to undergo ventilation (OR 0.27; CI 0.07-1.00) than younger patients. Middle-aged patients who preferred life-prolonging care were less likely to receive it than younger patients (OR 0.21; CI 0.08-0.54), but were more likely to avoid unwanted life-prolonging care (OR 2.38; CI 1.20-4.75) than younger patients. Older patients were less likely to receive desired life-prolonging care than younger patients (OR 0.23; CI 0.08-0.68), however, they were not more likely to avoid unwanted life-prolonging care than younger patients (OR 1.74; CI 0.87-3.47).

CONCLUSIONS

Likelihood of a patient's treatment preference being consistent with care differ by age and treatment preferences. Older patients preferring life-prolonging therapies are less likely to receive them than younger patients; middle-aged patients who want to avoid life-prolonging care are more likely to do so than younger patients. Both findings have implications for patients' quality-of-death, indicating a need for further research.

Toward an integrated research agenda for critical illness in aging

Aging brings an increased predisposition to critical illness. Patients older than 65 years of age account for approximately half of all intensive care unit (ICU) admissions in the United States, a proportion that is expected to increase considerably with the aging of the population. Emerging research suggests that elderly survivors of intensive care suffer significant long-term sequelae, including accelerated age-related functional decline. Existing evidence-based interventions are frequently underused and their efficacy untested in older subjects. Improving ICU outcomes in the elderly will require not only better methods for translating sound science into improved ICU practice but also an enhanced understanding of the underlying molecular, physiological, and pathophysiological interactions of critical illness with the aging process itself. Yet, significant barriers to research for critical illness in aging exist. We review the state of knowledge and identify gaps in knowledge, research opportunities, and barriers to research, with the goal of promoting an integrated research agenda for critical illness in aging.

Preferences versus practice: life-sustaining treatments in last months of life in long-term care

PURPOSE

To determine prevalence and correlates of decisions made about specific life-sustaining treatments (LSTs) among residents in long-term care (LTC) settings, including characteristics associated with having an LST performed when the resident reportedly did not desire the LST.

DESIGN AND PARTICIPANTS

After-death interviews with 1 family caregiver and 1 staff caregiver for each of 327 LTC residents who died in the facility.

SETTING

The setting included 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in 4 states.

MEASUREMENTS

Decedent demographics, facility characteristics, prevalence of decisions made about specific LSTs, percentage of time LSTs were performed when reportedly not desired, and characteristics associated with that.

RESULTS

Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in 5 of 7 (71.4%) resuscitations, 1 of 7 feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, P=.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared with 32.8% of those whose decisions were concordant (P=.034).

CONCLUSION

Most respondents reported decision making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.

End-of-life concerns and care preferences: congruence among terminally ill elders and their family caregivers

This study examined the end-of-life challenges, concerns, and care preferences of terminally ill elders and their family caregivers, with a focus on areas of congruence and incongruence. Ten elders and 10 family caregivers participated in separate, semi-structured, face-to-face interviews. Data analysis included team coding and thematic analysis, guided by an a priori set of categories based on the study questions. Shared challenges and concerns included experiencing decline, managing pain and discomfort, and living with uncertainty. There was also congruence regarding end-of-life care preferences, specifically the importance of quality care, treatment with dignity and respect, and avoiding unnecessary life-sustaining treatment. Areas of incongruence included the elders' difficulties in accepting dependence, their fears of becoming a burden, and desire to be prepared for death. Family caregivers were most concerned with providing adequate care to meet the elders' physical and spiritual care needs. Open family communication was associated with greater congruence. The authors discuss implications of these findings for research and intervention.