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Smith NLH, Sudore RL, Myers AL, Hammes BJ, Hickman SE. Reasons for Discordance Between Life-Sustaining Treatment Preferences and Medical Orders in Nursing Facilities Without POLST. Am J Hosp Palliat Care 2023; 40:837-843. [PMID: 36154692 PMCID: PMC10321076 DOI: 10.1177/10499091221127996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Life-sustaining treatment (LST) orders are important communication tools used to ensure preference-concordant care at the end of life. Recent studies reveal concerning rates of discordance between current preferences and documented LST orders, especially in nursing facilities without POLST. Reasons for discordance in facilities using POLST have been explored, however the majority of nursing facilities in the United States do not yet use the POLST form. DESIGN Qualitative descriptive study using constant comparative analysis. SETTING Nursing facilities in Indiana (n = 6) not using POLST. PARTICIPANTS Residents (n = 15) and surrogate decision-makers of residents without decisional capacity (n = 15) with discordance between current preferences and documented LST orders. MEASUREMENTS Do not resuscitate, do not hospitalize (DNH), and do not intubate (DNI) orders were extracted from medical charts. Current preferences were elicited using the Respecting Choices Advanced Steps model. A semi-structured interview guide was used to explore reasons for discordance between current preferences and LST orders. RESULTS Reasons for discordance included: (1) inadequate information about the range of available LST options, what each involves, and how to formally communicate preferences; (2) no previous discussion with facility staff; (3) no documentation of previously expressed preferences; and (4) family involvement. CONCLUSION Reasons for discordance between expressed preferences and LST orders suggest that in facilities without a uniform and systematic LST order documentation strategy like POLST, these conversations may not occur and/or be documented. Staff should be aware that residents and surrogates may have preferences about LSTs that require strategic solicitation and documentation.
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Affiliation(s)
- Nicholette L. Heim Smith
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Anne L. Myers
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
| | - Bernard J. Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, WI, USA
| | - Susan E. Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, IN, USA
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, IN, USA
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
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2
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Chen Y, Qiao C, Zhang X, Li W, Yang H. The Effect of Tele-palliative Care on Patient and Caregiver Outcomes: A Systematic Review. Am J Hosp Palliat Care 2023; 40:907-925. [PMID: 36113129 DOI: 10.1177/10499091221123566] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Objectives: To describe the use of tele-palliative care in patients with advanced disease and assess its effectiveness on quality of life (QOL), symptom burden and other outcomes for patients and their caregivers. Methods: We searched for randomised controlled trials to assess the outcomes of tele-palliative care on patients with advanced disease and their caregivers. Eight databases were searched for studies published in Chinese or English from inception to November 27, 2021. Data from the included trials were extracted independently by 2 reviewers and evaluated independently for methodological quality using the Cochrane Collaboration's tool. A narrative synthesis of the results of all trials was performed. Results: Thirty trials were included ultimately with more than one half of the studies were moderate to high quality, including, which involved 19 665 patients and 1153 caregivers. Results from 10/15 included trials (reporting patient QOL), 5/14 trials (reporting patient symptoms), 1/3 trials (reporting survival), 8/13 trials (reporting patient mood), 3/6 trials (reporting ACP related indicators), 3/7 trials (reporting resource utilization) showed statistically significant between tele-palliative care and control care groups. Of 30 trials, 8 measured caregiver outcomes, 1/4 trials (reporting caregiver QOL) showed statistically significant, and results from 3/3 trials (reporting caregiver mood), 3/4 trials (reporting caregiver burden) showed benefit in at least 1 domain at 1 or more time points. Conclusions: This systematic review suggests that although tele-palliative care can improve patient physical, patient and caregiver psychological health outcomes to some extent, there is still a lack of sufficient evidence to substantiate its application effects. Moreever, regional and cultural characteristics should also be taken into account when tele-palliative care interventions are carried out.
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Affiliation(s)
- Yiping Chen
- School of nursing, Shanxi Medical University, Shanxi Province, China
- Department of Neurology, First Hospital of Shanxi Medical University, Shanxi Province, China
| | - Caihong Qiao
- Department of Neurology, First Hospital of Shanxi Medical University, Shanxi Province, China
| | - Xianhui Zhang
- School of nursing, Shanxi Medical University, Shanxi Province, China
- Department of Neurology, First Hospital of Shanxi Medical University, Shanxi Province, China
| | - Wei Li
- International Medical Department, Peking Union Medical College Hospital, Beijing, China
| | - Hui Yang
- School of nursing, Shanxi Medical University, Shanxi Province, China
- Department of Neurology, First Hospital of Shanxi Medical University, Shanxi Province, China
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3
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Hickman SE, Mitchell SL, Hanson LC, Tu W, Stump TE, Unroe KT. The design and conduct of a pragmatic cluster randomized trial of an advance care planning program for nursing home residents with dementia. Clin Trials 2022; 19:623-635. [PMID: 35815777 PMCID: PMC9691516 DOI: 10.1177/17407745221108992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS A significant number of people with Alzheimer's disease or related dementia diagnoses will be cared for in nursing homes near the end of life. Advance care planning (ACP), the process of eliciting and documenting patient-centered preferences for care, is considered essential to providing high quality care for this population. Nursing homes are currently required by regulations to offer ACP to residents and families, but no training requirements exist for nursing home staff, and approaches to fulfilling this regulatory and ethical responsibility vary. As a result, residents may receive care inconsistent with their goals, such as unwanted hospitalizations. Pragmatic trials offer a way to develop and test ACP in real-world settings to increase the likelihood of adoption of sustainable best practices. METHODS The "Aligning Patient Preferences-a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support (APPROACHES)" project is designed to pragmatically test and evaluate a staff-led program in 137 nursing homes (68 = intervention, 69 = control) owned by two nursing home corporations. Existing nursing home staff receive standardized training and implement the ACP Specialist program under the supervision of a corporate lead. The primary trial outcome is the annual rate of hospital transfers (admissions and emergency department visits). Consistent with the spirit of a pragmatic trial, study outcomes rely on data already collected for quality improvement, clinical, or billing purposes. Configurational analysis will also be performed to identify conditions associated with implementation. RESULTS Partnerships with large corporate companies enable the APPROACHES trial to rely on corporate infrastructure to roll out the intervention, with support for a corporate implementation lead who is charged with the initial introduction and ongoing support for nursing home-based ACP Specialists. These internal champions connect the project with other company priorities and use strategies familiar to nursing home leaders for the initiation of other programs. Standardized data collection across nursing homes also supports the conduct of pragmatic trials in this setting. DISCUSSION Many interventions to improve care in nursing homes have failed to demonstrate an impact or, if successful, maintain an impact over time. Pragmatic trials, designed to test interventions in real-world contexts that are evaluated through existing data sources collected routinely as part of clinical care, are well suited for the nursing home environment. A robust program that increases access to ACP for nursing home residents has the potential to increase goal-concordant care and is expected to reduce hospital transfers. If successful, the ACP Specialist Program will be primed for rapid translation into nursing home practice to reduce unwanted, burdensome hospitalizations and improve the quality of care for residents with dementia.
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Affiliation(s)
- Susan E Hickman
- School of Nursing, Indiana University, Indianapolis,
Indiana, U.S.,RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
| | - Susan L Mitchell
- Harvard Medical School, Boston, Massachusetts, U.S.,Beth Israel Deaconess Medical Center, Boston,
Massachusetts, U.S.,Marcus Institute for Aging Research, Boston, Massachusetts,
U.S
| | - Laura C Hanson
- School of Medicine, University of North Carolina, Chapel Hill,
North Carolina
| | - Wanzhu Tu
- IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S.,Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Timothy E Stump
- Department of Biostatistics & Health Data ScienceS, School of Medicine,
Indiana University, Indiana, U.S
| | - Kathleen T Unroe
- RESPECT (Research in Palliative and End-of-Life
Communication and Training) Signature Center, Indiana University Purdue University
Indianapolis, Indianapolis, Indiana, U.S.,Division of General Internal Medicine and Geriatrics, Department of Medicine, School of Medicine, Indiana University, Indiana, U.S.,IU Center for Aging Research, Regenstrief Institute Inc.,
Indianapolis, Indiana, U.S
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4
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Moyo P, Loomer L, Teno J, Gutman R, McCreedy EM, Bélanger E, Volandes AE, Mitchell S, Mor V. Effect of a Video-Assisted Advance Care Planning Intervention on End-of-Life Health Care Transitions Among Long-Stay Nursing Home Residents. J Am Med Dir Assoc 2022; 23:394-398. [PMID: 34627753 PMCID: PMC8885779 DOI: 10.1016/j.jamda.2021.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness. DESIGN Pragmatic cluster randomized clinical trial. Five ACP videos were available on tablets or online at intervention facilities. PROVEN champions employed by nursing homes (usually social workers) were directed to offer residents (or their proxies) ≥1 video under certain circumstances. Control facilities employed usual ACP practices. SETTING AND PARTICIPANTS PROVEN occurred from February 2016 to May 2019 in 360 nursing homes (119 intervention, 241 control) owned by 2 health care systems. This post hoc study of PROVEN data analyzed long-stay residents ≥65 years who died during the trial who had either advanced dementia or cardiopulmonary disease (advanced illness). We required an observation time ≥90 days before death. The analytic sample included 923 and 1925 advanced illness decedents in intervention and control arms; respectively. METHODS Outcomes included the proportion of residents with 1 or more hospital transfer (ie, hospitalization, emergency department use, or observation stay), multiple (≥3) hospital transfers during the last 90 days of life, and late transitions (ie, hospital transfer during the last 3 days or hospice admission on the last day of life). RESULTS Hospital transfers in the last 90 days of life among decedents with advanced illness were significantly lower in the intervention vs control arm (proportion difference = -1.7%, 95% CI -3.2%, -0.1%). The proportion of decedents with multiple hospital transfers and late transitions did not differ between the trial arms. CONCLUSIONS AND IMPLICATIONS Video-assisted ACP was modestly associated with reduced hospital transfers in the last 90 days of life among nursing home residents with advanced illness. The intervention was not significantly associated with late health care transitions and multiple hospital transfers.
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Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Lacey Loomer
- University of Minnesota Duluth Labovitz School of Business
and Economics, Department of Economics and Health Care Management, Duluth, MN,
USA
| | - Joan Teno
- Oregon Health Sciences University School of Medicine,
Portland, OR, USA
| | - Roee Gutman
- Brown University School of Public Health, Department of
Biostatistics, Providence, RI, USA
| | - Ellen M. McCreedy
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA
| | - Emmanuelle Bélanger
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA
| | - Angelo E. Volandes
- General Medicine, Harvard Medical School, Boston, MA,
USA,Section of General Medicine, Massachusetts General
Hospital, Boston, MA
| | - Susan Mitchell
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for
Aging Research, Boston, MA, USA,Department of Medicine, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - Vincent Mor
- Brown University School of Public Health, Department of
Health Services, Policy, and Practice, Providence, RI, USA,Providence VA Medical Center, Long Term Services and
Supports Center of Innovation, Providence, RI, USA
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5
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Hickman SE, Cole CS, Unroe KT. Leveraging Value-Based Purchasing to Improve Advance Care Planning. J Gerontol Nurs 2022; 48:31-35. [PMID: 35103523 DOI: 10.3928/00989134-20220110-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Advance care planning (ACP) is an important component of person-centered care for older adults in nursing facilities. Although nursing facilities have a statutory obligation to offer ACP to residents, there are no minimum training requirements for staff. Lack of consistent ACP training contributes to significant variability in ACP conversation quality, inaccurate or incomplete documentation of preferences, and infrequent re-evaluation of prior decisions. Indiana added ACP training for nursing facility staff to the Value-Based Purchasing formula for 2019. Facilities received 5 points (of a 100-point total formula) if at least one staff member completed the designated ACP training during the year. ACP Foundations Training was developed by faculty at Indiana University and made available to all Indiana nursing facilities. A total of 1,087 participants, representing 94.2% (501 of 532) Indiana nursing facilities, completed the training. Approximately every participant (99.4%) agreed that the training had practical value. This academic-government partnership was successful in providing basic information about ACP to staff at most nursing facilities across Indiana and offers a model for states to provide critical educational content to nursing facility staff by incentivizing training. [Journal of Gerontological Nursing, 48(2), 31-35.].
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6
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Orth J, Cagle JG. Nursing Home Alzheimer's Special Care Units: Geographic Location Matters. J Am Med Dir Assoc 2022; 23:150-155. [PMID: 34411539 PMCID: PMC8712367 DOI: 10.1016/j.jamda.2021.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/10/2021] [Accepted: 07/18/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Limited data suggest nursing home (NH) Alzheimer's special care units (ASCUs) may improve care and outcomes among residents with dementia. Unfortunately, information describing NH characteristics related to presence of ASCUs is lacking, especially whether location and neighborhood resources influence their presence. We examined locations of NHs with ASCUs and assessed whether neighborhood socioeconomic deprivation, region, and levels of rurality were associated with NH ASCUs. DESIGN Cross-sectional. SETTING AND PARTICIPANTS Contiguous United States; we used 2017 LTCfocus and NH Compare data to identify free-standing NHs and obtain addresses (N = 13,207 NHs). METHODS NH ZIP+4 codes were linked to the Area Deprivation Index (ADI) (within-state ranking of neighborhood deprivation). The 9 census-defined regions of the United States and Rural Urban Continuum codes categorized location. Descriptive analyses and binary logistic regression models, adjusting for NH characteristics, examined associations between NH ASCUs and location. RESULTS Nearly 15% of NHs had ASCUs. In adjusted models, odds of NH ASCUs were 58% to 69% lower in Pacific, Middle Atlantic, and Southern regions compared with the East North Central region (P values <.001). Odds of NH ASCUs increased 25% to 47% as rurality increased relative to NHs in the most metropolitan areas (P < .01); however, odds of NH ASCUs decreased 63% in the most rural areas (P < .001). ADI was not significantly associated with NH ASCUs. For-profit NHs had 42% lower and chain-affiliated NHs 34% higher odds of ASCUs (P < .001). NHs with higher total staffing hours had 29% higher odds of ASCUs; odds of ASCUs were 46% lower in NHs with more RN staffing hours (P < .001). CONCLUSIONS AND IMPLICATIONS Using a robust sample, region, rurality, ownership, and nursing hours significantly predicted NH ASCUs whereas ADI did not. Geographically tailored interventions should be considered to promote use of NH-based ASCUs.
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Affiliation(s)
- Jessica Orth
- University of Maryland School of Social Work, Baltimore, MD, USA.
| | - John G Cagle
- University of Maryland School of Social Work, Baltimore, MD, USA
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7
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Loomer L, Ogarek JA, Mitchell SL, Volandes AE, Gutman R, Gozalo PL, McCreedy EM, Mor V. Impact of an Advance Care Planning Video Intervention on Care of Short-Stay Nursing Home Patients. J Am Geriatr Soc 2020; 69:735-743. [PMID: 33159697 DOI: 10.1111/jgs.16918] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES To assess whether an advance care planning (ACP) video intervention impacts care among short-stay nursing home (NH) patients. DESIGN PRagmatic trial of Video Education in Nursing Homes (PROVEN) was a pragmatic cluster randomized clinical trial. SETTING A total of 360 NHs (N = 119 intervention, N = 241 control) owned by two healthcare systems. PARTICIPANTS A total of 2,538 and 5,290 short-stay patients with advanced dementia or cardiopulmonary disease (advanced illness) in the intervention and control arms, respectively; 23,302 and 50,815 short-stay patients without advanced illness in the intervention and control arms, respectively. INTERVENTION Five ACP videos were available on tablets or online. Designated champions at each intervention facility were instructed to offer a video to patients (or proxies) on admission. Control facilities used usual ACP practices. MEASUREMENTS Follow-up time was at most 100 days for each patient. Outcomes included hospital transfers per 1000 person-days alive and the proportion of patients experiencing more than one hospital transfer, more than one burdensome treatment (tube-feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission), and hospice enrollment. Champions recorded whether a video was offered in the patients' electronic medical record. RESULTS There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention versus control groups with advanced illness (rate (95% confidence interval (CI)), 12.3 (11.6-13.1) vs 13.2 (12.5-13.7); rate difference: -0.8; 95% CI = -1.8-0.2)). There was a nonsignificant reduction in hospital transfers per 1000 person-days alive in the intervention versus control among short-stay patients without advanced illness. Secondary outcomes did not differ between groups among patients with and without advanced illness. Based on champion only reports 14.2% and 15.3% of eligible short-stay patients with and without advanced illness were shown videos, respectively. CONCLUSION An ACP video program did not significantly reduce hospital transfers, burdensome treatment, or hospice enrollment among short-stay NH patients; however, fidelity to the intervention was low.
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Affiliation(s)
- Lacey Loomer
- Department of Economics, Labovitz School of Business and Economics, Duluth, Minnesota, USA
| | - Jessica A Ogarek
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Angelo E Volandes
- General Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Section of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Pedro L Gozalo
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
| | - Ellen M McCreedy
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vincent Mor
- Centers for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA.,Providence Veterans Administration, Center of Innovation in Health Services Research and Development Service, Providence, Rhode Island, USA
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8
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Tappen RM, Worch SM, Newman DO, Hain D. Evaluation of a Novel Decision Guide "Go to the Hospital or Stay Here?" for Nursing Home Residents and Families: A Randomized Trial. Res Gerontol Nurs 2020; 13:309-319. [PMID: 33034651 DOI: 10.3928/19404921-20201002-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/24/2020] [Indexed: 12/11/2022]
Abstract
Initiatives to reduce potentially preventable hospitalizations of nursing home residents have focused on staff response to changes in condition and advance care planning. Yet, resident and family insistence on transfer has been one of the most intractable sources of these hospitalizations, although not the target of active intervention until now. Consented residents and family members in the intervention group received a newly developed decision aid entitled, "Go to the Hospital or Stay Here?," providing information on the risks and benefits of transfer versus remaining in the nursing home. This person-centered decision aid was developed from the results of 271 interviews of residents, families, and providers to identify what they wanted to know and any misunderstandings surrounding the transfer process. Engaging residents in the decision respects their right to participate and provides the information they need to make a deliberative decision. The intervention group showed a gain in knowledge and reduction in decisional conflict but reported decreased decisional preparation. There was no decrease in transfers compared to the control group. Evaluation of the decision guide by residents and families was positive. TARGETS Nursing home residents and their family members. INTERVENTION To provide information regarding the decision to stay in the nursing home or transfer to acute care due to a change in condition. MECHANISMS OF ACTION Decision aid "Go the "Hospital or Stay Here?" to impart knowledge regarding the decision to remain in the nursing home or transfer to acute care. OUTCOMES Use of the Guide was found to increase residents' and family members' knowledge and decrease decisional conflict, but it did not increase decisional preparation. No reduction in transfers was found. Residents and families rated the Guide as very helpful. [Research in Gerontological Nursing, 13(6), 309-319.].
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9
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McDermott CL, Engelberg RA, Khandelwal N, Steiner JM, Feemster LC, Sibley J, Lober WB, Curtis JR. The Association of Advance Care Planning Documentation and End-of-Life Healthcare Use Among Patients With Multimorbidity. Am J Hosp Palliat Care 2020; 38:954-962. [PMID: 33084357 DOI: 10.1177/1049909120968527] [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: 11/17/2022] Open
Abstract
PURPOSE Multimorbidity is associated with increased intensity of end-of-life healthcare. This association has been examined by number but not type of conditions. Our purpose was to understand how intensity of care is influenced by multimorbidity within specific chronic conditions to provide guidance for interventions to improve end-of-life care for these patients. METHODS We identified adults cared for in a multihospital healthcare system who died between 2010-2017. We categorized patients by 4 primary chronic conditions: heart failure, pulmonary disease, renal disease, or dementia. Within each condition, we examined the effect of multimorbidity (presence of 4 or more chronic conditions) on hospital and ICU admission in the last 30 days of life, in-hospital death, and advance care planning (ACP) documentation >30 days before death. We performed logistic regression to estimate associations between multimorbidity and end-of-life care utilization, stratified by the presence or absence of ACP documentation. RESULTS ACP documentation >30 days before death was associated with lower odds of in-hospital death for all 4 conditions both in patients with and without multimorbidity. With the exception of patients with renal disease without multimorbidity, we observed lower odds of hospitalization and ICU admission for all patients with ACP >30 days before death. CONCLUSIONS Patients with dementia and multimorbidity had the highest odds of high-intensity end-of-life care. For patients with dementia, heart failure, or pulmonary disease, ACP documentation >30 days before death was associated with lower likelihood of in-hospital death, hospitalization, and ICU use at end-of-life, regardless of multimorbidity.
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Affiliation(s)
- Cara L McDermott
- Division of Pulmonary, Critical Care and Sleep Medicine, 7284University of Washington, Seattle, WA, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, 7284University of Washington, Seattle, WA, USA
| | - Nita Khandelwal
- Division of Anesthesiology and Pain Medicine, 7284University of Washington, Seattle, WA, USA
| | - Jill M Steiner
- Division of Cardiology, 7284University of Washington, Seattle, WA, USA
| | - Laura C Feemster
- Division of Pulmonary, Critical Care and Sleep Medicine, 7284University of Washington, Seattle, WA, USA.,VA Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
| | - James Sibley
- Department of Biobehavioral Nursing and Health Informatics, 7284University of Washington, Seattle, WA, USA
| | - William B Lober
- Department of Biobehavioral Nursing and Health Informatics, 7284University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, 7284University of Washington, Seattle, WA, USA
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10
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Chaudhuri D, Herritt B, Lewis K, Diaz-Gomez JL, Fox-Robichaud A, Ball I, Granton J, Rochwerg B. Dosing Fluids in Early Septic Shock. Chest 2020; 159:1493-1502. [PMID: 33058814 DOI: 10.1016/j.chest.2020.09.269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/15/2020] [Accepted: 09/30/2020] [Indexed: 12/14/2022] Open
Abstract
Early IV fluid administration remains one of the modern pillars of sepsis treatment; however, questions regarding amount, type, rate, mechanism of action, and even the benefits of fluid remain unanswered. Administering the optimal fluid volume is important, because overzealous fluid resuscitation can precipitate multiorgan failure, prolong mechanical ventilation, and worsen patient outcomes. After the initial resuscitation, further fluid administration should be determined by individual patient factors and measures of fluid responsiveness. This review describes various static and dynamic measures that are used to assess fluid responsiveness and summarizes the evidence addressing these metrics. Subsequently, we outline a practical approach to the evaluation of fluid responsiveness in early septic shock and explore further areas crucial to ongoing research examining this topic.
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Affiliation(s)
- Dipayan Chaudhuri
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Brent Herritt
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jose L Diaz-Gomez
- Division of Cardiovascular Anesthesiology and Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Alison Fox-Robichaud
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Ottawa, ON, Canada
| | - Ian Ball
- Department of Medicine, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - John Granton
- Division of Respirology, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
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11
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Mitchell SL, Volandes AE, Gutman R, Gozalo PL, Ogarek JA, Loomer L, McCreedy EM, Zhai R, Mor V. Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents: A Pragmatic Cluster Randomized Clinical Trial. JAMA Intern Med 2020; 180:1070-1078. [PMID: 32628258 PMCID: PMC7399750 DOI: 10.1001/jamainternmed.2020.2366] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Standardized, evidenced-based approaches to conducting advance care planning (ACP) in nursing homes are lacking. OBJECTIVE To test the effect of an ACP video program on hospital transfers, burdensome treatments, and hospice enrollment among long-stay nursing home residents with and without advanced illness. DESIGN, SETTING, AND PARTICIPANTS The Pragmatic Trial of Video Education in Nursing Homes was a pragmatic cluster randomized clinical trial conducted between February 1, 2016, and May 31, 2019, at 360 nursing homes (119 intervention and 241 control) in 32 states owned by 2 for-profit corporations. Participants included 4171 long-stay residents with advanced dementia or cardiopulmonary disease (hereafter referred to as advanced illness) in the intervention group and 8308 long-stay residents with advanced illness in the control group, 5764 long-stay residents without advanced illness in the intervention group, and 11 773 long-stay residents without advanced illness in the control group. Analyses followed the intention-to-treat principle. INTERVENTIONS Five 6- to 10-minute ACP videos were made available on tablet computers or online. Designated champions (mostly social workers) in intervention facilities were instructed to offer residents (or their proxies) the opportunity to view a video(s) on admission and every 6 months. Control facilities used usual ACP practices. MAIN OUTCOMES AND MEASURES Twelve-month outcomes were measured for each resident. The primary outcome was hospital transfers per 1000 person-days alive in the advanced illness cohort. Secondary outcomes included the proportion of residents with or without advanced illness experiencing 1 or more hospital transfer, 1 or more burdensome treatment, and hospice enrollment. To monitor fidelity, champions completed reports in the electronic record whenever they offered to show residents a video. RESULTS The study included 4171 long-stay residents with advanced illness in the intervention group (2970 women [71.2%]; mean [SD] age, 83.6 [9.1] years), and 8308 long-stay residents with advanced illness in the control group (5857 women [70.5%]; mean [SD] age, 83.6 [8.9] years), 5764 long-stay residents without advanced illness in the intervention group (3692 women [64.1%]; mean [SD] age, 81.5 [9.2] years), and 11 773 long-stay residents without advanced illness in the control group (7467 women [63.4%]; mean [SD] age, 81.3 [9.2] years). There was no significant reduction in hospital transfers per 1000 person-days alive in the intervention vs control groups (rate [SE], 3.7 [0.2]; 95% CI, 3.4-4.0 vs 3.9 [0.3]; 95% CI, 3.6-4.1; rate difference [SE], -0.2 [0.3]; 95% CI, -0.5 to 0.2). Secondary outcomes did not significantly differ between trial groups among residents with and without advanced illness. Based on champions' reports, 912 of 4171 residents with advanced illness (21.9%) viewed ACP videos. Facility-level rates of showing ACP videos ranged from 0% (14 of 119 facilities [11.8%]) to more than 40% (22 facilities [18.5%]). CONCLUSIONS AND RELEVANCE This study found that an ACP video program was not effective in reducing hospital transfers, decreasing burdensome treatment use, or increasing hospice enrollment among long-stay residents with or without advanced illness. Intervention fidelity was low, highlighting the challenges of implementing new programs in nursing homes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02612688.
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Affiliation(s)
- Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Angelo E Volandes
- Section of General Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Lacey Loomer
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ellen M McCreedy
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ruoshui Zhai
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Affairs Medical Center, Providence, Rhode Island
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Howe EG. Sweetening the “Sweet Spot” of Dementia. THE JOURNAL OF CLINICAL ETHICS 2020. [DOI: 10.1086/jce2020312099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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13
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Palmer JA, Parker VA, Barre LR, Mor V, Volandes AE, Belanger E, Loomer L, McCreedy E, Mitchell SL. Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination. Trials 2019. [PMID: 31779684 DOI: 10.1186/s13063‐019‐3725‐5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is one of the first large pragmatic randomized clinical trials (pRCTs) to be conducted in U.S. nursing homes (N = 119 intervention and N = 241 control across two health-care systems). The trial aims to evaluate the effectiveness of a suite of videos to improve advance care planning (ACP) for nursing home patients. This report uses mixed methods to explore the optimal and suboptimal conditions necessary for implementation fidelity within pRCTs in nursing homes. METHODS PROVEN's protocol required designated facility champions to offer an ACP video to long-stay patients every 6 months during the 18-month implementation period. Champions completed a video status report, stored within electronic medical records, each time a video was offered. Data from the report were used to derive each facility's adherence rate (i.e., cumulative video offer). Qualitative interviews held after 15 months with champions were purposively sampled from facilities within the highest and lowest adherence rates (i.e., those in the top and bottom quintiles). Two researchers analyzed interview data thematically using a deductive approach based upon six domains of the revised Conceptual Framework for Implementation Fidelity (CFIF). Matrices were developed to compare coded narratives by domain across facility adherence status. RESULTS In total, 28 interviews involving 33 champions were analyzed. Different patterns were observed across high- versus low-adherence facilities for five CFIF domains. In low-adherence nursing homes, (1) there were limited implementation resources (Context), (2) there was often a perceived negative patient or family responsiveness to the program (Participant Responsiveness), and (3) champions were reticent in offering the videos (Recruitment). In high-adherence nursing homes, (1) there was more perceived patient and family willingness to engage in the program (Participant Responsiveness), (2) champions supplemented the video with ACP conversations (Quality of Delivery), (3) there were strategic approaches to recruitment (Recruitment), and (4) champions appreciated external facilitation (Strategies to Facilitate Implementation). CONCLUSIONS Critical lessons for implementing pRCTs in nursing homes emerged from this report: (1) flexible fidelity is important (i.e., delivering core elements of an intervention while permitting the adaptation of non-core elements), (2) reciprocal facilitation is vital (i.e., early and ongoing stakeholder engagement in research design and, reciprocally, researchers' and organizational leaders' ongoing support of the implementation), and (3) organizational and champion readiness should be formally assessed early and throughout implementation to facilitate remediation. TRIAL REGISTRATION ClinicalTrials.gov, NCT02612688. Registered on 19 November 2015.
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Affiliation(s)
- Jennifer A Palmer
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA. .,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA. .,Department of Medicine, Beth Israel Deaconess Medical Center, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Victoria A Parker
- Peter T. Paul College of Business and Economics, University of New Hampshire, 10 Garrison Avenue, Durham, NH, 03824, USA
| | - Lacey R Barre
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Administration Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Angelo E Volandes
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Section of General Medicine, Massachusetts General Hospital, 55 Fruit Street Gray 7-730, Boston, MA, 02114, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Susan L Mitchell
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA
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14
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Palmer JA, Parker VA, Barre LR, Mor V, Volandes AE, Belanger E, Loomer L, McCreedy E, Mitchell SL. Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination. Trials 2019; 20:656. [PMID: 31779684 PMCID: PMC6883560 DOI: 10.1186/s13063-019-3725-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/13/2019] [Indexed: 11/26/2022] Open
Abstract
Background The Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is one of the first large pragmatic randomized clinical trials (pRCTs) to be conducted in U.S. nursing homes (N = 119 intervention and N = 241 control across two health-care systems). The trial aims to evaluate the effectiveness of a suite of videos to improve advance care planning (ACP) for nursing home patients. This report uses mixed methods to explore the optimal and suboptimal conditions necessary for implementation fidelity within pRCTs in nursing homes. Methods PROVEN’s protocol required designated facility champions to offer an ACP video to long-stay patients every 6 months during the 18-month implementation period. Champions completed a video status report, stored within electronic medical records, each time a video was offered. Data from the report were used to derive each facility’s adherence rate (i.e., cumulative video offer). Qualitative interviews held after 15 months with champions were purposively sampled from facilities within the highest and lowest adherence rates (i.e., those in the top and bottom quintiles). Two researchers analyzed interview data thematically using a deductive approach based upon six domains of the revised Conceptual Framework for Implementation Fidelity (CFIF). Matrices were developed to compare coded narratives by domain across facility adherence status. Results In total, 28 interviews involving 33 champions were analyzed. Different patterns were observed across high- versus low-adherence facilities for five CFIF domains. In low-adherence nursing homes, (1) there were limited implementation resources (Context), (2) there was often a perceived negative patient or family responsiveness to the program (Participant Responsiveness), and (3) champions were reticent in offering the videos (Recruitment). In high-adherence nursing homes, (1) there was more perceived patient and family willingness to engage in the program (Participant Responsiveness), (2) champions supplemented the video with ACP conversations (Quality of Delivery), (3) there were strategic approaches to recruitment (Recruitment), and (4) champions appreciated external facilitation (Strategies to Facilitate Implementation). Conclusions Critical lessons for implementing pRCTs in nursing homes emerged from this report: (1) flexible fidelity is important (i.e., delivering core elements of an intervention while permitting the adaptation of non-core elements), (2) reciprocal facilitation is vital (i.e., early and ongoing stakeholder engagement in research design and, reciprocally, researchers’ and organizational leaders’ ongoing support of the implementation), and (3) organizational and champion readiness should be formally assessed early and throughout implementation to facilitate remediation. Trial registration ClinicalTrials.gov, NCT02612688. Registered on 19 November 2015.
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Affiliation(s)
- Jennifer A Palmer
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA. .,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA. .,Department of Medicine, Beth Israel Deaconess Medical Center, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Victoria A Parker
- Peter T. Paul College of Business and Economics, University of New Hampshire, 10 Garrison Avenue, Durham, NH, 03824, USA
| | - Lacey R Barre
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center of Innovation in Health Services Research and Development Service, Providence Veterans Administration Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Angelo E Volandes
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Section of General Medicine, Massachusetts General Hospital, 55 Fruit Street Gray 7-730, Boston, MA, 02114, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA.,Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Lacey Loomer
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, 121 S Main St, Providence, RI, 02903, USA
| | - Susan L Mitchell
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02215, USA.,Hebrew SeniorLife, Hinda & Arthur Marcus Institute for Aging Research, 1200 Centre Street, Roslindale, MA, 02131, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, East Campus, Yamins 419, 330 Brookline Avenue, Boston, MA, 02215, USA
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15
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Tropea J, Johnson CE, Nestel D, Paul SK, Brand CA, Hutchinson AF, Bicknell R, Lim WK. A screen-based simulation training program to improve palliative care of people with advanced dementia living in residential aged care facilities and reduce hospital transfers: study protocol for the IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) cluster randomised controlled trial. BMC Palliat Care 2019; 18:86. [PMID: 31647010 PMCID: PMC6813113 DOI: 10.1186/s12904-019-0474-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 10/02/2019] [Indexed: 11/26/2022] Open
Abstract
Background Many people with advanced dementia live in residential aged care homes. Care home staff need the knowledge and skills to provide high-quality end-of-life (EOL) dementia care. However, several studies have found EOL dementia care to be suboptimal, and care staff have reported they would benefit from training in palliative care and dementia. Simulation offers an immersive learning environment and has been shown to improve learners’ knowledge and skills. However, there is little research on simulation training for residential care staff. This article presents the development and evaluation protocol of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) - a screen-based simulation training program on palliative dementia care, targeted at residential care staff. IMPETUS-D aims to improve the quality of palliative care provided to people living with dementia in residential care homes, including avoiding unnecessary transfers to hospital. Methods A cluster RCT will assess the effect of IMPETUS-D. Twenty-four care homes (clusters) in three Australian cities will be randomised to receive either the IMPETUS-D intervention or usual training opportunities (control). The primary outcome is to reduce transfers to hospital and deaths in hospital by 20% over 6-months in the intervention compared to the control group. Secondary outcomes include uptake of goals of care plans over 6 and 12 months, change in staff knowledge and attitudes towards palliative dementia care over 6 months, change in transfers to hospital and deaths in hospital over 12 months. For the primary analysis logistic regression models will be used with standard errors weighted by the cluster effects. A mixed methods process evaluation will be conducted alongside the cluster RCT to assess the mechanisms of impact, the implementation processes and contextual factors that may influence the delivery and effects of the intervention. Discussion In Australia, the need for high-quality advanced dementia care delivered in residential aged care is growing. This study will assess the effect of IMPETUS-D a new simulation-based training program on dementia palliative and EOL care. This large multisite trial will provide robust evidence about the impact of the intervention. If successful, it will be distributed to the broader residential care sector. Trial registration ANZCTR, ACTRN12618002012257. Registered 14 December 2018.
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Affiliation(s)
- Joanne Tropea
- Melbourne EpiCentre, Royal Melbourne Hospital, University of Melbourne and Melbourne Health, 7 East Main building, 300 Grattan Street, Parkville, VIC, 3050, Australia.
| | - Christina E Johnson
- Monash Doctors Education, Monash Health Faculty of Medicine, Nursing and Health Sciences, Monash University, Monash Medical Centre, 246 Clayton Rd, Clayton, VIC, 3168, Australia
| | - Debra Nestel
- Monash Institute for Health & Clinical Education, Monash University, 27 Rainforest Walk Wellington Road, Clayton, VIC, 3800, Australia
| | - Sanjoy K Paul
- Melbourne EpiCentre, Royal Melbourne Hospital, University of Melbourne and Melbourne Health, 7 East Main building, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Caroline A Brand
- Melbourne EpiCentre, Royal Melbourne Hospital, University of Melbourne and Melbourne Health, 7 East Main building, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Anastasia F Hutchinson
- School of Nursing and Midwifery, Deakin University, Locked Bag 20000, Geelong, VIC, 3220, Australia
| | - Ross Bicknell
- Department of Medicine and Aged Care, Melbourne Health and Department of Medicine - Royal Melbourne Hospital, University of Melbourne, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Wen Kwang Lim
- Department of Medicine and Aged Care, Melbourne Health and Department of Medicine - Royal Melbourne Hospital, University of Melbourne, 300 Grattan Street, Parkville, VIC, 3050, Australia
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16
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Digout C, Lawson B, MacKenzie A, Burge F. Prevalence of Having Advance Directives and a Signed Power of Attorney in Nova Scotia. J Palliat Care 2019; 34:189-196. [DOI: 10.1177/0825859719831312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christian Digout
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Beverley Lawson
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Adrian MacKenzie
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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17
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Cohen SM, Volandes AE, Shaffer ML, Hanson LC, Habtemariam D, Mitchell SL. Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial. J Pain Symptom Manage 2019; 57:37-46.e1. [PMID: 30273717 PMCID: PMC6310643 DOI: 10.1016/j.jpainsymman.2018.09.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/14/2018] [Accepted: 09/20/2018] [Indexed: 11/23/2022]
Abstract
CONTEXT Care consistent with goals is the desired outcome of advance care planning (ACP). OBJECTIVES The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance. METHODS Data were from Educational Video to Improve Nursing home Care in End-stage dementia, a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N = 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube-feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined. RESULTS Among the residents (mean age, 86.6 years; 19.5% male), the most prevalent directive was DNR (89.3%) and foregoing antibiotics was least common (parenteral, 8.2%; any type, 4.0%). Concordance between directives and each level of care preference was as follows: comfort, 7%; basic, 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% vs. 2.5%; adjusted odds ratio, 2.48; 95% CI, 1.01-6.09). CONCLUSION Better alignment between preferences for comfort-focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal.
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Affiliation(s)
- Simon M Cohen
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA
| | - Angelo E Volandes
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele L Shaffer
- Department of Statistics, University of Washington, Seattle, Washington, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Cecil G. Sheps Center for Health Services Research and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel Habtemariam
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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McCarron M, McCallion P, Watchman K, Janicki MP, Coppus A, Service K, Fortea J, Hogan M, Reilly E, Stemp S. Quality Care for People with Intellectual Disability and Advanced Dementia: Guidance on Service Provision. J Palliat Med 2018; 21:1344-1352. [DOI: 10.1089/jpm.2017.0442] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mary McCarron
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Philip McCallion
- School of Social Work, Temple University, Philadelphia, Pennsylvania
| | - Karen Watchman
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, Scotland
| | | | - Antonia Coppus
- School of Medicine, Radboud University, Nijmegen, The Netherlands
| | | | - Juan Fortea
- Catalan Foundation for Down Syndrome, Barcelona, Spain
| | | | - Evelyn Reilly
- Daughters of Charity Disability Support Service, Dublin, Ireland
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Mitchell SL, Shaffer ML, Cohen S, Hanson LC, Habtemariam D, Volandes AE. An Advance Care Planning Video Decision Support Tool for Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial. JAMA Intern Med 2018; 178:961-969. [PMID: 29868778 PMCID: PMC6033645 DOI: 10.1001/jamainternmed.2018.1506] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Better advance care planning (ACP) can help promote goal-directed care in patients with advanced dementia. OBJECTIVES To test whether an ACP video (vs usual care) has an effect on documented advance directives, level of care preferences, goals-of-care discussions, and burdensome treatments among nursing home residents with advanced dementia. DESIGN, SETTING, AND PARTICIPANTS The Educational Video to Improve Nursing home Care in End-stage dementia (EVINCE) trial was a cluster randomized clinical trial conducted between February 2013 and July 2017, at 64 Boston-area nursing homes (32 facilities per arm). A total of 402 residents with advanced dementia and their proxies (intervention arm, n = 212; control arm, n = 190) were assessed quarterly for 12 months. INTERVENTIONS A 12-minute ACP video for proxies with written communication of their preferred level of care (comfort, basic, or intensive) to the primary care team. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of residents with do-not-hospitalize (DNH) directives by 6 months. Secondary outcomes included preference for comfort care, documented directives to withhold tube-feeding and intravenous hydration, documented goals-of-care discussions, and burdensome treatments (hospital transfers, tube-feeding, or parenteral therapy) per 1000 resident-days. Exploratory analyses examined associations between trial arm and documented advance directives when comfort care was preferred. RESULTS The mean age of the 402 study residents was 86.7 years [range, 67-102 years]; 350 were white (87.1%) and 323 were female (80.3%), with DNH directives that by 6 months did not differ between arms (63% in both arms; adjusted odds ratio [AOR], 1.08; 95% CI, 0.69-1.69). Preferences for comfort care, directives to withhold intravenous hydration, and burdensome treatments did not differ between arms. Residents in intervention vs control facilities were more likely to have directives for no tube-feeding at 6 months (70.10% vs 61.90%; AOR, 1.79; 95% CI, 1.13-2.82) and all other time periods, and documented goals-of-care discussions at 3 months (16.10% vs 7.90%; AOR, 2.58; 95% CI, 1.20-5.54). When comfort care was preferred, residents in the intervention arm were more likely to have both DNH and no tube-feeding directives (72.20% vs 52.80%; AOR, 2.68; 95% CI, 2.68-5.85). CONCLUSIONS AND RELEVANCE An ACP video did not have an effect on preferences, DNH status, or burdensome treatments among residents with advanced dementia, but did increase directives to withhold tube-feeding. When proxies preferred comfort care, advance directives of residents in the intervention arm were more likely to align with that preference. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01774799.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Simon Cohen
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research and School of Medicine, Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill
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Patira R, Zhao H, Azizi A. A retrospective analysis of care in patients with dementia hospitalized at a tertiary medical center. Aging Ment Health 2018; 22:773-777. [PMID: 28326805 DOI: 10.1080/13607863.2017.1304525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hospitalization is an opportunity to address various aspects related to management of dementia, including the goals of care to avoid futile care. We studied the prevalence of these factors when patients with dementia are hospitalized. DESIGN One hundred and thirty-one charts of patients with dementia admitted to a single university-based hospital were retrospectively reviewed. Data were collected and analyzed for age, gender, the severity of dementia, co-morbidities, co-existing vascular dementia, reversible causes of dementia, mental status scores, medications, consultations, procedures, complications, availability of advance directives, decision-maker, code status, and goals of care discussion. RESULTS In patients with dementia, co-morbidities and vascular disease burden were frequent. When these patients were hospitalized, use of psychotropic medications, invasive procedures, and multi-specialty consultations was common. Tests of mental status, screening for reversible causes, and use of FDA-approved medications for dementia is less common. Despite the lack of advance directives, goals of care were infrequently discussed. When goals of care were discussed, proxy decision-maker preferred palliative care and long-term institutionalization on discharge. CONCLUSION Goals of care and other aspects of management are not fully addressed in hospitalized patients with dementia.
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Affiliation(s)
- Riddhi Patira
- a Department of Neurology, Temple University Hospital , Philadelphia , PA , USA
| | - Huaqing Zhao
- b Department of Biostatistics, Temple University Hospital , Philadelphia , PA , USA
| | - Ausim Azizi
- a Department of Neurology, Temple University Hospital , Philadelphia , PA , USA
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Givens JL, Sudore RL, Marshall GA, Dufour AB, Kopits I, Mitchell SL. Advance Care Planning in Community-Dwelling Patients With Dementia. J Pain Symptom Manage 2018; 55:1105-1112. [PMID: 29247754 PMCID: PMC5866907 DOI: 10.1016/j.jpainsymman.2017.12.473] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/06/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Little is known about advance care planning (ACP) among community-dwelling patients with dementia. OBJECTIVES To describe aspects of ACP among patients with dementia and examine the association between ACP and health care proxy (HCP) acceptance of patients' illness. METHODS Cross-sectional observational survey of 62 HCPs of patients with dementia (N = 14 mild, N = 48 moderate/severe), from seven outpatient geriatric and memory disorder clinics in Boston. Aspects of ACP included HCP's report of patients' preferences for level of future care, communication with HCP and physician regarding care preferences, and proxy preparedness for shared decision making. The association between ACP and HCP acceptance with patients' illness was examined using the Peace, Equanimity, and Acceptance subscale of the Cancer Experience Scale. RESULTS Eleven percent of proxies believed that the patient would want life-prolonging treatment, 31% a time-limited trial of curative treatment, and 47% comfort-focused care. Thirty-one percent reported that the patient had communicated with their physician regarding preferences for care, and 77% had communicated with the HCP. Forty-four percent of HCPs wanted more discussion with the patient regarding care preferences. The HCP having discussed care preferences with the patient was associated with greater acceptance of the patient's illness (P = 0.004). CONCLUSION Our findings support need for greater ACP discussions between patients and proxies. Discussions regarding goals of care are likely to benefit patients through delivery of care congruent with their wishes and HCPs in terms of greater acceptance of patients' illness.
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Affiliation(s)
- Jane L Givens
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Gad A Marshall
- Department of Neurology, Brigham and Women's Hospital, Center for Alzheimer Research and Treatment, Boston, Massachusetts, USA; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alyssa B Dufour
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ilona Kopits
- Division of Geriatrics, Boston Medical Center, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Abstract
UNLABELLED ABSTRACTBackground:Advance directives are important for nursing home residents with dementia; for those with advanced dementia, surrogates determine medical decisions. However, in Taiwan, little is known about what influences the completion of these advance directives. The purpose of this study was to identify factors, which influence the presence of advance directives for nursing home residents with dementia in Taiwan. METHOD Our cross-sectional study analyzed a convenience sample of 143 nursing home dyads comprised of residents with dementia and family surrogates. Documentation of residents' advance directives, physical and cognitive status was obtained from medical charts. Surrogates completed the stress of end-of-life care decision scale and a questionnaire regarding their demographic characteristics. Nursing home characteristics were obtained from each chief administrator. RESULTS Less than half of the nursing home residents (39.2%) had advance directives and most (96.4%) had been completed by family surrogates. The following were predictors of an advance directive: surrogates had previously signed a do-not-resuscitate as a proxy and had been informed of advance directives by a healthcare provider; nursing homes had policies for advance directives and a religious affiliation. CONCLUSIONS Advance directives were uncommon for nursing home residents with dementia. Presence of an advance directive was associated with surrogate characteristics and the nursing home facilities; there was no association with characteristics of the nursing home resident. Our findings emphasize the need to develop policies and strategies, which ensure that all residents of nursing homes and their surrogates are aware of their right to an advance directive.
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Kurita K, Reid MC, Siegler EL, Diamond EL, Prigerson HG. Associations between Mild Cognitive Dysfunction and End-of-Life Outcomes in Patients with Advanced Cancer. J Palliat Med 2018; 21:536-540. [PMID: 29298104 DOI: 10.1089/jpm.2017.0385] [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] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cognitive function of patients with advanced cancer is frequently compromised. OBJECTIVE To determine the extent that patients' cognitive screening scores was associated with their end-of-life (EoL) treatment preferences, advance care planning (ACP), and care. DESIGN Patients were interviewed at baseline and administered a cognitive screen. Caregivers completed a postmortem assessment. SETTING/SUBJECTS Patients with distant metastases and disease progression after first-line chemotherapy and their caregivers (n = 609) were recruited from outpatient clinics and completed baseline and postmortem assessments. MEASUREMENTS In logistic regression models adjusting for patients' age, education level, and performance status, patients' scores on the Pfeiffer Short Portable Mental Status exam at baseline predicted ACP, treatments, and treatment preferences at baseline, and location of death and caregiver perceptions of the patients' death in a postmortem assessment. RESULTS For each additional error, patients were less likely to consider the intensive care unit a bad place to die (adjusted odds ratio [AOR] = 0.81; confidence interval [95% CI]: 0.66-0.98; p = 0.03) and less likely to have an inpatient hospice stay (AOR = 0.63; 95% CI: 0.40-1.00; p = 0.05). After death (n = 318), caregivers were more likely to perceive that patients died at patients' preferred location (AOR = 1.38; 95% CI: 1.01-1.88; p = 0.04) and less likely to perceive that patients preferred to extend life over relieving discomfort (AOR = 0.63; 95% CI: 0.40-0.99; p = 0.05). CONCLUSIONS Patient cognitive screening scores were associated with EoL outcomes. Rather than avoid patients who are cognitively impaired, oncologists should consider ACP with them.
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Affiliation(s)
- Keiko Kurita
- 1 Center for Research on End-of-Life Care , Weill Cornell Medicine, New York, New York.,2 Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine , New York, New York
| | - M Cary Reid
- 2 Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine , New York, New York
| | - Eugenia L Siegler
- 2 Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine , New York, New York
| | - Eli L Diamond
- 3 Department of Neurology, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Holly G Prigerson
- 1 Center for Research on End-of-Life Care , Weill Cornell Medicine, New York, New York.,2 Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine , New York, New York
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Mitchell SL, Palmer JA, Volandes AE, Hanson LC, Habtemariam D, Shaffer ML. Level of Care Preferences Among Nursing Home Residents With Advanced Dementia. J Pain Symptom Manage 2017; 54:340-345. [PMID: 28797857 PMCID: PMC5744260 DOI: 10.1016/j.jpainsymman.2017.04.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/18/2017] [Accepted: 04/13/2017] [Indexed: 11/16/2022]
Abstract
CONTEXT Delivering goal-directed care is a hallmark of high-quality palliative care, but requires an understanding of preferences. OBJECTIVES To describe and identify factors associated with level of care preferences among proxies of nursing home (NH) residents with advanced dementia. METHODS NH residents with advanced dementia and their proxies (N = 402 dyads) were recruited from 62 Boston-area facilities as part of an ongoing randomized clinical trial. At baseline, all proxies were asked to select which level of care they felt the resident should receive: intensive, basic, or comfort care. Multivariable logistic regression identified resident and proxy factors associated with a preference for comfort care (vs. basic or intensive medical care). RESULTS Proxy level of care preferences were: comfort, 62.2%; basic, 31.1%; and intensive medical care, 6.5%. In multivariable analyses, proxy perception that the resident had less than six months to live was most strongly associated with a preference for comfort-focused care (adjusted odds ratio 12.25, 95% CI 4.04-37.08). Additional factors significantly associated with a preference for comfort care included older resident age, worse resident cognitive impairment, and the proxy having been asked about goals of care preferences by a NH health care provider (adjusted odds ratio 1.71, 95% CI 1.07, 2.74). CONCLUSION Most proxies select comfort as the preferred level of care for NH residents with advanced dementia. Discussions regarding prognosis, as well as inquiry about goals of care, are modifiable factors that may promote a preference for comfort care in this population.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Jennifer A Palmer
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Angelo E Volandes
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Cecil G. Sheps Center for Health Services Research and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel Habtemariam
- Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts, USA
| | - Michele L Shaffer
- Department of Pediatrics, University of Washington and Children's Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, Washington, USA
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Agar M, Luckett T, Luscombe G, Phillips J, Beattie E, Pond D, Mitchell G, Davidson PM, Cook J, Brooks D, Houltram J, Goodall S, Chenoweth L. Effects of facilitated family case conferencing for advanced dementia: A cluster randomised clinical trial. PLoS One 2017; 12:e0181020. [PMID: 28786995 PMCID: PMC5546584 DOI: 10.1371/journal.pone.0181020] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/15/2017] [Indexed: 12/01/2022] Open
Abstract
Background Palliative care planning for nursing home residents with advanced dementia is often suboptimal. This study compared effects of facilitated case conferencing (FCC) with usual care (UC) on end-of-life care. Methods A two arm parallel cluster randomised controlled trial was conducted. The sample included people with advanced dementia from 20 Australian nursing homes and their families and professional caregivers. In each intervention nursing home (n = 10), Palliative Care Planning Coordinators (PCPCs) facilitated family case conferences and trained staff in person-centred palliative care for 16 hours per week over 18 months. The primary outcome was family-rated quality of end-of-life care (End-of-Life Dementia [EOLD] Scales). Secondary outcomes included nurse-rated EOLD scales, resident quality of life (Quality of Life in Late-stage Dementia [QUALID]) and quality of care over the last month of life (pharmacological/non-pharmacological palliative strategies, hospitalization or inappropriate interventions). Results Two-hundred-eighty-six people with advanced dementia took part but only 131 died (64 in UC and 67 in FCC which was fewer than anticipated), rendering the primary analysis under-powered with no group effect seen in EOLD scales. Significant differences in pharmacological (P < 0.01) and non-pharmacological (P < 0.05) palliative management in last month of life were seen. Intercurrent illness was associated with lower family-rated EOLD Satisfaction with Care (coefficient 2.97, P < 0.05) and lower staff-rated EOLD Comfort Assessment with Dying (coefficient 4.37, P < 0.01). Per protocol analyses showed positive relationships between EOLD and staff hours to bed ratios, proportion of residents with dementia and staff attitudes. Conclusion FCC facilitates a palliative approach to care. Future trials of case conferencing should consider outcomes and processes regarding decision making and planning for anticipated events and acute illness. Trial registration Australian New Zealand Clinical Trial Registry ACTRN12612001164886
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Affiliation(s)
- Meera Agar
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
- South Western Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
- Improving Palliative Care through Clinical Trials (ImPaCCT), Sydney, NSW, Australia
| | - Tim Luckett
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
- * E-mail:
| | - Georgina Luscombe
- Sydney Medical School, The University of Sydney, Ultimo, NSW, Australia
| | - Jane Phillips
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
| | - Elizabeth Beattie
- School of Nursing, Queensland University of Technology, Herston, Queensland (QLD), Australia
| | - Dimity Pond
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Geoffrey Mitchell
- Faculty of Medicine, The University of Queensland, St Lucia, QLD, Australia
| | - Patricia M. Davidson
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Janet Cook
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales (NSW), Australia
| | - Deborah Brooks
- School of Nursing, Queensland University of Technology, Herston, Queensland (QLD), Australia
| | - Jennifer Houltram
- Centre for Health Research and Evaluation (CHERE), Faculty of Business, UTS, Haymarket, NSW, Australia
| | - Stephen Goodall
- Centre for Health Research and Evaluation (CHERE), Faculty of Business, UTS, Haymarket, NSW, Australia
| | - Lynnette Chenoweth
- Centre for Healthy Brain Ageing, University of New South Wales, Randwick, NSW, Australia
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Are Hospital/ED Transfers Less Likely Among Nursing Home Residents With Do-Not-Hospitalize Orders? J Am Med Dir Assoc 2017; 18:438-441. [DOI: 10.1016/j.jamda.2016.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 11/21/2022]
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Oldham MA, Piddoubny W, Peterson R, Lee HB. Detection and Management of Preexisting Cognitive Impairment in the Critical Care Unit. Crit Care Clin 2017; 33:441-459. [PMID: 28601131 DOI: 10.1016/j.ccc.2017.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Older adults account for half of intensive care unit (ICU) admissions and ICU days, and approximately 2 in 5 older adults in the ICU have preexisting cognitive impairment (PCI). PCI identification is important for risk stratification and may influence ICU utilization and decision-making surrogacy. PCI is overlooked in more than half of patients without screening; however, screening instruments can identify PCI in less than 5 minutes. Management of PCI in the ICU involves addressing associated neuropsychiatric symptoms. Nonpharmacological interventions should be considered the mainstay of treatment; psychotropics may be considered, although available data on their efficacy is limited.
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Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, Yale School of Medicine, 20 York Street, Fitkin 615, New Haven, CT 06510, USA.
| | - Walter Piddoubny
- Department of Psychiatry, Yale School of Medicine, 20 York Street, Fitkin 615, New Haven, CT 06510, USA
| | - Ryan Peterson
- Department of Psychiatry, Yale School of Medicine, 20 York Street, Fitkin 615, New Haven, CT 06510, USA
| | - Hochang B Lee
- Department of Psychiatry, Yale School of Medicine, 20 York Street, Fitkin 615, New Haven, CT 06510, USA
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Mor V, Volandes AE, Gutman R, Gatsonis C, Mitchell SL. PRagmatic trial Of Video Education in Nursing homes: The design and rationale for a pragmatic cluster randomized trial in the nursing home setting. Clin Trials 2017; 14:140-151. [PMID: 28068789 PMCID: PMC5376219 DOI: 10.1177/1740774516685298] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background/Aims Nursing homes are complex healthcare systems serving an increasingly sick population. Nursing homes must engage patients in advance care planning, but do so inconsistently. Video decision support tools improved advance care planning in small randomized controlled trials. Pragmatic trials are increasingly employed in health services research, although not commonly in the nursing home setting to which they are well-suited. This report presents the design and rationale for a pragmatic cluster randomized controlled trial that evaluated the "real world" application of an Advance Care Planning Video Program in two large US nursing home healthcare systems. Methods PRagmatic trial Of Video Education in Nursing homes was conducted in 360 nursing homes (N = 119 intervention/N = 241 control) owned by two healthcare systems. Over an 18-month implementation period, intervention facilities were instructed to offer the Advance Care Planning Video Program to all patients. Control facilities employed usual advance care planning practices. Patient characteristics and outcomes were ascertained from Medicare Claims, Minimum Data Set assessments, and facility electronic medical record data. Intervention adherence was measured using a Video Status Report embedded into electronic medical record systems. The primary outcome was the number of hospitalizations/person-day alive among long-stay patients with advanced dementia or cardiopulmonary disease. The rationale for the approaches to facility randomization and recruitment, intervention implementation, population selection, data acquisition, regulatory issues, and statistical analyses are discussed. Results The large number of well-characterized candidate facilities enabled several unique design features including stratification on historical hospitalization rates, randomization prior to recruitment, and 2:1 control to intervention facilities ratio. Strong endorsement from corporate leadership made randomization prior to recruitment feasible with 100% participation of facilities randomized to the intervention arm. Critical regulatory issues included minimal risk determination, waiver of informed consent, and determination that nursing home providers were not engaged in human subjects research. Intervention training and implementation were initiated on 5 January 2016 using corporate infrastructures for new program roll-out guided by standardized training elements designed by the research team. Video Status Reports in facilities' electronic medical records permitted "real-time" adherence monitoring and corrective actions. The Centers for Medicare and Medicaid Services Virtual Research Data Center allowed for rapid outcomes ascertainment. Conclusion We must rigorously evaluate interventions to deliver more patient-focused care to an increasingly frail nursing home population. Video decision support is a practical approach to improve advance care planning. PRagmatic trial Of Video Education in Nursing homes has the potential to promote goal-directed care among millions of older Americans in nursing homes and establish a methodology for future pragmatic randomized controlled trials in this complex healthcare setting.
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Affiliation(s)
- Vincent Mor
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI, USA
- Providence Veterans Administration Medical Center, Center of Innovation in Health Services Research and Development Service, Providence, RI, USA
| | - Angelo E Volandes
- Massachusetts General Hospital, Section of General Medicine, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, USA
| | - Constantine Gatsonis
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, USA
- Center for Statistical Sciences, School of Public Health, Brown University, Providence, RI, USA
| | - Susan L Mitchell
- Harvard Medical School, Boston, MA, USA
- Hebrew SeniorLife, Institute for Aging Research, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA, USA
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Cohen AB, Knobf MT, Fried TR. Do-Not-Hospitalize Orders in Nursing Homes: "Call the Family Instead of Calling the Ambulance". J Am Geriatr Soc 2017; 65:1573-1577. [PMID: 28369740 DOI: 10.1111/jgs.14879] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine how do-not-hospitalize (DNH) orders are interpreted and used in nursing homes (NHs) once they are in place. DESIGN Qualitative study using in-depth semi-structured interviews performed from December 2013 to April 2014. SETTING Eight skilled nursing facilities in Connecticut that ranked in the top 10% or bottom 10% in hospitalization rates from 2008 to 2010. PARTICIPANTS Nursing facility staff members (N = 31). MEASUREMENTS A multidisciplinary team performed qualitative content analysis. The constant comparative method was used to develop a coding structure and identify themes. RESULTS DNH orders were uncommon at low- and high-hospitalizing facilities. Participants reported that they did not interpret these orders literally. A DNH order was not a prohibition against hospitalization but was understood to have a variety of exceptions. These orders functioned primarily as a signal that hospitalization should be questioned and discussed with the family when an acute event occurred. CONCLUSION In-the-moment discussions about hospitalization are still necessary even when a DNH order is in place. Work to reduce potentially burdensome NH-hospital transfers needs to focus not just on eliciting preferences in advance, but also on preparing residents and their families to make the best decisions about hospitalization when the time comes.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - M Tish Knobf
- Division of Acute Care/Health Systems, Yale School of Nursing, Yale University, New Haven, Connecticut
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut.,Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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Vasilevskis EE, Ouslander JG, Mixon AS, Bell SP, Jacobsen JML, Saraf AA, Markley D, Sponsler K, Shutes J, Long E, Kripalani S, Simmons SF, Schnelle JF. Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff. J Am Geriatr Soc 2017; 65:269-276. [PMID: 27981557 PMCID: PMC5311021 DOI: 10.1111/jgs.14557] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. OBJECTIVES To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives. DESIGN Prospective cohort study. SETTING One academic medical center and 23 SNFs. PARTICIPANTS We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. MEASUREMENTS Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions. RESULTS The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively. CONCLUSION A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
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Affiliation(s)
- Eduard E. Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Joseph G. Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | - Amanda S. Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN
| | - Susan P. Bell
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - J. Mary Lou Jacobsen
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Avantika A. Saraf
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Daniel Markley
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly Sponsler
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jill Shutes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | - Emily Long
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - S. Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN
| | - Sandra F. Simmons
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - John F. Schnelle
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Oud L. Predictors of Transition to Hospice Care Among Hospitalized Older Adults With a Diagnosis of Dementia in Texas: A Population-Based Study. J Clin Med Res 2017; 9:23-29. [PMID: 27924171 PMCID: PMC5127211 DOI: 10.14740/jocmr2783w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Decedent older adults with dementia are increasingly less likely to die in a hospital, though escalation of care to a hospital setting, often including critical care, remains common. Although hospice is increasingly reported as the site of death in these patients, the factors associated with transition to hospice care during end-of-life (EOL) hospitalizations of older adults with dementia and the extent of preceding escalation of care to an intensive care unit (ICU) setting among those discharged to hospice have not been examined. METHODS We identified hospitalizations aged ≥ 65 years with a diagnosis of dementia in Texas between 2001 and 2010. Potential factors associated with discharge to hospice were evaluated using multivariate logistic regression modeling, and occurrence of hospice discharge preceded by ICU admission was examined. RESULTS There were 889,008 elderly hospitalizations with a diagnosis of dementia during study period, with 40,669 (4.6%) discharged to hospice. Discharges to hospice increased from 908 (1.5%) to 7,398 (6.3%) between 2001 and 2010 and involved prior admission to ICU in 45.2% by 2010. Non-dementia comorbidities were generally associated with increased odds of hospice discharge, as were development of organ failure, the number of failing organs, or use of mechanical ventilation. However, discharge to hospice was less likely among non-white minorities (lowest among blacks: adjusted odds ratio (aOR): 0.67; 95% confidence interval (CI): 0.65 - 0.70) and those with non-commercial primary insurance or the uninsured (lowest among those with Medicaid: aOR (95% CI): 0.41 (0.37 - 0.46)). CONCLUSIONS This study identified potentially modifiable factors associated with disparities in transition to hospice care during EOL hospitalizations of older adults with dementia, which persisted across comorbidity and severity of illness measures. The prevalent discharge to hospice involving prior critical care suggests that key discussions about goals-of-care likely took place following further escalation of care to ICU. Together these findings can inform system- and clinician-level interventions to facilitate timely and consistent use of hospice to meet patients' goals of care.
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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.
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Prioleau PG, Soones TN, Ornstein K, Zhang M, Smith CB, Wajnberg A. Predictors of Place of Death of Individuals in a Home-Based Primary and Palliative Care Program. J Am Geriatr Soc 2016; 64:2317-2321. [PMID: 27640817 DOI: 10.1111/jgs.14465] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate factors associated with place of death of individuals in the Mount Sinai Visiting Doctors Program (MSVD). DESIGN A retrospective chart review was performed of all MSVD participants who died in 2012 to assess predictors of place of death in the last month of life. SETTING MSVD, a home-based primary and palliative care program in New York. PARTICIPANTS MSVD participants who were discharged from the program because of death between January 2012 and December 2012 and died at home, in inpatient hospice, or in the hospital (N = 183). MEASUREMENTS Electronic medical records were reviewed to collect information on demographic characteristics, physician visits, and end-of-life conversations. RESULTS Of 183 participants, 103 (56%) died at home, approximately twice the national average; 28 (15%) died in inpatient hospice; and 52 (28%) died in the hospital. Bivariate analyses showed that participants who were white, aged 90 and older, non-Medicaid, or had a recorded preference for place of death were more likely to die outside the hospital. Diagnoses and living situation were not significantly associated with place of death. Multivariate logistic regression analysis showed no statistical association between place of death and home visits in the last month of life (odds ratio = 1.21, 95% confidence interval = 0.52-2.77). CONCLUSION Home-based primary and palliative care results in a high likelihood of nonhospital death, although certain demographic characteristics are strong predictors of death in the hospital. For MSVD participants, home visits in the last month of life were not associated with death outside the hospital.
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Affiliation(s)
| | - Tacara N Soones
- Department of Geriatrics and Palliative Medicine, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Katherine Ornstein
- Department of Geriatrics and Palliative Medicine, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.,Division of General Internal Medicine, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Meng Zhang
- Department of Geriatrics and Palliative Medicine, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Cardinale B Smith
- Division of Hematology and Medical Oncology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Ania Wajnberg
- Division of General Internal Medicine, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York
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Cai S, Miller SC, Mukamel DB. Racial Differences in Hospitalizations of Dying Medicare-Medicaid Dually Eligible Nursing Home Residents. J Am Geriatr Soc 2016; 64:1798-805. [PMID: 27549337 PMCID: PMC5026884 DOI: 10.1111/jgs.14284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine whether racial differences in end-of-life (EOL) hospitalizations vary according to the presence of advance directives, specifically do-not-hospitalize (DNH) orders, and individual cognitive status in nursing home (NH) residents. DESIGN National data, including Medicare data and Minimum Data Set (MDS) 2.0, between January 1, 2007, and September 30, 2010, were linked. EOL hospitalizations were hospitalizations in the last 30 days of life. Linear probability models with an interaction term (between race and DNH) and NH fixed-effects were estimated. The analyses were stratified according to cognitive status. SETTING Nursing homes in the United States. PARTICIPANTS Dually eligible Medicare-Medicaid decedents enrolled in Medicare fee-for-service plans and long-stay NH residents (in NHs ≥ 90 days before death) (N = 394,948). MEASUREMENTS Racial difference in EOL hospitalizations from a NH. RESULTS End-of-life hospitalization rate was 31.7% for whites and 42.8% for blacks. For participants without DNH orders, adjusted probability of EOL hospitalization was higher for blacks than for whites: 2.7 percentage points in those with moderate cognitive impairment (P < .001) and 4.7 percentage points in those with severe cognitive impairment (P < .001). For those with DNH orders, adjusted racial differences in EOL hospitalization were not statistically significant in those with moderate (P = .25) or severe (P = .93) cognitive impairment, but blacks had a higher probability of EOL hospitalization than whites if they had relatively intact cognitive status. CONCLUSION Racial differences in EOL hospitalization varied with DNH orders and cognitive status in dying residents. Future research is necessary to understand the reasons behind these variations.
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Affiliation(s)
- Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York.
| | - Susan C Miller
- Center for Gerontology and Healthcare Research, Brown University, School of Public Health, Providence, Rhode Island
| | - Dana B Mukamel
- Division of General Internal Medicine, Department of Medicine and iTEQC Research Program, University of California at Irvine, Irvine, California
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Ashton SE, Roe B, Jack B, McClelland B. End of life care: The experiences of advance care planning amongst family caregivers of people with advanced dementia – A qualitative study. DEMENTIA 2016; 15:958-75. [DOI: 10.1177/1471301214548521] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background End of life decisions for people with advanced dementia are reported as often being difficult for families as they attempt to make appropriate and justified decisions. Aim To explore the experiences of advance care planning amongst family caregivers of people with advanced dementia. Design Qualitative research including a series of single cases (close family relatives). Methods A purposive sample of 12 family caregivers within a specialist dementia unit was interviewed about their experiences of advance care planning between August 2009 and February 2010. Results/Findings Family caregivers need encouragement to ask the right questions during advance care planning to discuss the appropriateness of nursing and medical interventions at the end of life. Conclusions Advance care planning can be facilitated with the family caregiver in the context of everyday practice within the nursing home environment for older people with dementia.
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Affiliation(s)
- Susan Elizabeth Ashton
- Faculty of Education, Health and Community, Liverpool John Moores University, Liverpool, United Kingdom
| | - Brenda Roe
- Evidence-based Practice Research Centre, Faculty of Health & Social Care, Edge Hill University, Ormskirk, United Kingdom
| | - Barbara Jack
- Evidence-Based Practice Research Centre (EPRC), Faculty of Health and Social Care, Edge Hill University, Ormskirk, United Kingdom
| | - Bob McClelland
- Centre for Public Services Management, Liverpool John Moores University, Liverpool Business School, Liverpool, United Kingdom
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Lessons Learned From Root Cause Analyses of Transfers of Skilled Nursing Facility (SNF) Patients to Acute Hospitals: Transfers Rated as Preventable Versus Nonpreventable by SNF Staff. J Am Med Dir Assoc 2016; 17:596-601. [DOI: 10.1016/j.jamda.2016.02.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/16/2016] [Indexed: 11/18/2022]
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Hospital Transfers of Skilled Nursing Facility (SNF) Patients Within 48 Hours and 30 Days After SNF Admission. J Am Med Dir Assoc 2016; 17:839-45. [PMID: 27349621 DOI: 10.1016/j.jamda.2016.05.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/20/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Close to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30 days, and a substantial percentage are readmitted within 2 days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF. OBJECTIVES To describe the characteristics of SNF to hospital transfers that occur within 48 hours and 30 days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs. DESIGN Trained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period. SETTING SNFs from across the United States. PARTICIPANTS 64 of 88 SNFs randomized to the intervention group submitted RCAs. INTERVENTIONS SNFs were implementing the INTERACT quality improvement program. MEASURES Data were abstracted from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. RESULTS Among 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48 hours of SNF admission, 524 (11%) 3 to 6 days after SNF admission, 1450 (31%) 7 to 29 days after SNF admission, and 2331 (50%) occurred 30 days or longer after admission. Comparisons between transfers that occurred within 48 hours and within 30 days of SNF admission to transfers that occurred 30 days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30 days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48 hours or 30 days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30 days versus 30 days or longer as potentially preventable (25.1% vs 21.5%, P = .005). Case descriptions derived from the QI tools of transfers back to the hospital within 48 hours of SNF admission illustrate several factors underlying these rapid returns to the hospital. CONCLUSION RCAs on transfers back to the hospital shortly after SNF admission provide insights into strategies that both hospitals and SNFs can consider in collaborative efforts to reduce potentially avoidable hospital readmissions.
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Abstract
BACKGROUND Infections frequently occur in patients with dementia and antibiotics are often prescribed, but may also be withheld. OBJECTIVES The aim of this systematic review is to provide a systematic overview of the prevalence of antibiotic use, and factors associated with prescribing antibiotics in patients with dementia. DATA SOURCES A systematic search of MEDLINE, EMBASE, PSYCINFO, CINAHL, and the Cochrane library databases until February 13, 2014 was performed, using both controlled terms and free-text terms. RESULTS Thirty-seven articles were included. The point prevalence of antibiotic use in patients with dementia ranged from 3.3 to 16.6%. The period prevalence ranged from 4.4 to 88% overall, and from 23.5 to 94% in variable time frames before death; the median use was 52% (median period 14 days) and 48% (median period 22 days), respectively. Most patients with lower respiratory tract infections or urinary tract infections (77-91%) received antibiotic treatment. Factors associated with antibiotic use related to patients, families, physicians, and the healthcare context. More severe dementia and a poor prognosis were associated with less antibiotic use in various countries. Associations with aspiration and illness severity differed by country. CONCLUSIONS AND IMPLICATIONS Antibiotic use in patients with dementia is substantial, and probably highly associated with the particular healthcare context. Future studies may report antibiotic use by infection type and stage of dementia, and compare cross-nationally.
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Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations. J Am Med Dir Assoc 2016; 17:256-62. [DOI: 10.1016/j.jamda.2015.11.018] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 11/24/2015] [Indexed: 11/23/2022]
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Agar M, Beattie E, Luckett T, Phillips J, Luscombe G, Goodall S, Mitchell G, Pond D, Davidson PM, Chenoweth L. Pragmatic cluster randomised controlled trial of facilitated family case conferencing compared with usual care for improving end of life care and outcomes in nursing home residents with advanced dementia and their families: the IDEAL study protocol. BMC Palliat Care 2015; 14:63. [PMID: 26589957 PMCID: PMC4654825 DOI: 10.1186/s12904-015-0061-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 11/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care for people with advanced dementia requires a palliative approach targeted to the illness trajectory and tailored to individual needs. However, care in nursing homes is often compromised by poor communication and limited staff expertise. This paper reports the protocol for the IDEAL Project, which aims to: 1) compare the efficacy of a facilitated approach to family case conferencing with usual care; 2) provide insights into nursing home- and staff-related processes influencing the implementation and sustainability of case conferencing; and 3) evaluate cost-effectiveness. DESIGN/METHODS A pragmatic parallel cluster randomised controlled trial design will be used. Twenty Australian nursing homes will be randomised to receive either facilitated family case conferencing or usual care. In the intervention arm, we will train registered nurses at each nursing home to work as Palliative Care Planning Coordinators (PCPCs) 16 h per week over 18 months. The PCPCs' role will be to: 1) use evidence-based 'triggers' to identify optimal time-points for case conferencing; 2) organise, facilitate and document case conferences with optimal involvement from family, multi-disciplinary nursing home staff and community health professionals; 3) develop and oversee implementation of palliative care plans; and 4) train other staff in person-centred palliative care. The primary endpoint will be symptom management, comfort and satisfaction with care at the end of life as rated by bereaved family members on the End of Life in Dementia (EOLD) Scales. Secondary outcomes will include resident quality of life (Quality of Life in Late-stage Dementia [QUALID]), whether a palliative approach is taken (e.g. hospitalisations, non-palliative medical treatments), staff attitudes and knowledge (Palliative Care for Advanced Dementia [qPAD]), and cost effectiveness. Processes and factors influencing implementation, outcomes and sustainability will be explored statistically via analysis of intervention 'dose' and qualitatively via semi-structured interviews. The pragmatic design and complex nature of the intervention will limit blinding and internal validity but support external validity. DISCUSSION The IDEAL Project will make an important contribution to the evidence base for dementia-specific case conferencing in nursing homes by considering processes and contextual factors as well as overall efficacy. Its strengths and weaknesses will both lie in its pragmatic design. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612001164886. Registered 02/11/2012.
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Affiliation(s)
- Meera Agar
- Discipline of Palliative and Supportive Services, Flinders University, Adelaide, Australia.
- South West Sydney Clinical School, and Improving Palliative Care through Clinical trials (ImPACCT), University of New South Wales, Sydney, Australia.
- Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, Australia.
- Ingham Institute of Applied Medical Research, Sydney, Australia.
| | - Elizabeth Beattie
- Dementia Collaborative Research Centre, Queensland University of Technology, Brisbane, Australia.
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Australia.
| | - Tim Luckett
- South West Sydney Clinical School, and Improving Palliative Care through Clinical trials (ImPACCT), University of New South Wales, Sydney, Australia.
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.
- University of Technology Sydney (UTS) Faculty of Health, Building 10, Level 7, 235-253 Jones St, Ultimo, NSW 2007, Australia.
| | - Jane Phillips
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia.
| | - Georgina Luscombe
- School of Rural Health, Faculty of Medicine, The University of Sydney, Sydney, Australia.
| | - Stephen Goodall
- Centre for health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, Australia.
| | - Geoffrey Mitchell
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Australia.
| | - Dimity Pond
- School of Medicine and Public Health, Faculty of Health, University of Newcastle, Newcastle, Australia.
| | | | - Lynnette Chenoweth
- Faculty of Health, University of Technology Sydney, Sydney, Australia.
- Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia.
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Nicholas LH, Bynum JPW, Iwashyna TJ, Weir DR, Langa KM. Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia. Health Aff (Millwood) 2015; 33:667-74. [PMID: 24711329 DOI: 10.1377/hlthaff.2013.1258] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The number of older adults with cognitive impairment is increasing, and such adults often require a surrogate to make decisions about health care. However, little is known about the aggressiveness of end-of-life care for these people, especially those who reside in the community. We found that cognitive impairment is common among older adults approaching the end of life, whether they live in the community or in a nursing home, and that nearly 30 percent of patients with severe dementia remained in the community until death. Among those patients, having an advance directive in the form of a living will was associated with significantly less aggressive care at the end of life, compared to similar patients without an advance directive-as measured by Medicare spending ($11,461 less per patient), likelihood of in-hospital death (17.9 percentage points lower), and use of the intensive care unit (9.4 percentage points lower). In contrast, advance directives were not associated with differences in care for people with normal cognition or mild dementia, whether they resided in the community or in a nursing home. Timely advance care planning after a diagnosis of cognitive impairment may be particularly important for older adults who reside in the community.
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Tsai CF, Lee YT, Lee WJ, Hwang JP, Wang SJ, Fuh JL. Depression of Family Caregivers Is Associated with Disagreements on Life-Sustaining Preferences for Treating Patients with Dementia. PLoS One 2015; 10:e0133711. [PMID: 26230958 PMCID: PMC4521939 DOI: 10.1371/journal.pone.0133711] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 07/01/2015] [Indexed: 12/03/2022] Open
Abstract
Background Family caregivers may not agree with patients with dementia regarding attitudes toward end-of-life preferences, and the effects of this type of disagreement are not well understood. This study sought to identify such a disagreement and its predictors. Methods A cross-sectional sample of 84 family caregivers and patients with dementia was recruited from memory clinics. We used the Mini-Mental State Examination, Neuropsychiatric Inventory, Clinical Dementia Rating, and Katz index of independence in activities of daily living to assess patient symptoms, functions, and severity of dementia. Caregivers completed questionnaires on perceived patient end-of-life care preferences, caregiver end-of-life care preferences for patients, Zarit Burden Interview (ZBI), Center for Epidemiological Studies–Depression Scale (CES-D), and knowledge of clinical complications of advanced dementia. Results The self-disclosure rates of patient preferences were 34.5% for tube feeding, 39.3% for cardiopulmonary resuscitation, and 45.2% for mechanical ventilation. For patients who had disclosed preferences, the disagreement rate between them and their caregivers was 48.3% for tube feeding, 48.5% for cardiopulmonary resuscitation, and 60.3% for mechanical ventilation. Caregiver depression (i.e., CES-D ≥16) was associated with disagreements on cardiopulmonary resuscitation (adjusted odds ratio (aOR) = 6.6, 95% CI = 1.4–31.1, P = 0.01) and mechanical ventilation (aOR = 14, 95% CI = 2.2–87.2, P = 0.005) preferences. Conclusion The preferences of end-of-life issues differed greatly between dementia patients and their caregivers. Depression in caregivers is associated with such discrepancy.
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Affiliation(s)
- Chia-Fen Tsai
- Department of Psychiatry, Neurological Institute, Veterans General Hospital, Taipei, Taiwan
- Institute of Brain Science, National Yang-Ming University Schools of Medicine, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan
| | - Yao-Tung Lee
- Department of Psychiatry, Taipei Medical University–Shuang Ho Hospital, New Taipei City, Taiwan
| | - Wei-Ju Lee
- Institute of Clinical Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jen-Ping Hwang
- Department of Psychiatry, Neurological Institute, Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan
- * E-mail:
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Unplanned Transfer to Emergency Departments for Frail Elderly Residents of Aged Care Facilities: A Review of Patient and Organizational Factors. J Am Med Dir Assoc 2015; 16:551-62. [DOI: 10.1016/j.jamda.2015.03.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/07/2015] [Accepted: 03/05/2015] [Indexed: 12/20/2022]
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Critical decisions for older people with advanced dementia: a prospective study in long-term institutions and district home care. J Am Med Dir Assoc 2015; 16:535.e13-20. [PMID: 25843621 DOI: 10.1016/j.jamda.2015.02.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 02/16/2015] [Accepted: 02/16/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe and compare the decisions critical for survival or quality of life [critical decisions (CDs)] made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services. DESIGN Prospective cohort study with a follow-up of 6 months. SETTING Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy. PARTICIPANTS Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score ≥ 7) and expected survival ≥ 2 weeks. MEASUREMENTS At baseline, the patients' demographic data, date of admission and of dementia diagnosis, type of dementia, main comorbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients' general condition and CDs (deemed critical by the doctor or team) was collected by an interview with the doctor. For each CD, the physician reported the problem that led to the decision, that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after 1 week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤ 15 days). RESULTS For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than 1 CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs); and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1% vs 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life. CONCLUSIONS Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately one-half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life.
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Maxwell CJ, Amuah JE, Hogan DB, Cepoiu-Martin M, Gruneir A, Patten SB, Soo A, Le Clair K, Wilson K, Hagen B, Strain LA. Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada. J Am Med Dir Assoc 2015; 16:568-77. [PMID: 25717011 DOI: 10.1016/j.jamda.2015.01.079] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 12/10/2014] [Accepted: 01/07/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Assisted living (AL) is an increasingly used residential option for older adults with dementia; however, lower staffing rates and service availability raise concerns that such residents may be at increased risk for adverse outcomes. Our objectives were to determine the incidence of hospitalization over 1 year for dementia residents of designated AL (DAL) facilities, compared with long-term care (LTC) facilities, and identify resident- and facility-level predictors of hospitalization among DAL residents. METHODS Participants were 609 DAL (mean age 85.7 ± 6.6 years) and 691 LTC (86.4 ± 6.9 years) residents with dementia enrolled in the Alberta Continuing Care Epidemiological Studies. Research nurses completed a standardized comprehensive assessment of residents and interviewed family caregivers at baseline (2006-2008) and 1 year later. Standardized administrator interviews provided facility level data. Hospitalization was determined via linkage with the provincial Inpatient Discharge Abstract Database. Multivariable Cox proportional hazards models were used to identify predictors of hospitalization. RESULTS The cumulative annual incidence of hospitalization was 38.6% (34.5%-42.7%) for DAL and 10.3% (8.0%-12.6%) for LTC residents with dementia. A significantly increased risk for hospitalization was observed for DAL residents aged 90+ years, with poor social relationships, less severe cognitive impairment, greater health instability, fatigue, high medication use (11+ medications), and 2+ hospitalizations in the preceding year. Residents from DAL facilities with a smaller number of spaces, no chain affiliation, and from specific health regions showed a higher risk of hospitalization. CONCLUSIONS DAL residents with dementia had a hospitalization rate almost 4-fold higher than LTC residents with dementia. Our findings raise questions about the ability of some AL facilities to adequately address the needs of cognitively impaired residents and highlight potential clinical, social, and policy areas for targeted interventions to reduce hospitalization risk.
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Affiliation(s)
- Colleen J Maxwell
- Schools of Pharmacy and Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
| | - Joseph E Amuah
- Health System Performance Branch, Canadian Institute for Health Information, Ottawa, Ontario, Canada
| | - David B Hogan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Division of Geriatric Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Monica Cepoiu-Martin
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Gruneir
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Scott B Patten
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kenneth Le Clair
- Division of Geriatric Psychiatry, Queen's University and Center for Studies in Aging and Health, Providence Care, Kingston, Ontario, Canada
| | - Kimberley Wilson
- Department of Family Relations and Applied Nutrition, University of Guelph, Macdonald Institute, Guelph, Ontario, Canada
| | - Brad Hagen
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Laurel A Strain
- Department of Sociology, University of Alberta, Edmonton, Alberta, Canada
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Woodman AC, Mailick MR, Anderson KA, Esbensen AJ. Residential transitions among adults with intellectual disability across 20 years. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2014; 119:496-515. [PMID: 25354121 PMCID: PMC4215165 DOI: 10.1352/1944-7558-119.6.496] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The present study addresses critical gaps in the literature by examining residential transitions among 303 adults with intellectual disability (ID) over 10 years (Part 1) and 75 adults with Down syndrome over 20 years (Part 2). All adults lived at home at the start of the study, but many moved to a variety of settings. Several characteristics of the adults with ID differed across settings, most notably adaptive behavior and the number of residential transitions, whereas characteristics such as age, type of disability, and behavior problems were less predictive of residential placements. The number of moves over the course of the study varied widely, with critical links to earlier family dynamics, social relationships, and health and adaptive behavior.
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Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations. Alzheimers Dement 2014; 10:835-43. [PMID: 25028060 DOI: 10.1016/j.jalz.2014.03.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 03/13/2014] [Accepted: 03/31/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services. METHODS We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation. RESULTS Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant. CONCLUSIONS Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.
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Affiliation(s)
- Caroline E Stephens
- Department of Community Health Systems, UCSF School of Nursing, San Francisco, CA, USA; Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA.
| | - Robert Newcomer
- Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA
| | - Mary Blegen
- Department of Community Health Systems, UCSF School of Nursing, San Francisco, CA, USA
| | - Bruce Miller
- Department of Neurology, UCSF School of Medicine, San Francisco, CA, USA
| | - Charlene Harrington
- Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA
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Houttekier D, Reyniers T, Deliens L, Van Den Noortgate N, Cohen J. Dying in Hospital with Dementia and Pneumonia: A Nationwide Study Using Death Certificate Data. Gerontology 2014; 60:31-7. [DOI: 10.1159/000354378] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 07/15/2013] [Indexed: 11/19/2022] Open
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Goldfeld KS, Grabowski DC, Caudry DJ, Mitchell SL. Health insurance status and the care of nursing home residents with advanced dementia. JAMA Intern Med 2013; 173:2047-53. [PMID: 24061265 PMCID: PMC3859713 DOI: 10.1001/jamainternmed.2013.10573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Nursing home residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve the quality of life. Fragmentation in health care has contributed to poor coordination of care for acutely ill nursing home residents. OBJECTIVE To compare patterns of care and quality outcomes for nursing home residents with advanced dementia covered by managed care with those covered by traditional fee-for-service Medicare. DESIGN, SETTING, AND PARTICIPANTS Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE) was a prospective cohort study including 22 nursing homes in the Boston, Massachusetts, area that monitored 323 nursing home residents for 18 months to better understand the course of advanced dementia at or near the end of life. Data from CASCADE and Medicare were linked to determine the health insurance status of study participants. EXPOSURES The health insurance status of the resident, either managed care or traditional fee for service. MAIN OUTCOMES AND MEASURES The outcomes included survival, symptoms related to comfort, treatment of pain and dyspnea, presence of pressure ulcers, presence of a do-not-hospitalize order, treatment of pneumonia, hospital transfer (admission or emergency department visit) for an acute illness, hospice referral, primary care visits, and family satisfaction with care. RESULTS Residents enrolled in managed care (n = 133) were more likely to have do-not-hospitalize orders compared with those in traditional Medicare fee for service (n = 158) (63.7% vs 50.9%; adjusted odds ratio, 1.9; 95% CI, 1.1-3.4), were less likely to be transferred to the hospital for acute illness (3.8% vs 15.7%; adjusted odds ratio, 0.2; 95% CI, 0.1-0.5), had more primary care visits per 90 days (mean [SD], 4.8 [2.6] vs 4.2 [5.0]; adjusted rate ratio, 1.3; 95% CI, 1.1-1.6), and had more nurse practitioner visits (3.0 [2.1] vs 0.8 [2.6]; adjusted rate ratio, 3.0; 95% CI, 2.2-4.1). Survival, comfort, and other treatment outcomes did not differ significantly across groups. CONCLUSIONS AND RELEVANCE Medicare managed-care programs may offer a promising approach to ensure that nursing homes are able to provide appropriate, less burdensome, and affordable care, especially at the end of life.
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Affiliation(s)
- Keith S Goldfeld
- Department of Population Health, New York University School of Medicine, New York
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Goldfeld KS, Hamel MB, Mitchell SL. The cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia. J Pain Symptom Manage 2013; 46:640-51. [PMID: 23571207 PMCID: PMC3708971 DOI: 10.1016/j.jpainsymman.2012.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 11/14/2012] [Accepted: 12/07/2012] [Indexed: 11/23/2022]
Abstract
CONTEXT Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported. OBJECTIVES To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia. METHODS NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months. RESULTS Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355). CONCLUSION Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.
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Affiliation(s)
- Keith S Goldfeld
- Department of Population Health, New York University School of Medicine, New York, New York, USA.
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