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Xie Z, Chen G, Oladeru OT, Hamadi HY, Montgomery L, Robinson MT, Hong YR. Inpatient Palliative Care and Healthcare Utilization Among Older Patients With Alzheimer's Disease and Related Dementia (ADRD) and High Risk of Mortality in U.S. Hospitals. Am J Hosp Palliat Care 2024:10499091241252685. [PMID: 38710104 DOI: 10.1177/10499091241252685] [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: 05/08/2024] Open
Abstract
Background. Despite the potential of palliative care (PC) to enhance the quality of life for patients with advanced dementia, there is limited knowledge of its inpatient utilization patterns. This study investigated inpatient PC consultation utilization patterns and evaluated its impact on hospital length of stay (LOS) and medical costs among older patients diagnosed with Alzheimer's Disease and Related Dementia who were at a high risk of mortality (ADRD-HRM). Methods. Using the 2016-2019 National Inpatient Sample database, we conducted multivariable logistic regression analyses to identify individual and hospital characteristics influencing PC consultation utilization. We subsequently performed generalized linear models to estimate LOS (using Poisson distribution) and hospital charges (via log-transformation). Results. Our sample encompassed 965,644 hospital discharges (weighted n = 4,828,219) of patients aged 65 years and above with ADRD-HRM. Among them, 14.6% received inpatient PC. There was a notable uptrend in PC consultation utilization from 13.3% in 2016 to 16.3% in 2019 (p trend<.001). Factors positively influencing and associated with PC utilization included patients that are older, non-Hispanic White, with higher income, receiving care from teaching hospitals, and facilitated with greater bed capacity (all P < .05). Although patients who received PC were more likely to have 3.0% longer LOS (P < .001), they had 19.2% lower hospital charges (P < .001). Conclusions. PC substantially reduced hospital expenditures for older patients with ADRD-HRM, but the prevalence remained low at 14.6% in the study period. Future studies should explore the unmet needs of patients with lower sociodemographic status and those in rural hospitals to further increase their PC consultation utilization.
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Affiliation(s)
- Zhigang Xie
- Department of Public Health, University of North Florida, Jacksonville, FL, USA
| | - Guanming Chen
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Hanadi Y Hamadi
- Department of Health Administration, University of North Florida, Jacksonville, FL, USA
| | - Lucinda Montgomery
- Department of Public Health, University of North Florida, Jacksonville, FL, USA
| | | | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
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Liu H, Cook A, Ding J, Lu H, Jiao J, Bai W, Johnson CE. Palliative care needs and specialist services post stroke: national population-based study. BMJ Support Palliat Care 2023:spcare-2023-004280. [PMID: 37500566 DOI: 10.1136/spcare-2023-004280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES (1) To compare palliative care needs of patients admitted primarily with stroke and (2) to determine how the care needs of these patients affect their use of different types of specialist palliative care services. METHODS Observational study based on point-of-care data from the Australian Palliative Care Outcomes Collaboration. Multivariate logistic regression models were used to explore the association between patients' palliative care needs and use of community versus inpatient specialist palliative care services. RESULTS The majority of patients who had a stroke in this study population had mild or no symptom distress, but experienced a high degree of functional impairment and needed substantial help with basic tasks of daily living. A lower Australia-modified Karnofsky Performance Status score (OR=1.82, 95% CI 1.06 to 3.13) and occurrence of an 'unstable' palliative care phase (OR=28.34, 95% CI 9.03 to 88.94) were associated with use of inpatient versus community palliative care, but otherwise, no clear association was observed between the majority of symptoms and use of different care services. CONCLUSIONS Many people with stroke could potentially have been cared for and could have experienced the terminal phases of their condition in a community setting if more community support services were available for their families.
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Affiliation(s)
- Huiqin Liu
- Health Management Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Angus Cook
- School of Population and Global Health, University of Western Australia, Crawley, Western Australia, Australia
| | - Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
- Yale School of Internal Medicine, New Haven, Connecticut, USA
| | - Hongwei Lu
- Health Management Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jingjing Jiao
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Wenhui Bai
- Department of Nursing, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Claire E Johnson
- AHSRI, University of Wollongong Faculty of Business, Wollongong, New South Wales, Australia
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Brennan F, Chapman M, Gardiner MD, Narasimhan M, Cohen J. Our dementia challenge: arise palliative care. Intern Med J 2023; 53:186-193. [PMID: 36822608 DOI: 10.1111/imj.16011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 12/13/2022] [Indexed: 02/25/2023]
Abstract
While many of the maladies of the 20th century are steadily coming under control, the march of neurodegenerative disorders continues largely unchecked. Dementias are an exemplar of such disorders; their incidence and prevalence continue to rise, in large part due to a steadily ageing population worldwide. They represent a group of chronic, progressive and, ultimately, fatal neurodegenerative diseases. Dementia has remained therapeutically recalcitrant. It is not a single disease, and because of that, we cannot expect a single panacea. While primary prevention rightly gains prominence, those with established disease currently require a shift in focus from curative intent towards improved quality of life. Enter palliative care. The sheer number and complexity of needs of patients with dementia, from the physical to the psychosocial and spiritual, necessitates the engagement of a wide range of medical disciplines, nursing and allied health professionals. One of those disciplines, as highlighted in the recent Australian Royal Commission into Aged Care Quality and Safety, is palliative care. This paper shall expand upon that role in the overall context of care for those with dementia.
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Affiliation(s)
- Frank Brennan
- Department of Palliative Care, Calvary Hospital, Kogarah, New South Wales, Australia.,Department of Palliative Care, The St George Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of NSW Sydney, Sydney, New South Wales, Australia
| | - Michael Chapman
- Department of Palliative Care, Canberra Hospital, ACT, Canberra, Australian Capital Territory, Australia.,Medical School, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Matthew D Gardiner
- Department of Palliative Care, Calvary Hospital, Kogarah, New South Wales, Australia.,Faculty of Medicine, The University of NSW Sydney, Sydney, New South Wales, Australia
| | - Manisha Narasimhan
- Department of Neurology, The Sutherland Hospital, Sydney, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Joshua Cohen
- Department of Palliative Care, Calvary Hospital, Kogarah, New South Wales, Australia
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Hill JD, Schmucker AM, Siman N, Goldfeld KS, Cuthel AM, Chodosh J, Bouillon-Minois JB, Grudzen CR. Emergency and post-emergency care of older adults with Alzheimer's disease/Alzheimer's disease related dementias. J Am Geriatr Soc 2022; 70:2582-2591. [PMID: 35612546 PMCID: PMC9489611 DOI: 10.1111/jgs.17833] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The emergency department (ED) is a critical juncture in the care of persons living with dementia (PLwD), as they have a high rate of hospital admission, ED revisits, and subsequent inpatient stays. We examine ED disposition of PLwD compared with older adults with non-dementia chronic disease as well as healthcare utilization and survival. METHODS Medicare claims data were used to identify community-dwelling older adults 66+ years old from 34 hospitals with either Alzheimer's disease/Alzheimer's disease related dementias (AD/ADRD) or a non-AD/ADRD chronic condition between January 1, 2014, and December 31, 2018. We compared ED disposition at the index visit, as well as healthcare utilization and mortality in the 12 months following an index ED visit, and adjusted for age, gender, and risk of mortality. RESULTS There were 29,626 patients in the AD/ADRD sample, and 317,046 in the comparison sample. The AD/ADRD sample was older (82.4 years old [SD: 8.2] vs. 76.0 years old [SD: 7.7]) and had more female patients (59.9% vs. 54.7%). The AD/ADRD sample was more likely to experience ED disposition to acute care (OR 1.039, p < 0.001, 95% CI 1.029-1.050), to have an ED revisit (OR 1.077, p < 0.001, 95% CI 1.066-1.087), and an inpatient stay in the subsequent 12 months (OR 1.085, p < 0.001, 95% CI 1.075-1.095). ED disposition to hospice was low in both samples (0.2%). AD/ADRD patients had a higher risk of mortality (OR 1.099, p < 0.001, 95% CI 1.091-1.107) and high short-term mortality (31.9% within 12 months) than those without AD/ADRD (15.3% within 12 months). CONCLUSIONS PLwD who visit the ED have high short-term mortality. Despite this, disposition to acute care, ED revisits, and inpatient stays, rather than hospice, remain the predominant mode of care delivery. Transition directly from the ED to hospice for PLwD is rare.
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Affiliation(s)
- Jacob D. Hill
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Abigail M. Schmucker
- Department of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nina Siman
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Keith S. Goldfeld
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Allison M. Cuthel
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Joshua Chodosh
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
- Department of Medicine, Division of Geriatrics and Palliative Care, NYU Langone Health, NY, USA
| | - Jean-Baptiste Bouillon-Minois
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
- CHU Clermont-Ferrand, Emergency Department, Clermont-Ferrand, F-63000, France
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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Goss A, O'Riordan DL, Pantilat S. Inpatients With Dementia Referred for Palliative Care Consultation: A Multicenter Analysis. Neurol Clin Pract 2022; 12:288-297. [DOI: 10.1212/cpj.0000000000001168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/14/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives:Specialty palliative care (PC) may benefit patients with dementia by aligning treatment with goals and relieving symptoms. We aimed to compare demographics and processes and outcomes of PC for inpatients with dementia to those with systemic illnesses or cancer.Methods:This multicenter cohort study included standardized data for hospitalized patients with a primary diagnosis of dementia, systemic illnesses (cardiovascular, pulmonary, hepatic, renal disease) or cancer among the 98 PC teams submitting data to the Palliative Care Quality Network from 2013-2019.Results:Out of 155,356 patients, 4.5% (n= 6,925) had a primary diagnosis of dementia, 32.5% (n=50,501) systemic illness, and 29.2% (n=45,386) cancer. Patients with dementia were older (mean 85.5 years, 95%CI 85.3-85.6) than those with systemic illnesses (mean 73.2, 95%CI 73.0-73.3) or cancer (mean 66.6, 95%CI 66.4-66.7; p<0.0001). Patients with dementia were more likely to receive a PC consult within 24 hours of admission (52.3% vs. systemic illnesses 37.4%; cancer 45.3%; p<0.0001), more likely to be bed-bound (vs. systemic illnesses OR 2.23, 95%CI 2.09-2.39, p<0.0001; vs. cancer OR 3.45, 95%CI 3.21-3.72, p<0.0001) and more likely to be discharged alive (vs. systemic illnesses OR 2.22, 95%CI 2.03-2.43, p<0.0001; vs. cancer OR 1.51, 95%CI 1.36-1.67, p<0.0001). Advance care planning / Goals of care (GOC) was the primary reason for consultation for all groups. Few patients overall had advance directives or Physician Orders for Life-Sustaining Treatment (POLSTs) prior to consultation. At the time of referral and at discharge, patients with dementia were more likely to have a code status of DNR/DNI (62.6% and 81.0% vs. 38.7 and 64.2% for patients with systemic illnesses, and 33.4% and 60.5% for patients with cancer; p<0.0001). Among the minority of patients with dementia that could self-report, moderate-to-severe symptoms were uncommon (pain 6.4%, anxiety 5.8%, nausea 0.4%, dyspnea 3.5%).Discussion:Inpatients with a primary diagnosis of dementia receiving PC consultation were older and more functionally impaired than those with other illnesses. They were more likely to have a code status of DNR/DNI at discharge. Few reported distressing symptoms. These results highlight the need for routine clarification of GOC for patients with dementia.
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Miu DKY, Lam KY, Chan CO. Do Cognitively Impaired Elderly Patients with Cancer Respond Differently on Self-reported Symptom Scores? A 5-Year Retrospective Analysis. Indian J Palliat Care 2022; 28:167-173. [PMID: 35673685 PMCID: PMC9168287 DOI: 10.25259/ijpc_18_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/17/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: An increasing number of elderly subjects with cancer were admitted to the palliative care unit and they have suffered both distressing symptoms and cognitive impairment. We aim to identify the prevalence of cognitive impairment among elderly cancer patients receiving in-patient palliative care and to examine any difference between patients with cognitive impairment on self-reported symptoms. Materials and Methods: Subjects’ age ≥65 admitted to a palliative care unit from 01 September 2015 to 31 August 2020 was included in the study. Exclusion criteria were those with an impaired conscious state, severe cognitive impairment, or language problems that were non-communicable. Variables collected included baseline demographics, cancer diagnosis, cancer stage, mobility state using the modified Barthel index (mBI), and performance status as measured by the palliative performance scale. Cognitive impairment was defined by abbreviated mental test ≤6. Self-reported symptoms scales were measured by the Chinese version of MD Anderson Symptom Inventory and EORTC QLQ C-30 (European Organisation for Research and Treatment of Cancer, Quality of Life Core Questionnaire 30). Results: Nine hundred and ninety-one subjects with 1174 admissions were retrieved. Eight hundred and seventy-three admission episodes were included in this study. Three hundred and eight (35%) have cognitive impairment. Cognitively impaired subjects were older, showed worse physical function and performance status, and more often residing in old age homes. Independent predictors of cognitive impairment were age (OR 1.09), mBI (OR 0.96), chair/bed bound state (OR 1.79), and presence of brain metastasis (OR 2.63). They reported lower scores in pain (P < 0.001), distress (P < 0.001), sleep disturbance (P < 0.001) and nausea and vomiting (P = 0.012) in the self-reported symptoms scale. Conclusion: Elderly cancer patients with cognitive impairment were older with poorer performance status. They have reported a lower level of pain, distress, and sleep disturbance. Clinicians should be alerted to this phenomenon to tackle the unmet concomitant symptoms.
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Affiliation(s)
- Doris Ka Ying Miu
- Department of Rehabilitation and Extended Care, Wong Tai Sin Hospital, Hong Kong,
| | - Kai Yin Lam
- Department of Rehabilitation and Extended Care, Wong Tai Sin Hospital, Hong Kong,
| | - Chung On Chan
- Department of Rehabilitation and Extended Care, Wong Tai Sin Hospital, Hong Kong,
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Cowey E, Schichtel M, Cheyne JD, Tweedie L, Lehman R, Melifonwu R, Mead GE. Palliative care after stroke: A review. Int J Stroke 2021; 16:632-639. [PMID: 33949268 PMCID: PMC8366189 DOI: 10.1177/17474930211016603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care is an integral aspect of stroke unit care. In 2016, the American Stroke Association published a policy statement on palliative care and stroke. Since then there has been an expansion in the literature on palliative care and stroke. AIM Our aim was to narratively review research on palliative care and stroke, published since 2015. RESULTS The literature fell into three broad categories: (a) scope and scale of palliative care needs, (b) organization of palliative care for stroke, and (c) shared decision making. Most literature was observational. There was a lack of evidence about interventions that address specific palliative symptoms or improve shared decision making. Racial disparities exist in access to palliative care after stroke. There was a dearth of literature from low- and middle-income countries. CONCLUSION We recommend further research, especially in low- and middle-income countries, including research to explore why racial disparities in access to palliative care exist. Randomized trials are needed to address specific palliative care needs after stroke and to understand how best to facilitate shared decision making.
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Affiliation(s)
- Eileen Cowey
- Nursing & Health Care School, University of Glasgow, Glasgow, UK
| | - Markus Schichtel
- Institute of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Joshua D Cheyne
- Cochrane Stroke Group, Centre for Clinical Brain Sciences (CCBS), University of Edinburgh, Edinburgh, UK
| | | | - Richard Lehman
- Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Birmingham, UK
| | - Rita Melifonwu
- Life After Stroke Centre, Stroke Action Nigeria, Onitsha, Nigeria
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Paal P, Brandstötter C, Bükki J, Elsner F, Ersteniuk A, Jentschke E, Stähli A, Slugotska I. One-week multidisciplinary post-graduate palliative care training: an outcome-based program evaluation. BMC MEDICAL EDUCATION 2020; 20:276. [PMID: 32811498 PMCID: PMC7437175 DOI: 10.1186/s12909-020-02200-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/12/2020] [Indexed: 05/13/2023]
Abstract
BACKGROUND A multi-professional, post-graduate, one-week palliative care training program was piloted in November 2019 at the University of Ivano-Frankivsk, Ukraine. A formal evaluation of this program was performed. METHODS This is a comparative, retrospective outcome-based evaluation of an educational intervention. Participants completed evaluation forms at the end of the course (post-intervention = T1), covering demographics, comparative retrospective self-assessment (40 items, 6-point Likert scale), organizational aspects, and general feedback (free text). At T1, the responses represent actual self-assessment, pre-interventional (T0) scores were generated by retrospective self-assessment. The Retrospective Performance Gain (RPG) was calculated on group level for the comparative self-assessment, demographic and organizational variables were analyzed by descriptive statistics, and free text answers were processed by qualitative methodology (content analysis). RESULTS Fifty-three of 56 attendants from all professions relevant to palliative care completed the evaluation forms (response 94,6%), with mean age 39y (22-64) and mean working experience 13,6y (1-44). Overall ratings of the program were very positive. Comparative retrospective self-assessment demonstrated a marked RPG from T0 to T1 on all items. Free text comments emphasized the need for regular nation-wide educational programs and for further education in bereavement care; inter-professional practice; communication; palliative care philosophy; professional self-care; specific nursing skills; dementia care; and advocacy, while the general contribution of the program to palliative care development in Ukraine was acknowledged. CONCLUSIONS Systematic evaluation of a post-graduate international training program in palliative care may provide a mutual learning experience and map country-specific barriers and facilitators that have to be addressed when setting up palliative care services.
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Affiliation(s)
- Piret Paal
- WHO Collaborating Centre, Institute for Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria.
| | - Cornelia Brandstötter
- WHO Collaborating Centre, Institute for Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Johannes Bükki
- Palliative Care Center at the Cantonal Hospital, St. Gallen, Switzerland
| | - Frank Elsner
- Department of Palliative Medicine, RWTH Aachen University, Aachen, Germany
| | - Anna Ersteniuk
- Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
| | - Elisabeth Jentschke
- Psycho-oncological, palliative-psychological and gerontological department, Comprehensive Cancer Center of the University Hospital, Wuerzburg, Germany
| | | | - Iryna Slugotska
- Regional Clinical Palliative Care Centre, Ivano-Frankivsk, Ukraine
- Family Medicine Department, Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
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