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Cohen AB, McDonald WM, O'Leary JR, Omer ZB, Fried TR. High-Intensity Care for Nursing Home Residents with Severe Dementia Hospitalized at the End of Life: A Mixed Methods Study. J Am Med Dir Assoc 2024; 25:871-875. [PMID: 38462230 PMCID: PMC11065599 DOI: 10.1016/j.jamda.2024.02.001] [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: 10/25/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE For nursing home residents with severe dementia, high-intensity medical treatment offers little possibility of benefit but has the potential to cause significant distress. Nevertheless, mechanical ventilation and intensive care unit (ICU) transfers have increased in this population. We sought to understand how and why such care is occurring. DESIGN Mixed methods study, with retrospective collection of qualitative and quantitative data. SETTING Department of Veterans Affairs (VA) hospitals. METHODS Using the Minimum Data Set, we identified veterans aged ≥65 years who had severe dementia, lived in nursing homes, and died in 2013. We selected those who underwent mechanical ventilation or ICU transfer in the last 30 days of life. We restricted our sample to patients receiving care at VA hospitals because these hospitals share an electronic medical record, from which we collected structured information and constructed detailed narratives of how medical decisions were made. We used qualitative content analysis to identify distinct paths to high-intensity treatment in these narratives. RESULTS Among 163 veterans, 41 (25.2%) underwent mechanical ventilation or ICU transfer. Their median age was 85 (IQR, 80-94), 97.6% were male, and 67.5% were non-Hispanic white. More than a quarter had living wills declining some or all treatment. There were 5 paths to high-intensity care. The most common (18 of 41 patients) involved families who struggled with decisions. Other patients (15 of 41) received high-intensity care reflexively, before discussion with a surrogate. Four patients had families who advocated repeatedly for aggressive treatment, against clinical recommendations. In 2 cases, information about the patient's preferences was erroneous or unavailable. In 2 cases, there was difficulty identifying a surrogate. CONCLUSIONS AND IMPLICATIONS Our findings highlight the role of surrogates' difficulty with decision making and of health system-level factors in end-of-life ICU transfers and mechanical ventilation among nursing home residents with severe dementia.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA.
| | | | - John R O'Leary
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Zehra B Omer
- Department of Medicine, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
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Hinton L, Tran D, Peak K, Meyer OL, Quiñones AR. Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review. Alzheimers Dement 2024; 20:3000-3020. [PMID: 38265164 PMCID: PMC11032576 DOI: 10.1002/alz.13612] [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: 03/28/2023] [Revised: 08/25/2023] [Accepted: 11/25/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers. METHODS We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings. RESULTS Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life. DISCUSSION Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.
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Affiliation(s)
- Ladson Hinton
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Duyen Tran
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Kate Peak
- Department of Family MedicineOregon Health & Science University (OHSU)PortlandOregonUSA
| | - Oanh L. Meyer
- School of MedicineUniversity of CaliforniaDavisSacramentoCaliforniaUSA
| | - Ana R. Quiñones
- Department of Family MedicineOregon Health & Science University (OHSU)PortlandOregonUSA
- OHSU‐PSU School of Public HealthOregon Health & Science UniversityPortlandOregonUSA
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3
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Abdelmalek FM, Angriman F, Moore J, Liu K, Burry L, Seyyed-Kalantari L, Mehta S, Gichoya J, Celi LA, Tomlinson G, Fralick M, Yarnell CJ. Association between Patient Race and Ethnicity and Use of Invasive Ventilation in the United States. Ann Am Thorac Soc 2024; 21:287-295. [PMID: 38029405 DOI: 10.1513/annalsats.202305-485oc] [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: 05/29/2023] [Accepted: 11/28/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: Outcomes for people with respiratory failure in the United States vary by patient race and ethnicity. Invasive ventilation is an important treatment initiated based on expert opinion. It is unknown whether the use of invasive ventilation varies by patient race and ethnicity. Objectives: To measure 1) the association between patient race and ethnicity and the use of invasive ventilation; and 2) the change in 28-day mortality mediated by any association. Methods: We performed a multicenter cohort study of nonintubated adults receiving oxygen within 24 hours of intensive care admission using the Medical Information Mart for Intensive Care IV (MIMIC-IV, 2008-2019) and Phillips eICU (eICU, 2014-2015) databases from the United States. We modeled the association between patient race and ethnicity (Asian, Black, Hispanic, White) and invasive ventilation rate using a Bayesian multistate model that adjusted for baseline and time-varying covariates, calculated hazard ratios (HRs), and estimated 28-day hospital mortality changes mediated by differential invasive ventilation use. We reported posterior means and 95% credible intervals (CrIs). Results: We studied 38,258 patients, 52% (20,032) from MIMIC-IV and 48% (18,226) from eICU: 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% White (31,113). Invasive ventilation occurred in 9.2% (3,511), and 7.5% (2,869) died. The adjusted rate of invasive ventilation was lower in Asian (HR, 0.82; CrI, 0.70-0.95), Black (HR, 0.78; CrI, 0.71-0.86), and Hispanic (HR, 0.70; CrI, 0.61-0.79) patients compared with White patients. For the average patient, lower rates of invasive ventilation did not mediate differences in 28-day mortality. For a patient on high-flow nasal cannula with inspired oxygen fraction of 1.0, the odds ratios for mortality if invasive ventilation rates were equal to the rate for White patients were 0.97 (CrI, 0.91-1.03) for Asian patients, 0.96 (CrI, 0.91-1.03) for Black patients, and 0.94 (CrI, 0.89-1.01) for Hispanic patients. Conclusions: Asian, Black, and Hispanic patients had lower rates of invasive ventilation than White patients. These decreases did not mediate harm for the average patient, but we could not rule out harm for patients with more severe hypoxemia.
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Affiliation(s)
| | - Federico Angriman
- Institute of Health Policy, Management, and Evaluation
- Interdepartmental Division of Critical Care Medicine
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Julie Moore
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Kuan Liu
- Institute of Health Policy, Management, and Evaluation
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine
- Leslie Dan Faculty of Pharmacy, and
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Laleh Seyyed-Kalantari
- Department of Electrical Engineering and Computer Science, Lassonde School of Engineering, York University, Toronto, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Judy Gichoya
- Department of Radiology and Biomedical Informatics, Emory University, Atlanta, Georgia
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George Tomlinson
- Institute of Health Policy, Management, and Evaluation
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Michael Fralick
- University Health Network/Sinai Health, Toronto, Ontario, Canada
| | - Christopher J Yarnell
- Institute of Health Policy, Management, and Evaluation
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health, Toronto, Ontario, Canada
- Department of Critical Care Medicine and
- Scarborough Health Network Research Institute, Scarborough Health Network, Toronto, Ontario, Canada
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de Miguel-Diez J, Lopez-de-Andres A, Jimenez-Garcia R, Hernández-Barrera V, Carabantes-Alarcon D, Zamorano-Leon JJ, Omaña-Palanco R, González-Barcala FJ, Cuadrado-Corrales N. Trends in prevalence and the effects on hospital outcomes of dementia in patients hospitalized with acute COPD exacerbation. Respir Med 2023; 212:107223. [PMID: 36965589 DOI: 10.1016/j.rmed.2023.107223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 03/27/2023]
Abstract
AIMS To assess changes in prevalence and the effects on hospital outcomes of dementia among patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD); and to evaluate sex-differences, as well as the impact of COVID-19 pandemic in this relationship. METHODS We used a nationwide discharge database to select patients admitted with AE-COPD in Spain from 2011 to 2020. We identified those with any type of dementia, vascular dementia (VaD) or Alzheimer's disease (AD). RESULTS We identified 658,429 hospitalizations with AE-COPD (4.45% had any type of dementia, 0.79% VaD and 1.57% AD). The presence of any type of dementia remained stable from 2011 to 2015, and increased significantly between 2016 and 2020. For VaD, the time trend showed no change until 2020, when a significant increment was found. The probability of AD decreased significantly overtime. The in-hospital mortality (IHM) among patients with any type of dementia remained stable overtime until 2020, when it increased significantly. Older age, higher comorbidity, COVID-19, and use of mechanical ventilation were variables associated to IHM. Women had lower risk of dying in the hospital than men in all subgroups. CONCLUSIONS After a previous period of stability, the prevalence of any type of dementia increased over the last 5 years of the study, although we identified different trends depending on the specific cause of dementia. The IHM remained stable overtime until 2020, when it increased, probably related to the COVID-19 pandemic. It is remarkable the protective effect of female sex for IHM.
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Affiliation(s)
- Javier de Miguel-Diez
- Respiratory Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, 28007, Madrid, Spain
| | - Ana Lopez-de-Andres
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28040, Madrid, Spain.
| | - Rodrigo Jimenez-Garcia
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28040, Madrid, Spain
| | - Valentin Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, 28922, Alcorcón, Spain
| | - David Carabantes-Alarcon
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28040, Madrid, Spain
| | - Jose J Zamorano-Leon
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28040, Madrid, Spain
| | - Ricardo Omaña-Palanco
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28040, Madrid, Spain
| | - Francisco Javier González-Barcala
- Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela. Universidad de Santiago de Compostela, 15706, Santiago de Compostela, Spain
| | - Natividad Cuadrado-Corrales
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28040, Madrid, Spain
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Ouellet GM, O’Leary JR, Leggett CG, Skinner J, Tinetti ME, Cohen AB. Benefits and harms of oral anticoagulants for atrial fibrillation in nursing home residents with advanced dementia. J Am Geriatr Soc 2023; 71:561-568. [PMID: 36310367 PMCID: PMC9957933 DOI: 10.1111/jgs.18108] [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: 08/09/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Approximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life. We aimed to quantify the benefits and harms of anticoagulation in this population. METHODS Using Minimum Data Set and Medicare claims, we conducted a retrospective cohort study with 14,877 long-stay nursing home residents aged ≥66 between 2013 and 2018 who had advanced dementia and AF. We excluded individuals with venous thromboembolism and valvular heart disease. We measured anticoagulant exposure quarterly, using Medicare Part D claims. The primary outcome was all-cause mortality; secondary outcomes were ischemic stroke and serious bleeding. We performed survival analyses with multivariable adjustment and inverse probability of treatment (IPT) weighting. RESULTS In the study sample, 72.0% were female, 82.7% were aged ≥80 years, and 13.5% were nonwhite. Mean CHA2 DS2 VASC score was 6.19 ± 1.58. In multivariable survival analysis, anticoagulation was associated with decreased risk of death (HR 0.71, 95% CI 0.67-0.75) and increased bleeding risk (HR 1.15, 95% CI 1.02-1.29); the association with stroke risk was not significant (HR 1.08, 95% CI 0.80-1.46). Results were similar in models with IPT weighting. While >50% of patients in both groups died within a year, median weighted survival was 76 days longer for anticoagulated individuals. CONCLUSION Persons with advanced dementia and AF derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding. The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.
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Affiliation(s)
- Gregory M. Ouellet
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - John R. O’Leary
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Christopher G. Leggett
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH
| | - Mary E. Tinetti
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
| | - Andrew B. Cohen
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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6
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Zhu Y, Olchanski N, Cohen JT, Freund KM, Faul JD, Fillit HM, Neumann PJ, Lin PJ. Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life. J Alzheimers Dis 2023; 96:1183-1193. [PMID: 37955089 PMCID: PMC10777481 DOI: 10.3233/jad-230692] [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: 11/14/2023]
Abstract
BACKGROUND Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. OBJECTIVE This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. METHODS This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. RESULTS Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. CONCLUSIONS Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.
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Affiliation(s)
- Yingying Zhu
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Natalia Olchanski
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Joshua T. Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Karen M. Freund
- Center for Health Equity Research, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Jessica D. Faul
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Sharma RK, Teng A, Asirot MG, Taylor JO, Borson S, Turner AM. Challenges and Opportunities in Conducting Research with Older Adults with Dementia during
COVID
‐19 and Beyond. J Am Geriatr Soc 2022; 70:1306-1313. [PMID: 35285942 PMCID: PMC9106837 DOI: 10.1111/jgs.17750] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/14/2022] [Accepted: 02/24/2022] [Indexed: 11/28/2022]
Abstract
The coronavirus disease 19 (COVID‐19) pandemic has created significant and new challenges for the conduct of clinical research involving older adults with Alzheimer's disease and related dementias (ADRD). It has also stimulated positive adaptations in methods for engaging older adults with ADRD in research, particularly through the increased availability of virtual platforms. In this paper, we describe how we adapted standard in‐person participant recruitment and qualitative data collection methods for virtual use in a study of decision‐making experiences in older adults with ADRD. We describe key considerations for the use of technology and virtual platforms and discuss our experience with using recommended strategies to recruit a diverse sample of older adults. We highlight the need for research funding that supports the community‐based organizations on which improving equity in ADRD research participation often depends.
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Affiliation(s)
- Rashmi K. Sharma
- Division of General Internal Medicine University of Washington Seattle Washington
| | - Andrew Teng
- Department of Biomedical Informatics and Medical Education School of Medicine, University of Washington, Seattle Washington
| | - Mary Grace Asirot
- Department of Health Systems and Population Health School of Public Health, University of Washington Seattle Washington
| | - Jean O. Taylor
- Department of Health Systems and Population Health School of Public Health, University of Washington Seattle Washington
| | - Soo Borson
- Department of Psychiatry and Behavioral Sciences University of Washington Seattle Washington
- Department of Family Medicine, Keck School of Medicine University of Southern California Los Angeles California
| | - Anne M. Turner
- Department of Biomedical Informatics and Medical Education School of Medicine, University of Washington, Seattle Washington
- Department of Health Systems and Population Health School of Public Health, University of Washington Seattle Washington
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Jia Z, Leiter RE, Sanders JJ, Sullivan DR, Gozalo P, Bunker JN, Teno JM. Asian American Medicare Beneficiaries Disproportionately Receive Invasive Mechanical Ventilation When Hospitalized at the End-of-Life. J Gen Intern Med 2022; 37:737-744. [PMID: 33904035 PMCID: PMC8075023 DOI: 10.1007/s11606-021-06794-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/01/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Asian Americans are the fastest-growing ethnic minority in the USA, but we know little about the end-of-life care for this population. OBJECTIVE Compare invasive mechanical ventilation (IMV) use between older Asian and White decedents with hospitalization in the last 30 days of life. DESIGN Population-based retrospective cohort study. PARTICIPANTS A 20% random sample of 2000-2017 Medicare fee-for-service decedents who were 66 years or older and had a hospitalization in the last 30 days of life. EXPOSURE White and Asian ethnicity as collected by the Social Security Administration. MAIN MEASURES We identified IMV using validated procedural codes. We compared IMV use between Asian and White fee-for-service decedents using random-effects logistic regression analysis, adjusting for sociodemographics, admitting diagnosis, comorbidities, and secular trends. KEY RESULTS From 2000 to 2017, we identified 2.1 million White (54.5% female, 82.4±8.1 mean age) and 28,328 Asian (50.8% female, 82.6±8.1 mean age) Medicare fee-for-service decedents hospitalized in the last 30 days. Compared to White decedents, Asian fee-for-service decedents have an increased adjusted odds ratio (AOR) of 1.42 (95%CI: 1.38-1.47) for IMV. In sub-analyses, Asians' AOR for IMV differed by admitting diagnoses (cancer AOR=1.32, 95%CI: 1.15-1.51; congestive heart failure AOR=1.75, 95%CI: 1.47-2.08; dementia AOR=1.93, 95%CI: 1.70-2.20; and chronic obstructive pulmonary disease AOR=2.25, 95%CI: 1.76-2.89). CONCLUSIONS Compared to White decedents, Asian Medicare decedents are more likely to receive IMV when hospitalized at the end-of-life, especially among patients with non-cancer admitting diagnoses. Future research to better understand the reasons for these differences and perceived quality of end-of-life care among Asian Americans is urgently needed.
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Affiliation(s)
- Zhimeng Jia
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Ariadne Labs, Boston, MA, USA
| | - Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University (OHSU), Portland, OR, USA.,Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, OR, USA
| | - Pedro Gozalo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Jennifer N Bunker
- Division of General Internal Medicine and Geriatrics, School of Medicine, Health & Science University, Portland, OR, USA
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Health & Science University, Portland, OR, USA
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9
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Wilkinson DJC. Dementia, Frailty and Triage in a Pandemic. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:W1-W4. [PMID: 34806972 DOI: 10.1080/15265161.2021.1991047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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10
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Cohen AB, Han L, OʼLeary JR, Fried TR. Guardianship and End-of-Life Care for Veterans with Dementia in Nursing Homes. J Am Geriatr Soc 2020; 69:342-348. [PMID: 33170957 DOI: 10.1111/jgs.16900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/20/2020] [Accepted: 08/30/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES Experts have suggested that patients represented by professional guardians receive higher intensity end-of-life treatment than other patients, but there is little corresponding empirical data. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Among veterans aged 65 and older who died from 2011 to 2013, we used Minimum Data Set assessments to identify those who were nursing home residents and had moderately severe or severe dementia. We applied methods developed in prior work to determine which of these veterans had professional guardians. Decedent veterans with professional guardians were matched to decedent veterans without guardians in a 1:4 ratio, according to age, sex, race, dementia severity, and nursing facility type (VA based vs non-VA). MEASUREMENTS Our primary outcome was intensive care unit (ICU) admission in the last 30 days of life. Secondary outcomes included mechanical ventilation and cardiopulmonary resuscitation in the last 30 days of life, feeding tube placement in the last 90 days of life, three or more nursing home-to-hospital transfers in the last 90 days of life, and in-hospital death. RESULTS ICU admission was more common among patients with professional guardians than matched controls (17.5% vs 13.7%), but the difference was not statistically significant (adjusted odds ratio = 1.33; 95% confidence interval = .89-1.99). There were no significant differences in receipt of any other treatment; nor was there a consistent pattern. Mechanical ventilation and cardiopulmonary resuscitation were more common among patients with professional guardians, and feeding tube placement, three or more end-of-life hospitalizations, and in-hospital death were more common among matched controls. CONCLUSION Rates of high-intensity treatment were similar whether or not a nursing home resident with dementia was represented by a professional guardian. This is in part because high-intensity treatment occurred more frequently than expected among patients without guardians.
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Affiliation(s)
- Andrew B Cohen
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Health System, West Haven, Connecticut, USA
| | - Ling Han
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R OʼLeary
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Health System, West Haven, Connecticut, USA
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