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Luth EA, Brennan C, Hurley SL, Phongtankuel V, Prigerson HG, Ryvicker M, Shao H, Zhang Y. Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice. JAMA Netw Open 2024; 7:e2411520. [PMID: 38753329 PMCID: PMC11099680 DOI: 10.1001/jamanetworkopen.2024.11520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/14/2024] [Indexed: 05/19/2024] Open
Abstract
Importance Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied. Objective To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services. Design, Setting, and Participants This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024. Exposure Live hospice discharge. Main Outcomes and Measures Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death. Results This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions. Conclusion and Relevance This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.
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Affiliation(s)
| | | | | | | | | | | | - Hui Shao
- Emory University, Gainesville, Georgia
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Wladkowski SP, Wallace CL, Coccia K, Hyde RC, Hinyard L, Washington KT. Live Discharge of Hospice Patients with Alzheimer's Disease and Related Dementias: A Systematic Review. Am J Hosp Palliat Care 2024; 41:228-239. [PMID: 36977504 PMCID: PMC10763573 DOI: 10.1177/10499091231168401] [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: 03/30/2023] Open
Abstract
Background: Hospice is intended to promote the comfort and quality of life of dying patients and their families. When patients are discharged from hospice prior to death (ie, experience a "live discharge"), care continuity is disrupted. This systematic review summarizes the growing body of evidence on live discharge among hospice patients with Alzheimer's Disease and related dementias (ADRD), a clinical subpopulation that disproportionately experiences this often burdensome care transition. Methods: Researchers conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Reviewers searched AgeLine, APA PsycINFO (Ovid), CINAHL Plus with Full Text, ProQuest Dissertations & Theses Global, PubMed, Scopus, and Web of Science (Core Collection). Reviewers extracted data and synthesized findings from 9 records, which reported findings from 10 individual studies. Results: The reviewed studies, which were generally of high quality, consistently identified diagnosis of ADRD as a risk factor for live discharge from hospice. The relationship between race and live hospice discharge was less clear and likely dependent upon the type of discharge under investigation and other (eg, systemic-level) factors. Research on patient and family experiences underscored the extent to which live hospice discharge can be distressing, confusing, and associated with numerous losses. Conclusion: Research specific to live discharge among ADRD patients and their families is limited. Synthesis across included studies points to the importance for future research to differentiate between types of live discharge-revocation vsversus decertification-as these are vastly different experiences in choice and circumstances.
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Affiliation(s)
- Stephanie P Wladkowski
- College of Health and Human Services, Bowling Green State University Department of Human Services, Bowling Green, OH, USA
| | - Cara L Wallace
- School of Social Work, Saint Louis University, St. Louis, MO, USA
| | - Kathryn Coccia
- School of Social Work, Saint Louis University, St. Louis, MO, USA
| | - Rebecca C Hyde
- Pius XII Memorial Library, Saint Louis University, St. Louis, MO, USA
| | - Leslie Hinyard
- Department of Health and Clinical Outcomes Research, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Karla T Washington
- Division of Palliative Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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Wallace CL, Wladkowski SP. Improving Policy and Practices of Hospice Live Discharge: A Historical Exploration of the Medicare Hospice Benefit. J Aging Soc Policy 2023:1-16. [PMID: 38037716 PMCID: PMC11143077 DOI: 10.1080/08959420.2023.2286164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/13/2023] [Indexed: 12/02/2023]
Abstract
Hospice care in the US is heavily regulated to ensure access to the Medicare Hospice Benefit (MHB) for individuals with serious illness. Policy changes to the MHB, many of which intended to minimize potential fraud (e.g. focused medical reviews; documentation requirements for certifications, recertifications, and discharges; requirements of physician narratives and face-to-face visits), directly impact current hospice discharge practices and experiences. When patients revoke hospice or are unable to be recertified due to a stabilized condition, they lose access to the holistic philosophy of care and experience additional stressors with increased potential for burdensome transitions. Patients with chronic conditions, such as Alzheimer's disease or related dementias, Chronic Obstructive Pulmonary Disease, or heart failure are more likely to have longer length of stays and are more often discharged alive from hospice. Few policy changes have been made to account for growing incidents of patients dying of chronic illness though the policy was originally created primarily for cancer patients, reflecting a time when most patients were dying of cancer. This manuscript describes the uniquely American phenomenon of a hospice live discharge, reviews relevant and historical policies, and provides recommendations for future research, policy, and practice to better support patients and families during this critical healthcare transition.
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Affiliation(s)
- Cara L Wallace
- Trudy Busch Valentine School of Nursing, Saint Louis University, Saint Louis, MO, USA
| | - Stephanie P Wladkowski
- Social Work, Health & Human Services, Bowling Green State University, Bowling Green, Ohio, USA
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Wang Y, Hong Q, Xia Y, Zhang Z, Wen B. The Lysine Demethylase KDM7A Regulates Immediate Early Genes in Neurons. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2301367. [PMID: 37565374 PMCID: PMC10558696 DOI: 10.1002/advs.202301367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/11/2023] [Indexed: 08/12/2023]
Abstract
Lysine demethylase KDM7A removes histone modifications H3K9me1/2 and H3K27me1/2. KDM7A plays critical roles in gene expression and contribute to biological processes including tumorigenesis, metabolism, and embryonic development. However, the functions of KDM7A in mammalian nervous system are still poorly explored. In this study, functional roles of KDM7A are comprehensively investigated in neuronal cells by applying CUT&Tag-seq, RNA-seq and mice models. Knockdown of Kdm7a in N2A cells result in the alteration of histone modifications near transcription start sites (TSSs) and the expression changes of a large number of genes. In particular, the expression of immediate early genes (IEGs), a series of genes maintaining the function of the nervous system and associating with neurological disorders, are significantly decreased upon Kdm7a knockdown. Furthermore, in vivo knockdown of Kdm7a in dentate gyrus (DG) neuron of mice hippocampus, via Adeno-associated virus (AAV)-based stereotaxic microinjection, led to a significant decrease of the expression of c-Fos, a marker of neuron activity. Behavior assays in mice further revealed that Kdm7a knockdown in hippocampus repress neuron activity, which leading to impairment of emotion and memory. Collectively, the study reveals that KDM7A affects neuron functions by regulating IEGs, which may provide new clues for understanding epigenetic mechanisms in neurological disorders.
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Affiliation(s)
- Yifan Wang
- Key Laboratory of Metabolism and Molecular Medicine of Ministry of Education, Department of Biochemistry and Molecular Biology, School of Basic Medical SciencesFudan University200032130 Dong An RoadShanghaiChina
| | - Qin Hong
- Shengli Clinical Medical College of Fujian Medical University, Center for Experimental Research in Clinical MedicineFujian Provincial Hospital134 East StreetFuzhou350001China
| | - Yueyue Xia
- Key Laboratory of Metabolism and Molecular Medicine of Ministry of Education, Department of Biochemistry and Molecular Biology, School of Basic Medical SciencesFudan University200032130 Dong An RoadShanghaiChina
| | - Zhao Zhang
- Key Laboratory of Metabolism and Molecular Medicine of Ministry of Education, Department of Biochemistry and Molecular Biology, School of Basic Medical SciencesFudan University200032130 Dong An RoadShanghaiChina
| | - Bo Wen
- Key Laboratory of Metabolism and Molecular Medicine of Ministry of Education, Department of Biochemistry and Molecular Biology, School of Basic Medical SciencesFudan University200032130 Dong An RoadShanghaiChina
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Wladkowski SP, Enguídanos S. Alzheimer's Disease and Related Dementias: Caregiver Perspectives on Hospice Re-Enrollment Following a Hospice Live Discharge. J Palliat Med 2023; 26:1374-1379. [PMID: 37155702 DOI: 10.1089/jpm.2023.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: The number of individuals dying of Alzheimer's disease and related dementias (ADRDs) is steadily increasing and they represent the largest group of hospice enrollees. In 2020, 15.4% of hospice patients across the United States were discharged alive from hospice care, with 5.6% decertified due to being "no longer terminally ill." A live discharge from hospice care can disrupt care continuity, increase hospitalizations and emergency room visits, and reduce the quality of life for patients and families. Furthermore, this discontinuity may impede re-enrollment into hospice services and receipt of community bereavement services. Objectives: The aim of this study is to explore the perspectives of caregivers of adults with ADRDs around hospice re-enrollment following a live discharge from hospice. Design: We conducted semistructured interviews of caregivers of adults with ADRDs who experienced a live discharge from hospice (n = 24). Thematic analysis was used to analyze data. Results: Three-quarters of participants (n = 16) would consider re-enrolling their loved one in hospice. However, some believed they would have to wait for a medical crisis (n = 6) to re-enroll, while others (n = 10) questioned the appropriateness of hospice for patients with ADRDs if they cannot remain in hospice care until death. Conclusions: A live discharge for ADRD patients impacts caregivers' decisions on whether they will choose to re-enroll a patient who has been discharged alive from hospice. Further research and support of caregivers through the discharge process are necessary to ensure that patients and their caregivers remain connected to hospice agencies postdischarge.
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Affiliation(s)
| | - Susan Enguídanos
- USC Leonard Davis School of Gerontology, Los Angeles, California, USA
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Zhang Y, Shao H, Zhang M, Li J. Healthcare Utilization and Mortality After Hospice Live Discharge Among Medicare Patients With and Without Alzheimer's Disease and Related Dementias. J Gen Intern Med 2023; 38:2272-2278. [PMID: 36650330 PMCID: PMC10406979 DOI: 10.1007/s11606-023-08031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Little is known about post-discharge outcomes among patients who were discharged alive from hospice. OBJECTIVE To compare healthcare utilization and mortality after hospice live discharge among Medicare patients with and without Alzheimer's disease and related dementias (ADRD). DESIGN Retrospective cohort study using Medicare claims data of a 20% random sample of Medicare fee-for-service (FFS) patients. PARTICIPANTS A total of 153,696 Medicare FFS patients experienced live discharge from hospice between 2014 and 2019. MEASURES Two types of burdensome transition (type 1: live discharge from hospice followed by hospitalization and subsequent hospice readmission; type 2: live discharge from hospice followed by hospitalization with the patient deceased in the hospital), acute care utilization, hospice readmission, and mortality in the 30 and 180 days after live discharge and between live discharge and death. RESULTS Compared with non-ADRD patients, ADRD patients were less likely to experience burdensome transitions (type 1: adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.90-0.98; type 2: aOR, 0.70; 95% CI, 0.65-0.75), more likely to have ED visits (aOR, 1.05; 95% CI, 1.01-1.09), less likely to die (aOR, 0.71; 95% CI, 0.69-0.73), and less likely to be readmitted to hospice (aOR, 0.86; 95% CI, 0.84-0.89) 30 days after live discharge. Results of 180-day post-discharge outcomes were largely consistent with results of 30-day outcomes. Among patients who died as of December 31, 2019, ADRD patients were less likely to be hospitalized (aOR, 0.88; 95% CI, 0.85-0.92) and more likely to be readmitted to hospice (aOR, 1.12; 95% CI, 1.08-1.16) between live discharge and death. Significant racial/ethnicity disparities in acute care utilization and mortality after live discharge existed in both ADRD and non-ADRD groups. CONCLUSION ADRD patients had lower mortality, a longer survival time, a lower rate of hospitalization, and an initially lower but gradually increasing rate of hospice readmission than non-ADRD patients after hospice live discharge. These different trajectories warrant further investigation of the eligibility of their initial hospice enrollment. Black patients had significantly worse outcomes after hospice live discharge compared with White patients.
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Affiliation(s)
- Yongkang Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, 402 East 67th Street, New York, NY, 10065, USA.
| | - Hui Shao
- Center for Drug Evaluation and Safety, Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Manyao Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, 402 East 67th Street, New York, NY, 10065, USA
| | - Jing Li
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
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Wittenberg E, Goldsmith JV, Savage MW, Sullivan SS. Exploring Differences in Caregiver Communication in Serious Illness. J Palliat Med 2023. [PMID: 36603111 DOI: 10.1089/jpm.2022.0406] [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: 01/07/2023] Open
Abstract
Background: Demographic factors, such as disease context and family relationships, are communication mediators and moderators; however, little is known about how understanding these factors can improve caregiver communication with providers. Recognition of communication differences among caregivers may aid the development of approaches to improve serious illness communication. Objective: To explore whether caregiver communication differs by disease context (cancer vs. dementia) and caregiver communication type (Manager, Carrier, Partner, and Lone). Caregiver communication type is based on communication patterns between the care recipient and caregiver. Design and Measurements: Caregivers of persons with cancer and/or dementia were surveyed from a U.S. national research registry website. Measures of caregiver communication included information needs, communication confidence, perception of provider understanding of the caregiver, perceived frequency of caregiver assessment, and caregiver stress. Analysis of variance (ANOVA) determined significant differences between caregiver communication (p < 0.05) based on disease context and caregiver communication type. Results: Cancer caregivers reported higher unrecognized-demanded information states (i.e., not recognizing information was needed), more communication confidence, and more frequent caregiver assessment compared to dementia caregivers. Among caregiver communication types, Manager caregiver types were more confident communicating than other caregiver types and perceived greater understanding by providers than the Lone caregiver type. Manager caregivers reported significantly less stress than other caregiver communication types. Conclusions: Understanding disease context and caregiver communication type may help improve caregiver communication with health care providers.
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Affiliation(s)
- Elaine Wittenberg
- Department of Communication Studies, California State University, Los Angeles, Los Angeles, California, USA
| | - Joy V Goldsmith
- Department of Communication and Film, University of Memphis, Memphis, Tennessee, USA
| | - Matthew W Savage
- School of Communication, San Diego State University, San Diego, California, USA
| | - Suzanne S Sullivan
- School of Nursing, University at Buffalo, State University of New York, Buffalo, New York, USA
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Alshakhs S, Sweet E, Luth E, Reid M, Henderson CR, Phongtankuel V. Hospice Composition Based on Diagnosis is Associated with Caregiver-Reported Quality Measures. Am J Hosp Palliat Care 2022; 39:1410-1417. [PMID: 35442840 PMCID: PMC9582045 DOI: 10.1177/10499091221088497] [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: 11/16/2022] Open
Abstract
Context: Given that the composition of hospice patients' terminal diagnoses has become increasingly diverse, understanding whether hospices provide quality care to patients, regardless of disease, is important. However, data comparing diagnosis and caregiver-reported outcomes remain scarce. Objectives: To analyze the association between the composition of patients' terminal diagnoses and caregiver-reported quality measures. Methods: Using cross-sectional, publicly available data from the Centers for Medicare & Medicare Services (CMS), we analyzed data collected from 2015-2019. We conducted general linear model analyses to identify associations between hospice characteristics/practices and caregiver-reported outcomes. Results: Of the 2810 hospices, those that cared for a greater percentage of dementia patients had fewer caregivers, on average, who rated hospice a 9 or 10 (where 0 = low, 10 = high; β = -.094; 95% CI = -.147, -.038), reported they always received help for pain and symptoms (β = -.106, CI = -.156, -.056), and reported definitely having received the training they needed (β = -.151, CI = -.207, -.095). Those caring for more stroke patients had fewer caregivers, on average, who rated hospice a 9 or 10 (β = -.184, CI = .252, -.115), reported they always received help for pain and symptoms (β = -.188, CI = -.251, -.126), reported definitely having received the training they needed (β = -.254, CI = -.324, -.184), and reported that the hospice offered the right amount of emotional/spiritual support (β = -.056, CI = -.093, -.019). Conclusion: Hospices that cared for a greater proportion of dementia and stroke patients had poorer scores on caregiver-reported quality measures. These findings support efforts to identify mechanisms underlying these differences and to design strategies to ensure optimal outcomes for hospice patients regardless of diagnosis.
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Affiliation(s)
| | | | | | - M.C. Reid
- Weill Cornell Medicine, New York, USA
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Gerlach LB, Zhang L, Strominger J, Kim HM, Teno J, Bynum JPW, Maust DT. Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies. J Gen Intern Med 2022; 37:3814-3822. [PMID: 35469359 PMCID: PMC9640505 DOI: 10.1007/s11606-022-07604-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/06/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Benzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies. OBJECTIVE Examine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice. DESIGN Retrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice. PARTICIPANTS Medicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment. MAIN MEASURES The primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics. KEY RESULTS A total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing. CONCLUSIONS The pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Lan Zhang
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Joan Teno
- Department of General Internal Medicine and Geriatrics, Oregon Health and Sciences University, Portland, OR, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Sullivan SS, de Rosa C, Li CS, Chang YP. Dementia caregiver burdens predict overnight hospitalization and hospice utilization. Palliat Support Care 2022; 21:1-15. [PMID: 36263744 PMCID: PMC10115915 DOI: 10.1017/s1478951522001249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To determine sociodemographics and caregiver burdens associated with overnight hospitalization, hospice utilization, and hospitalization frequency among persons with dementia (PWD). METHODS Cross-sectional analysis of PWD (n = 899) of the National Health and Aging Trends Study linked to the National Study of Caregiving. Logistic and proportional odds regression determined the effects of caregiver burdens on overnight hospitalization, hospice use, and hospitalization frequency. Differences between PWD alive not-alive groups were compared on overnight hospitalization and frequency. RESULTS Alive PWD (n = 804) were 2.36 times more likely to have an overnight hospital stay (p = 0.004) and 1.96 times more likely to have multiple hospitalizations when caregivers found it physically difficult to provide care (p = 0.011). Decedents aged 65-74 (n = 95) were 4.55 times more likely to experience overnight hospitalizations than 85+, hospitalizations were more frequent (odds ratio [OR] = 4.84), and there was a significant difference between PWD alive/not alive groups (p = 0.035). Decedents were 5.60 times more likely to experience an overnight hospitalization when their caregivers had financial difficulty, hospitalizations were more frequent when caregivers had too much to handle (OR = 8.44) and/or no time for themselves (OR = 10.67). When caregivers had no time for themselves, a significant difference between alive/not alive groups (p = 0.018) was detected in hospitalization frequency. PWD whose caregivers had emotional difficulty helping were 5.89 times more likely to utilize hospice than caregivers who did not report emotional difficulty. SIGNIFICANCE OF RESULTS Care transitions among PWD at the end of life are impacted by the circumstances and experiences of their caregivers. Subjective caregiver burdens represent potentially modifiable risks for undesired care transitions and opportunities for promoting hospice use. Future work is warranted to identify and address these issues as they occur.
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Affiliation(s)
| | | | - Chin-Shang Li
- School of Nursing, University at Buffalo, Buffalo, NY, USA
| | - Yu-Ping Chang
- School of Nursing, University at Buffalo, Buffalo, NY, USA
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Luth EA, Manful A, Prigerson HG, Xiang L, Reich A, Semco R, Weissman JS. Associations between dementia diagnosis and end-of-life care utilization. J Am Geriatr Soc 2022; 70:2871-2883. [PMID: 35822659 PMCID: PMC9588556 DOI: 10.1111/jgs.17952] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/27/2022] [Accepted: 06/09/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Dementia is a leading cause of death for older adults and is more common among persons from racial/ethnic minoritized groups, who also tend to experience more intensive end-of-life care. This retrospective cohort study compared end-of-life care in persons with and without dementia and identified dementia's moderating effects on the relationship between race/ethnicity and end-of-life care. METHODS Administrative claims data for 463,590 Medicare fee-for-service decedents from 2016 to 2018 were analyzed. Multivariable logistic and linear regression analyses examined the association of dementia with 5 intensive and 2 quality of life-focused measures. Intensity measures included hospital admission, ICU admission, receipt of any of 5 intensive procedures (CPR, mechanical ventilation, intubation, dialysis initiation, and feeding tube insertion), hospital death, and Medicare expenditures (last 30 days of life). Quality of life measures included timely hospice care (>3 days before death) and days at home (last 6 months of life). Models were adjusted for demographic and clinical factors. RESULTS 54% of Medicare decedents were female, 85% non-Hispanic White, 8% non-Hispanic Black, and 4% Hispanic. Overall, 51% had a dementia diagnosis claim. In adjusted models, decedents with dementia had 16%-29% lower odds of receiving intensive services (AOR hospital death: 0.71, 95% CI: 0.70-0.72; AOR hospital admission: 0.84, 95% CI: 0.83-0.86). Patients with dementia had 45% higher odds of receiving timely hospice (AOR: 1.45, 95% CI: 1.42-1.47), but spent 0.74 fewer days at home (adjusted mean: -0.74, 95% CI: (-0.98)-(-0.49)). Compared to non-Hispanic White individuals, persons from racial/ethnic minoritized groups were more likely to receive intensive services. This effect was more pronounced among persons with dementia. CONCLUSIONS Although overall dementia was associated with fewer intensive services near death, beneficiaries from racial/ethnic groups minoritized with dementia experienced more intensive service use. Particular attention is needed to ensure care aligns with the needs and preferences of persons with dementia and from racial/ethnic minoritized groups.
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Affiliation(s)
- Elizabeth A. Luth
- Institute for Health, Healthcare Policy and Aging Research, Department of Family Medicine and Community HealthRutgers UniversityNew BrunswickNew JerseyUSA
| | - Adoma Manful
- School of Medicine, Division of EpidemiologyVanderbilt UniversityNashvilleUSA
| | - Holly G. Prigerson
- Department of Geriatrics and Palliative MedicineWeill Cornell MedicineNew York CityNew YorkUSA
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women's HospitalHarvard UniversityCambridgeMassachusettsUSA
| | - Amanda Reich
- Center for Surgery and Public Health, Brigham and Women's HospitalHarvard UniversityCambridgeMassachusettsUSA
| | | | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women's HospitalHarvard UniversityCambridgeMassachusettsUSA
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12
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Wen Y, Rahman MF, Zhuang Y, Pokojovy M, Xu H, McCaffrey P, Vo A, Walser E, Moen S, Tseng TLB. Time-to-event modeling for hospital length of stay prediction for COVID-19 patients. MACHINE LEARNING WITH APPLICATIONS 2022; 9:100365. [PMID: 35756359 PMCID: PMC9213016 DOI: 10.1016/j.mlwa.2022.100365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/30/2022] [Accepted: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Providing timely patient care while maintaining optimal resource utilization is one of the central operational challenges hospitals have been facing throughout the pandemic. Hospital length of stay (LOS) is an important indicator of hospital efficiency, quality of patient care, and operational resilience. Numerous researchers have developed regression or classification models to predict LOS. However, conventional models suffer from the lack of capability to make use of typically censored clinical data. We propose to use time-to-event modeling techniques, also known as survival analysis, to predict the LOS for patients based on individualized information collected from multiple sources. The performance of six proposed survival models is evaluated and compared based on clinical data from COVID-19 patients.
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Affiliation(s)
- Yuxin Wen
- Dale E. and Sarah Ann Fowler School of Engineering, Chapman University, Orange, CA 92866, USA
| | - Md Fashiar Rahman
- Department of Industrial, Manufacturing and Systems Engineering, The University of Texas at El Paso, El Paso, TX 79968, USA
| | - Yan Zhuang
- Department of Biomedical Engineering, Sichuan University, Chengdu, Sichuan 610065, China
| | - Michael Pokojovy
- Department of Mathematical Sciences, The University of Texas at El Paso, El Paso, TX 79968, USA
| | - Honglun Xu
- Department of Industrial, Manufacturing and Systems Engineering, The University of Texas at El Paso, El Paso, TX 79968, USA
| | - Peter McCaffrey
- The University of Texas Medical Branch, Galveston, TX 77550, USA
| | - Alexander Vo
- The University of Texas Medical Branch, Galveston, TX 77550, USA
| | - Eric Walser
- The University of Texas Medical Branch, Galveston, TX 77550, USA
| | - Scott Moen
- The University of Texas Medical Branch, Galveston, TX 77550, USA
| | - Tzu-Liang Bill Tseng
- Department of Industrial, Manufacturing and Systems Engineering, The University of Texas at El Paso, El Paso, TX 79968, USA
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13
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Harrison KL, Cenzer I, Ankuda CK, Hunt LJ, Aldridge MD. Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:821-830. [PMID: 35666964 PMCID: PMC9662595 DOI: 10.1377/hlthaff.2021.01985] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Medicare hospice benefit was originally designed around a cancer disease paradigm but increasingly serves people living with dementia. At this time, almost half of all older adults receiving hospice care have dementia. Yet there is minimal evidence as to whether hospice benefits people living with dementia outside of nursing facilities. We asked whether and how the perceived quality of last-month-of-life care differed between people with and without dementia and whether hospice use among people living with dementia was associated with perceived quality of care compared with the quality of care for those who did not use hospice. We used nationally representative data from the National Health and Aging Trends Study and Medicare claims from the period 2011-17 to examine the impact of hospice enrollment on proxy perceptions of last-month-of-life care quality. Proxies of people living with dementia enrolled in hospice compared with proxies of those not enrolled more often reported care to be excellent (predicted probability: 52 percent versus 41 percent), more often reported having anxiety or sadness managed (67 percent versus 46 percent), and less often reported changes in care settings in the last three days of life (10 percent versus 25 percent). There were no differences in the impact of hospice on proxy ratings of care for people with and without dementia. Policy makers should consider these benefits when weighing changes to hospice policy and regulations that may affect people living with dementia.
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Affiliation(s)
- Krista L Harrison
- Krista L. Harrison , University of California San Francisco, San Francisco, California
| | - Irena Cenzer
- Irena Cenzer, University of California San Francisco
| | - Claire K Ankuda
- Claire K. Ankuda, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lauren J Hunt
- Lauren J. Hunt, University of California San Francisco
| | - Melissa D Aldridge
- Melissa D. Aldridge, Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center, Bronx, New York
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14
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David D, Lin SY, Groom LL, Ford A, Brody AA. Aliviado Mobile App for Hospice Providers: A Usability Study. J Pain Symptom Manage 2022; 63:e37-e45. [PMID: 34389414 PMCID: PMC8766865 DOI: 10.1016/j.jpainsymman.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/13/2021] [Accepted: 07/22/2021] [Indexed: 01/03/2023]
Abstract
CONTEXT Evaluation of usability and mobile health content is critical for ensuring effective implementation of technology utilizing interventions tailored to the needs of hospice care providers for people living with dementia in community-based settings. OBJECTIVES To evaluate the usability, content, and "readiness to launch" of the Aliviado mobile health app for interdisciplinary team members participating in the Hospice Advanced Dementia Symptom Management and Quality of Life. METHODS Usability of the Aliviado app was assessed in 86 respondents with an adapted IBM Computer Usability Satisfaction Questionnaire following Hospice Advanced Dementia Symptom Management and Quality of Life training and implementation of the mobile app. RESULTS More than half of users receiving training employed the mobile app in practice. Users reported use as: Daily-6.3%, Weekly-39.6%, monthly-54.2%. The highest measured attributes were usefulness, value, and effectiveness. Over 90% deemed the app "ready to launch" with no or minimal problems. CONCLUSION This study shows that a newly-developed mobile app is usable and can be successfully adopted for care of people living with dementia.
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Affiliation(s)
- Daniel David
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA.
| | - Shih-Yin Lin
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Lisa L Groom
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Ariel Ford
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
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15
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Wladkowski SP, Wallace CL. The Forgotten and Misdiagnosed Care Transition: Live Discharge From Hospice Care. Gerontol Geriatr Med 2022; 8:23337214221109984. [PMID: 35846976 PMCID: PMC9280841 DOI: 10.1177/23337214221109984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 11/16/2022] Open
Abstract
Every aspect of the United States healthcare industry presents transitions in care—hospitalizations, rehabilitation, long-term care placement—each requiring careful attention. With a goal of maintaining safety during a known point of vulnerability for patients, discharge planning is required in hospitals, skilled nursing facilities, and home health agencies under Medicare guidelines. Yet, no required discharge planning or clear guidelines are available for a discharge from hospice; it is a forgotten care transition in our healthcare system. Of the 1.6 million Medicare recipients hospices serve each year, hospices discharge 17.4% alive. Under Medicare regulations, if clinicians cannot document acceptable patient decline, then patients are decertified from hospice categorized as “no longer terminally ill”, otherwise known as a live discharge. These patients are often referred to as “not dying fast enough,” or “failure to die on time,” as ultimately, they are still dying, and they are still terminally ill, just not within the prescribed 6-month framework. This paper outlines what is known about the occurrences and experiences of live discharge from hospice care and provides suggestions for improving both practice and policy.
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16
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Vaughan CL, Bruno V. What neurologists wish palliative care physicians knew. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:93-104. [PMID: 36055723 DOI: 10.1016/b978-0-323-85029-2.00005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
As the incidence of neurologic (particularly neurodegenerative) diseases continues to rise, so too will the palliative needs in this patient population. To appropriately care for these patients and families, neurologists and palliative care providers will need to strengthen collaboration. Palliative care providers not formally trained in neurology may feel ill-equipped to manage some of the distinct neuropalliative care needs of these patients. Here, we provide insights into the unique characteristics of patients with neurologic disease and emphasize the relevance of the palliative care skillset in this population to aid the collaboration between palliative care providers and neurologists.
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Affiliation(s)
- Christina L Vaughan
- Department of Neurology and Medicine, Anschutz Medical Center, University of Colorado, Aurora, CO, United States; Department of Neurology, VA Eastern Colorado Health System, Aurora, CO, United States.
| | - Veronica Bruno
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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17
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Nguyen HQ, Vallejo JD, Macias M, Shiffman MG, Rosen R, Mowry V, Omotunde O, Hong B, Liu ILA, Borson S. A mixed-methods evaluation of home-based primary care in dementia within an integrated system. J Am Geriatr Soc 2021; 70:1136-1146. [PMID: 34936090 DOI: 10.1111/jgs.17627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 11/07/2021] [Accepted: 12/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND No prior studies have examined the effects of home-based primary care (HBPC) in persons living with dementia (PLWD), within an ecosystem of serious illness care in an integrated healthcare system. Our objectives were to compare the characteristics of PLWD receiving HBPC and their hospital utilization and end-of-life care, with those of a matched comparison group, and to understand the experiences of family caregivers of PLWD receiving HBPC. METHODS This mixed-methods study used a retrospective observational cohort design with PLWD receiving HBPC (n = 287) from 2015 to 2020 and a strata-matched comparison group (n = 861), and qualitative phone interviews with 16 HBPC family caregivers in 2020. Inverse probability of treatment weighting propensity score-adjusted models were used to compare time-to-first hospital-based utilization and, for decedents, home palliative and hospice care and place of death. Care experience was captured through caregiver interviews. RESULTS Patients receiving HBPC had a similar risk of hospital utilization [adjusted hazard ratio, 1.06 (95% CI: 0.89-1.26), p = 0.51] as a matched non-HBPC comparison group after a median follow-up of 199 days. However, HBPC decedents (n = 159) were more likely to receive home palliative care or hospice [rate ratio, RR: 1.23 (95% CI: 1.07-1.42), p < 0.01] and to die at home [RR: 1.66 (95% CI: 1.35-2.05), p < 0.001] than were non-HBPC decedents (n = 423). Caregivers reported that HBPC provided coordinated, continuous, and convenient care that was aligned with families' priorities and goals; however, some expressed unmet needs, especially for help paying for personal care and medical supplies/equipment, and a desire for clearer communication about program operations and more quality oversight for contract services. CONCLUSIONS Although HBPC for PLWD was associated with a similar risk of hospital utilization compared to a matched non-HBPC comparison group, HBPC resulted in more patient-centered end-of-life care for decedents. Prospective studies of HBPC that further elicit and address unmet needs are warranted.
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Affiliation(s)
- Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jessica D Vallejo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Mayra Macias
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Romina Rosen
- Woodland Hills Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Velda Mowry
- Panorama City Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Omotayo Omotunde
- Panorama City Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Benjamin Hong
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Soo Borson
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Family Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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18
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Kang Y, Hur Y. Nurses' Experience of Nursing Workload-Related Issues during Caring Patients with Dementia: A Qualitative Meta-Synthesis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10448. [PMID: 34639748 PMCID: PMC8508301 DOI: 10.3390/ijerph181910448] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 11/24/2022]
Abstract
The behavioral and psychological symptoms of dementia (BPSD), which appear in all dementia patients, demand sizable commitments of time and effort from nurses. This study aims to identify issues related to the workloads of nurses who provide care for dementia patients via qualitative meta-synthesis. Eleven articles were selected using a systematic review flowchart, which were then evaluated for their quality using the Critical Appraisal Skills Program checklist. Collected data were analyzed using a line-of-argument method. Theme clusters were "increased workload due to characteristics of dementia", "increased mental stress", "difficulty associated with playing a mediator role in addition to nursing duties", and "lacking systematic support for dementia patient care". To reduce the workload and mental stress of nurses in dementia care, supportive measures appropriate for their occupational characteristics should be developed, based on workload estimates that account for the attributes of dementia patients.
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Affiliation(s)
- Younhee Kang
- Division of Nursing, College of Nursing, Ewha Womans University, Seoul 03760, Korea;
- Graduate Program in System Health and Engineering, Ewha Womans University, Seoul 03760, Korea
| | - Yujin Hur
- Division of Nursing, College of Nursing, Ewha Womans University, Seoul 03760, Korea;
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Hunt LJ, Harrison KL. Live discharge from hospice for people living with dementia isn't "graduating"-It's getting expelled. J Am Geriatr Soc 2021; 69:1457-1460. [PMID: 33855701 DOI: 10.1111/jgs.17107] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/28/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Lauren J Hunt
- Department of Physiological Nursing, University of California, San Francisco, California, USA.,Global Brain Health Institute, University of California, San Francisco, California, USA
| | - Krista L Harrison
- Global Brain Health Institute, University of California, San Francisco, California, USA.,Division of Geriatrics, University of California, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
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