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Jijakli A, Skeels K, Zebelean D, Swanson K, LaChance A, Dwyer B, Savitz A, Melkumova E, Leung LY. Quality Improvement Initiative Using Predictive Swallowing Score to Guide Nutritional Support for Patients With Post-Stroke Dysphagia. Neurol Clin Pract 2024; 14:e200352. [PMID: 39185102 PMCID: PMC11341003 DOI: 10.1212/cpj.0000000000200352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 05/10/2024] [Indexed: 08/27/2024]
Abstract
Background and Objectives Decisions on enteral nutrition for patients with dysphagia after acute ischemic stroke (AIS) are often not evidence based. We sought to determine whether development of a nutritional support algorithm leveraging the Predictive Swallowing Score (PRESS) could improve process times without placement of unnecessary gastrostomies. Methods This is a quality improvement study conducted at an academic medical center comparing a 6-month cohort of adults with AIS and dysphagia prepathway (PRE, July 1, 2019-December 31, 2019) and a 6-month cohort postpathway (POST, January 1, 2020-June 30, 2020). Gastrostomy recommendation, time to gastrostomy decision (TTD), discharge with gastrostomy, discharge with a nasogastric tube (NGT), and length of stay (LOS) were compared between groups. Results Among 121 patients with AIS and dysphagia, 58 (48%) were hospitalized prealgorithm and 63 (52%) postalgorithm. PRE TTD was longer than POST TTD (4.5 vs 1.5 days, p = 0.004). Frequency of gastrostomy was similar between PRE and POST (12% vs 8%, p = 0.58). LOS for patients recommended gastrostomy was longer in PRE (14.5 vs 6.5 days, p = 0.03). Frequency of discharge with NGT was numerically higher in POST but not significantly different (0.7% vs 6%, p = 0.4). Overall, LOS was the same in both groups (5 days). Discussion Development of a structured nutritional support algorithm incorporating PRESS may help facilitate sooner gastrostomy placement without increasing gastrostomy placement frequency and encourage more discharges to inpatient rehabilitation facilities with NGTs.
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Affiliation(s)
- Amr Jijakli
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
| | - Katelyn Skeels
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
| | - Devin Zebelean
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
| | - Krista Swanson
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
| | - Ashley LaChance
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
| | - Brigid Dwyer
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
| | - Ariel Savitz
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
| | - Emiliya Melkumova
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
| | - Lester Y Leung
- Division of Stroke and Cerebrovascular Diseases (AJ, K. Skeels, DZ, AL, EM, LYL), Department of Neurology; Department of Speech Language Pathology (K. Swanson), Tufts Medical Center; Department of Neurology (BD), Boston Medical Center, MA; Department of Rehabilitation Medicine (AS), Tufts Medical Center, Boston; and Encompass Health Rehabilitation Hospitals (BD, AS), MA
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Huang AP, Holloway RG. Navigating Neurologic Illness: Skills in Neuropalliative Care for Persons Hospitalized with Neurologic Disease. Semin Neurol 2024; 44:503-513. [PMID: 39053504 DOI: 10.1055/s-0044-1788723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Persons hospitalized for neurologic illness face multidimensional care needs. They can benefit from a palliative care approach that focuses on quality of life for persons with serious illness. We describe neurology provider "skills" to help meet these palliative needs: assessing the patient as a whole; facilitating conversations with patients to connect prognosis to care preferences; navigating neurologic illness to prepare patients and care partners for the future; providing high-quality end-of-life care to promote peace in death; and addressing disparities in care delivery.
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Affiliation(s)
- Andrew P Huang
- Department of Neurology, University of Rochester, Rochester, New York
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, New York
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3
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Yang SM, Wu HW, Hsueh HW, Lin YH, Lai TJ, Lin MT. Factors associated with oropharyngeal dysphagia and unsuccessful nasogastric tube removal after endovascular thrombectomy for anterior circulation stroke. Eur Geriatr Med 2024:10.1007/s41999-024-01069-9. [PMID: 39317881 DOI: 10.1007/s41999-024-01069-9] [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: 06/22/2024] [Accepted: 09/16/2024] [Indexed: 09/26/2024]
Abstract
PURPOSE To identify the predictive variables for post-stroke dysphagia (PSD) among anterior circulation large vessel occlusion (LVO) stroke patients who underwent endovascular thrombectomy (EVT). METHODS This retrospective cohort study enrolled hospitalized patients with anterior LVO stroke who underwent EVT between January 1, 2018 and October 31, 2022. PSD was defined as the unsuccessful removal of the nasogastric (NG) tube. Factors, such as premorbid characteristics, laboratory results, EVT, rehabilitation-related parameters, and neuro-imaging, were analyzed for correlations to PSD at 4 and 12 weeks. RESULTS The study enrolled 136 patients, with a mean age of 72.9 ± 13.0 years, and 59 patients (43.4%) were male. At 4 weeks, 47.1% of the patients needed an NG tube, and at 12 weeks, 16.2% still required an NG tube. We found that lower albumin, lower body mass index (BMI), higher initial and 24-h post-EVT National Institute of Health Stroke Scale (NIHSS) scores, stroke-associated pneumonia, poor initial sitting balance and ability to sit up, insula or frontal operculum lesions, and bilateral hemisphere involvement were all associated with PSD at both 4 and 12 weeks in the univariate logistic regression. Multivariate analysis revealed that significant predictors of unsuccessful NG tube removal at 4 weeks included lower BMI (adjusted OR [aOR] 0.73, p = 0.005), hemorrhagic transformation (aOR 4.01, p = 0.0335), higher NIHSS scores at 24 h post-EVT (aOR 1.13, p = 0.0288), poor initial sitting ability (aOR 0.52, p = 0.0231), insular cortex ischemia (aOR 7.26, p = 0.0056), and bilateral hemisphere involvement (aOR 41.19, p < 0.0001). At 12 weeks, lower BMI (aOR 0.78, p = 0.0098), poor initial sitting balance (aOR 0.57, p = 0.0287), insular cortex lesions (aOR 4.83, p = 0.0092), and bilateral hemisphere involvement (aOR 4.07, p = 0.0139) remained significant predictors. CONCLUSIONS In patients with anterior LVO following EVT, PSD was associated with lower BMI, higher NIHSS scores, poor initial sitting balance and sitting ability, insular lesions, and bilateral hemisphere involvement.
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Affiliation(s)
- Shu-Mei Yang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Hao-Wei Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Hsueh-Wen Hsueh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Ting-Ju Lai
- Department of Medical Research, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Meng-Ting Lin
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan.
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Drennan JC, Sheehan TO, Schroeder T, Haller JT. Implementation of a Nurse-Initiated Protocol to Improve Enteral Medication Administration Documentation in Stroke Patients. J Neurosci Nurs 2024:01376517-990000000-00108. [PMID: 39231433 DOI: 10.1097/jnn.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
ABSTRACT BACKGROUND: Medication documentation falls under the "7 rights" of medication administration, but strategies to prevent medication administration documentation errors (MADEs) related to route of administration are underreported in the literature. This study aimed to report the outcomes of a nurse-initiated protocol designed to prevent MADEs and align both actual and documented medication administration routes in hospitalized stroke patients with feeding tubes (FTs). METHODS: This was a retrospective descriptive study conducted at a Comprehensive Stroke Center and large academic medical center in the Western United States. Adults admitted with the diagnosis of stroke between February 2022 and August 2023, who had an FT on arrival, or placed during admission, and received at least 1 enteral medication ordered for by mouth (PO) administration, were included. The protocol allowed nurses to place a communication order to a pharmacist via the electronic health record, requesting all enteral medications ordered for PO administration be changed to FT administration. RESULTS: There were 481 patients included with a median age of 68 years (interquartile range, 58-76 years). The nurse-initiated protocol was used in 170 patients (35.3%), with 99 patients (58.2%) having all enteral medication orders converted completely by a pharmacist. Of the 170 patients in which the protocol was initiated, 145 (85.3%) had all scheduled enteral medication orders converted. For the 71 patients who did not have all enteral medication orders converted completely, the median number of potential MADEs was 2 (1-4.5). CONCLUSION: A nurse-initiated protocol designed to prevent MADEs and improve the accuracy of actual and documented route of medication administration for patients hospitalized for stroke with FTs had modest use. The nurse-initiated protocol in this study is the first of its kind and may help guide further research on preventing and reducing MADEs.
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Magee PM, October TW. Culturally Centered Palliative Care: A Framework for Equitable Neurocritical Care. Neurocrit Care 2024:10.1007/s12028-024-02041-y. [PMID: 38955929 DOI: 10.1007/s12028-024-02041-y] [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: 04/19/2024] [Accepted: 05/31/2024] [Indexed: 07/04/2024]
Abstract
Health disparities continue to plague racial and ethnic underserved patients in the United States. Disparities extend to the most critically ill patients, including those experiencing neurologic injury and patients at the end of life. Achieving health equity in palliative care in the neurointensive care unit requires clinicians to acknowledge and address structural racism and the social determinants of health. This article highlights racial and ethnic disparities in neurocritical care and palliative care and offers recommendations for an anti-racist approach to palliative care in the neurointensive care unit for clinicians.
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Affiliation(s)
- Paula M Magee
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 9 Main Suite 9NW45, Philadelphia, PA, 19104, USA.
| | - Tessie W October
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
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Abedini NC, Shulein OM, Berrú-Villalobos S, Ramírez-Quiñones J, Creutzfeldt CJ, Portocarrero J, Zunt JR, Abanto-Argomedo C. Outcomes and Experiences of Patients and Their Caregivers After Severe Stroke Requiring Tube Feeding in Peru. J Pain Symptom Manage 2024; 67:296-305. [PMID: 38215896 DOI: 10.1016/j.jpainsymman.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/11/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVES Evaluate clinical outcomes of stroke survivors in Peru discharged with artificial nutrition via a feeding tube (FT), and explore perspectives and experiences of these patients and their caregivers. METHODS Retrospective chart review to describe the prevalence of FT placement and characteristics of patients admitted with stroke to the Instituto Nacional de Ciencias Neurológicas in Lima, Peru between January 2019 and 2021. Follow-up calls to stroke survivors discharged home with FTs or their caregivers included quantitative and qualitative questions to assess long-term outcome and explore perspectives around poststroke care and FT management. We analyzed quantitative data descriptively and applied thematic analysis to qualitative data using a consensus-driven codebook. RESULTS Of 812 hospitalized patients with stroke, 146 (18%) were discharged home with FT, all with nasogastric tubes (NGTs). Follow-up calls were performed a median of 18 months after stroke with 96 caregivers and three patients. Twenty-five patients (25%) had died, and 82% of survivors (n = 61) remained dependent for some care. Four themes emerged from interviews: (1) perceived suffering (physical, emotional, existential) associated with the NGT and stroke-related disability, often exacerbated by lack of preparedness or prognostic awareness; (2) concerns around compromised personhood and value-discordant care; (3) coping with their loved-one's illness and the caregiving role; and (4) barriers to NGT care and skill acquisition. CONCLUSION We identified a high burden of palliative and supportive needs among severe stroke survivors with NGTs and their caregivers suggesting opportunities to improve poststroke care through education, communication, and support.
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Affiliation(s)
- Nauzley C Abedini
- Department of Medicine (N.C.A.), University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., C.J.C.), Seattle, Washington, USA
| | - Orli M Shulein
- Department of Rehabilitation (O.M.S.), University of Washington, Seattle, Washington, USA
| | | | | | - Claire J Creutzfeldt
- Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., C.J.C.), Seattle, Washington, USA; Department of Neurology (C.J.C.), University of Washington, Seattle, Washington, USA.
| | - Jill Portocarrero
- CRONICAS Center of Excellence in Chronic Diseases (J.P.), Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Joseph R Zunt
- Departments of Neurology and Global Health (J.R.Z.), University of Washington, Seattle, Washington, USA
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George BP, Barbosa WA, Sethi A, Richard IH. Complications and outcomes of hospitalizations for patients with and without Parkinson disease. Front Aging Neurosci 2023; 15:1276731. [PMID: 38161593 PMCID: PMC10757345 DOI: 10.3389/fnagi.2023.1276731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
Objective To examine complications and outcomes of hospitalizations for common indications for hospitalization among patients with Parkinson disease (PD). Methods We identified and selected the ten most common indications for hospitalization among individuals ≥65 years of age using principal diagnoses from the California State Inpatient Database, 2018-2020. Patients with comorbid PD were identified using secondary diagnosis codes and matched one-to-one to patients without PD based on principal diagnosis (exact matching), age, gender, race and ethnicity, and Elixhauser comorbidity index (coarsened exact matching). We identified potentially preventable complications based on the absence of present on admission indicators among secondary diagnoses. In the matched cohort, we compared inpatient complications, early Do-Not-Resuscitate (DNR) orders (placed within 24 h of admission), use of life-sustaining therapies, new nursing facility requirement on discharge, and death or hospice discharge for patients with and without PD. Results We identified 35,457 patients with PD among the ten leading indications for hospitalization in older adults who were matched one-to-one to patients without PD (n = 70,914 in total). Comorbid PD was associated with an increased odds of developing aspiration pneumonia (OR 1.17 95% CI 1.02-1.35) and delirium (OR 1.11 95% CI 1.02-1.22) during admission. Patients with PD had greater odds of early DNR orders [placed within 24 h of admission] (OR 1.34 95% CI 1.29-1.39). While there was no difference in the odds of mechanical ventilation (OR 1.04 95% CI 0.98-1.11), patients with PD demonstrated greater odds of tracheostomy (OR 1.41 95% CI 1.12-1.77) and gastrostomy placement (OR 2.00 95% CI 1.82-2.20). PD was associated with greater odds of new nursing facility requirement upon discharge (OR 1.58 95% CI 1.53-1.64). Patients with PD were more likely to die as a result of their hospitalization (OR 1.11 95% CI 1.06-1.16). Conclusion Patients with PD are at greater risk of developing aspiration pneumonia and delirium as a complication of their hospitalization. While patients with PD more often have early DNR orders, they have greater utilization of life-sustaining therapies and experience worse outcomes of their hospitalization including new nursing facility requirement upon discharge and greater mortality.
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Affiliation(s)
- Benjamin P. George
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - William A. Barbosa
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Anish Sethi
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Drexel University College of Medicine, Philadelphia, PA, United States
| | - Irene H. Richard
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
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Bommena S, Rangan P, Lee-Iannotti J, Wassef W, Nanda R. Timing and Outcomes of Percutaneous Endoscopic Gastrostomy After Ischemic Stroke. Gastroenterology Res 2023; 16:281-288. [PMID: 38186586 PMCID: PMC10769609 DOI: 10.14740/gr1653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/23/2023] [Indexed: 01/09/2024] Open
Abstract
Background Guidelines recommend using percutaneous endoscopic gastrostomy (PEG) for dysphagia after 2 weeks of stroke onset. We aimed to study the impact of PEG timing on outcomes in patients with ischemic stroke. Methods In this retrospective study of patients with ischemic stroke and PEG between 2014 and 2019, early PEG was defined as PEG tube placed within 14 days of stroke and late PEG after 14 days. Outcomes of 30-day mortality, PEG-related complications, and functional swallow recovery were compared between early and late PEG. Logistic regression model assessed factors associated with PEG timing. Results The median time of PEG tube placement after stroke was 10.9 days. Of the 161 included patients, 60.9% had early PEG, and its associated patient factors were nursing facility discharge (adjusted odds ratio (OR): 3.4, confidence interval (CI): 1.48 - 7.82) and infection (OR: 0.32, CI: 0.139 - 0.178). Late PEG had 3.27 times greater odds of swallowing recovery, but mortality and complications were not significantly different between early and late PEG. Conclusions Skilled nursing facility disposition and lack of infection were predictors of early PEG, constituting the majority of PEG placed for ischemic stroke-related dysphagia. Although better odds of swallowing recovery were seen with late PEG, likely implicating better patient selection, overall, the timing of PEG tube placement did not impact short-term mortality and complications.
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Affiliation(s)
- Shoma Bommena
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, AZ, USA
| | - Pooja Rangan
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, AZ, USA
| | - Joyce Lee-Iannotti
- Department of Neurology, University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, AZ, USA
| | - Wahid Wassef
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, AZ, USA
| | - Rakesh Nanda
- Division of Gastroenterology, University of Arizona College of Medicine-Phoenix, Phoenix VA Health Care System, Phoenix, AZ, USA
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Hendershot KA, Elias MN, Taylor BL, Wahlster S, Creutzfeldt CJ. An Update on Palliative Care in Neurocritical Care: Providing Goal‑Concordant Care in the Face of Prognostic Uncertainty. Curr Treat Options Neurol 2023; 25:517-529. [PMID: 39055121 PMCID: PMC11271663 DOI: 10.1007/s11940-023-00778-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 07/27/2024]
Abstract
Purpose of review We investigate the complexities and interplay between the concepts of prognostic uncertainty and patient preferences as they relate to the delivery of goal-concordant care to patients with severe acute brain injuries (SABI) in the Neurological Intensive Care Unit (Neuro-ICU). Recent findings Patients with SABI in the Neuro-ICU have unique palliative care needs due to sudden, often unexpected changes in personhood and quality of life. A substantial amount of uncertainty is inherent and poses a challenge to both the patient's prognosis and treatment preferences. The delivery of goal-concordant care can be difficult to achieve.
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Affiliation(s)
- Kristopher A. Hendershot
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Maya N. Elias
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA
| | - Breana L. Taylor
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Claire J. Creutzfeldt
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, 325 9th Avenue, Box 359775, Seattle, WA 98104‑2499, USA
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Zhang L, Albert GP, Pieters TA, McHugh DC, Asemota AO, Roberts DE, Hwang DY, Bender MT, George BP. Association of Do-Not-Resuscitate orders and in-hospital mortality among patients undergoing cranial neurosurgery. J Clin Neurosci 2023; 118:26-33. [PMID: 37857061 DOI: 10.1016/j.jocn.2023.10.006] [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] [Received: 08/13/2023] [Revised: 09/21/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Previous studies identified pre-existing DNR orders as a predictor of mortality after surgery. We sought to evaluate mortality of patients receiving cranial neurosurgery with DNR orders placed at the time of, or within 24 h of admission. METHODS We performed a retrospective cohort study using the California State Inpatient Database, January 2018 to December 2020. We used International Classification of Diseases, 10th Revision (ICD-10) codes to identify emergent hospitalizations with principal diagnosis of brain injury, including traumatic brain injury [TBI], ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], or malignant brain tumor [mBT]. We used procedure and Diagnosis Related Group codes to identify cranial neurosurgery. Patients with DNR were one-to-one matched to non-DNR controls based on diagnosis (exact matching), age, sex, Elixhauser comorbidity index, and organ failure (coarsened matching). The primary outcome was inpatient mortality. RESULTS In California, 30,384 patients underwent cranial neurosurgery, 2018-2020 (n = 3,112, 10% DNR). DNR patients were older, more often female, more often White, with greater comorbidity and organ system dysfunction. There were 2,505 patients with DNR orders 1:1 matched to controls. Patients with DNR had greater inpatient mortality (56% vs. 23%, p < 0.001; Hazard Ratio 3.11, 95% CI 2.50-3.86), received tracheostomy (Odds Ratio [OR] 0.37, 95% CI 0.24-0.57) and gastrostomy less (OR 0.48, 95% CI 0.39-0.58) compared to controls. Multivariable analysis of the unmatched cohort demonstrated similar results. CONCLUSION Patients undergoing cranial neurosurgery with early or pre-existing DNR have high inpatient mortality compared to clinically similar non-DNR patients; 1 in 2 died during their hospitalization.
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Affiliation(s)
- Lan Zhang
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - George P Albert
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Thomas A Pieters
- University of Massachusetts Memorial Health, Department of Neurosurgery, Worcester, MA, United States
| | - Daryl C McHugh
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Anthony O Asemota
- University of Texas Southwestern Medical Center, Department of Neurosurgery, Dallas, TX, United States
| | - Debra E Roberts
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - David Y Hwang
- University of North Carolina School of Medicine, Department of Neurology, Chapel Hill, NC, United States
| | - Matthew T Bender
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Benjamin P George
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States.
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Wang Y, Zhang J, Zhu HM, Yu CP, Bao Y, Hou XF, Huang SC. The Therapeutic Effect of Swallow Training with a Xanthan Gum-Based Thickener in Addition to Classical Dysphagia Therapy in Chinese Patients with Post-Stroke Oropharyngeal Dysphagia: A Randomized Controlled Study. Ann Indian Acad Neurol 2023; 26:742-748. [PMID: 38022444 PMCID: PMC10666846 DOI: 10.4103/aian.aian_139_23] [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: 02/15/2023] [Revised: 07/30/2023] [Accepted: 08/08/2023] [Indexed: 12/01/2023] Open
Abstract
Objective In patients with post-stroke oropharyngeal dysphagia (PSOD), classical dysphagia therapy (CDT) continues to provide unsatisfactory outcomes and makes it challenging for them to remove the nasal feeding tube. Increasing bolus viscosity helps prevent aspiration in PSOD. However, conventional starch thickeners enhance post-digestion residue. This study aims to evaluate the efficacy of swallow training with xanthan gum-based thickener (XGT) (Softia G, NUTRI Co., Ltd., Yokkaichi, Japan) additional to CDT in Chinese PSOD patients with a nasogastric tube when compared to CDT alone. Methods Patients with PSOD who had a nasogastric tube were randomly assigned to either the experimental group (E-group) or the control group (C-group) in this randomized controlled, single-blind, parallel-group study. Both groups received CDT for 4 weeks. The E-group cases received additional swallow training with a Softia G-prepared hydrogel training material. The Functional Oral Intake Scale (FOIS) and modified volume-viscosity swallow test (M-VVST) for swallowing safety and efficacy according to adjusted Chinese dietary habits were administered before and after treatment. Post-training, both groups' nasogastric tube removal rates were calculated. Results One hundred sixty-seven participants (E-group: 82 and C-group: 85) completed the study. The E-group's median score of FOIS improved significantly than the C-group after training (median = 5 vs. 3, P < 0.001). The incidence of coughing, voice changes, oxygen desaturation of 3% or more, pharyngeal residue and piecemeal deglutition in the E-group was significantly lower than that in the C-group (P < 0.05). The E-group had 100% nasogastric tube removal, while the C-group had 28.24% (P < 0.001). Conclusion Swallow training with XGT Softia G in addition to CDT can promote swallowing safety and efficacy in Chinese patients with PSOD more effectively than CDT alone.
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Affiliation(s)
- Yao Wang
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Jie Zhang
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Hui-Min Zhu
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Can-Ping Yu
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Yan Bao
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Xiao-Fang Hou
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Shao-Chun Huang
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
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12
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Urban MJ, Shimomura A, Shah S, Losenegger T, Westrick J, Jagasia AA. Rural Otolaryngology Care Disparities: A Scoping Review. Otolaryngol Head Neck Surg 2022; 166:1219-1227. [PMID: 35015580 DOI: 10.1177/01945998211068822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To broadly synthesize the literature regarding rural health disparities in otolaryngology, categorize findings, and identify research gaps to stimulate future work. STUDY DESIGN Scoping review. DATA SOURCES A comprehensive literature search was performed in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and CINAHL. REVIEW METHODS The methods were developed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Peer-reviewed, English-language, US-based studies examining a rural disparity in otolaryngology-related disease incidence, prevalence, diagnosis, treatment, or outcome were included. Descriptive studies, commentaries, reviews, and letters to the editor were excluded. Studies published prior to 1980 were excluded. RESULTS The literature search resulted in 1536 unique abstracts and yielded 79 studies that met final criteria for inclusion. Seventy-five percent were published after 2010. The distribution of literature was as follows: otology (34.2%), head and neck cancer (20.3%), endocrine surgery (13.9%), rhinology and allergy (8.9%), trauma (5.1%), laryngology (3.8%), other pediatrics (2.5%), and adult sleep (1.3%). Studies on otolaryngology health care systems also accounted for 10.1%. The most common topics studied were practice patterns (41%) and epidemiology (27%), while the Southeast (47%) was the most common US region represented, and database study (42%) was the most common study design. CONCLUSION Overall, there was low-quality evidence with large gaps in the literature in all subspecialties, most notably facial plastic surgery, laryngology, adult sleep, and pediatrics. Importantly, there were few studies on intervention and zero studies on resident exposure to rural populations, which will be critical to making rural otolaryngology care more equitable in the future.
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Affiliation(s)
- Matthew J Urban
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Aoi Shimomura
- Loyola University of Chicago, Stritch School of Medicine, Maywood, Illinois, USA
| | - Swapnil Shah
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Tasher Losenegger
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Ashok A Jagasia
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Siegel CL, Besbris J, Everett EA, Lavi ES, Mehta AK, Jones CA, Creutzfeldt CJ, Kramer NM. Top Ten Tips Palliative Care Clinicians Should Know About Strokes. J Palliat Med 2021; 24:1877-1883. [PMID: 34704853 DOI: 10.1089/jpm.2021.0449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Stroke is a common cause of long-term disability and death, which leaves many patients with significant and unique palliative care (PC) needs. Shared decision-making for patients with stroke poses distinct challenges due to the sudden nature of stroke, the uncertainty inherent in prognostication around recovery, and the common necessity of relying on surrogates for decision-making. Patients with stroke suffer from frequently underrecognized symptoms, which PC clinicians should feel comfortable identifying and treating. This article provides 10 tips for palliative clinicians to increase their knowledge and comfort in caring for this important population.
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Affiliation(s)
- Cara L Siegel
- Departments of Neurology and Palliative Care, University of California, Los Angeles, Los Angeles, California, USA
| | - Jessica Besbris
- Departments of Neurology and Supportive Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elyse A Everett
- Departments of Medicine and Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Elana S Lavi
- Department of Speech Language Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ambereen K Mehta
- Palliative Care Program, Department of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Neha M Kramer
- Departments of Neurology and Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Gao L, Zhao CW, Hwang DY. End-of-Life Care Decision-Making in Stroke. Front Neurol 2021; 12:702833. [PMID: 34650502 PMCID: PMC8505717 DOI: 10.3389/fneur.2021.702833] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/31/2021] [Indexed: 12/21/2022] Open
Abstract
Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.
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Affiliation(s)
- Lucy Gao
- Yale School of Medicine, New Haven, CT, United States
| | | | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, United States
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15
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Madden LL, Hernandez BO, Russell GB, Wright SC, Kiell EP. The Demographics of Patients Presenting for Laryngological Care at an Academic Medical Center. Laryngoscope 2021; 132:626-632. [PMID: 34415070 DOI: 10.1002/lary.29831] [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: 03/12/2021] [Revised: 07/11/2021] [Accepted: 07/31/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Few studies address the demographics/epidemiology/socioeconomic status of patients presenting to a laryngologist at a tertiary care center for treatment. To identify any possible disparities in voice, airway, and swallowing care, we sought to analyze the aforementioned data for new patients presenting to the voice center at an academic medical center. METHODS This is a retrospective cohort study of prospectively collected data from an institutional database of 4,623 new adult patients presenting for laryngological care at a tertiary care, academic medical center from 2015 to 2020. Demographic data were analyzed. RESULTS Of 4,623 patients, 62.8% were female and 37.2% were male with ages ranging from 19 to 99 years (Avg 59.51, standard deviation 15.83). Patients were 81.8% white, 13% black, and 5.2% other, compared with 56.3% white, 34.8% black, 20% other in the local municipality from US Census Data. Payer mix included 46.98% Medicare, 42.59% commercial insurance, 3.22% Medicaid, 5.19% other, and 2.01% uninsured/self-insured. Patient demographics based on primary diagnosis codes were also examined. A majority of patients presented with voice-related complaints. CONCLUSIONS Understanding the demographics of those with laryngological disorders will help to develop targeted interventions and effective outreach programs for underrepresented patient populations. Future multicenter studies could provide further insight into the distribution of healthcare disparities in laryngology. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Lyndsay L Madden
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Brian O Hernandez
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Gregory B Russell
- Department of Biostatistics and Data Sciences, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - S Carter Wright
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Eleanor P Kiell
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
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Chu KM, Jones EM, Meeks JR, Pan AP, Agarwal KL, Taffet GE, Vahidy FS. Decade-Long Nationwide Trends and Disparities in Use of Comfort Care Interventions for Patients With Ischemic Stroke. J Am Heart Assoc 2021; 10:e019785. [PMID: 33823605 PMCID: PMC8174182 DOI: 10.1161/jaha.120.019785] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Stroke remains one of the leading causes of disability and death in the United States. We characterized 10-year nationwide trends in use of comfort care interventions (CCIs) among patients with ischemic stroke, particularly pertaining to acute thrombolytic therapy with intravenous tissue-type plasminogen activator and endovascular thrombectomy, and describe in-hospital outcomes and costs. Methods and Results We analyzed the National Inpatient Sample from 2006 to 2015 and identified adult patients with ischemic stroke with or without thrombolytic therapy and CCIs using validated International Classification of Diseases, Ninth Revision (ICD-9) codes. We report adjusted odds ratios (ORs) and 95% CI of CCI usage across five 2-year periods. Of 4 249 201 ischemic stroke encounters, 3.8% had CCI use. CCI use increased over time (adjusted OR, 4.80; 95% CI, 4.15-5.55) regardless of acute treatment type. Advanced age, female sex, White race, non-Medicare insurance, higher income, disease severity, comorbidity burden, and discharge from non-northeastern teaching hospitals were independently associated with receiving CCIs. In the fully adjusted model, thrombolytic therapy and endovascular thrombectomy, respectively, conferred a 6% and 10% greater likelihood of receiving CCIs. Among CCI users, there was a significant decline in in-hospital mortality compared with all other dispositions over time (adjusted OR, 0.46; 95% CI, 0.38-0.56). Despite longer length of stay, CCI hospitalizations incurred 16% lower adjusted costs. Conclusions CCI use among patients with ischemic stroke has increased regardless of acute treatment type. Nonetheless, considerable disparities persist. Closing the disparities gap and optimizing access, outcomes, and costs for CCIs among patients with stroke are important avenues for further research.
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Affiliation(s)
- Kristie M Chu
- Department of Neurology McGovern Medical School University of Texas Health Science Center at Houston TX
| | - Erica M Jones
- Department of Neurology McGovern Medical School University of Texas Health Science Center at Houston TX
| | | | - Alan P Pan
- Center for Outcomes Research Houston Methodist Houston TX
| | - Kathryn L Agarwal
- Department of Geriatric Medicine Baylor College of Medicine Houston TX
| | - George E Taffet
- Department of Geriatric Medicine Baylor College of Medicine Houston TX
| | - Farhaan S Vahidy
- Center for Outcomes Research Houston Methodist Houston TX.,The Houston Methodist Neurological Institute Houston Methodist Houston TX
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17
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Carollo MF, Patrício TD, Montibeller CG, Luchesi KF. Tube feeding predictors after ischemic hemispheric stroke during hospitalization. LOGOP PHONIATR VOCO 2021; 47:171-176. [PMID: 33775213 DOI: 10.1080/14015439.2021.1899279] [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: 10/21/2022]
Abstract
PURPOSE To verify the factors associated with the need of tube feeding (TF) during patients post-ischemic stroke hospitalization. METHOD This is a retrospective study with 70 adult post-ischemic hemispheric stroke adult patients hospitalized in the Neurology department at a tertiary public hospital in Santa Catarina, Brazil. We investigated associations between the need of a feeding tube during hospitalization and the variables age, gender, admission and discharge NIHSS and FOIS, length of hospital stay in days, presence of thrombolytic therapy, extensive stroke, hemisphere affected, prior stroke, pneumonia during hospitalization, presence of signs of laryngeal penetration and laryngotracheal aspiration and dysphagia in the first and last swallowing clinical evaluation. RESULTS A total of 33 participants used tube feeding. There was a significant relationship among tube feeding and the following parameters: NIHSS (p value .001), FOIS (p value .001), extensive stroke (p value .034), left hemisphere involvement (p value .035), pneumonia during hospitalization (p value .001), length of hospital stay in days (p value .001), signs of laryngotracheal penetration/aspiration (p value .001) and dysphagia in speech-language assessment (p value .001). CONCLUSION Tube feeding during patients hospitalization after ischemic hemispheric stroke was predicted by the severity of stroke and signs of airway permeation.Key pointsSwallowing difficulty is one of the most common post-stroke consequences.There are few studies on the characterization of post-stroke patients with tube feeding.Tube feeding after ischemic stroke predictors were severity of stroke and signs of airway permeation.
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Affiliation(s)
- Marília Fernandes Carollo
- Department of Health Sciences, Speech-Language Pathology Department, Universidade Federal de Santa Catarina, Florianopolis, Brazil
| | - Tyalla Duarte Patrício
- Speech-Language Pathology Department, Hospital Governador Celso Ramos, Florianopolis, Brazil
| | | | - Karen Fontes Luchesi
- Department of Health Sciences, Speech-Language Pathology Department, Universidade Federal de Santa Catarina, Florianopolis, Brazil
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18
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Feit NZ, Wang Z, Demetres MR, Drenis S, Andreadis K, Rameau A. Healthcare Disparities in Laryngology: A Scoping Review. Laryngoscope 2020; 132:375-390. [PMID: 33314122 DOI: 10.1002/lary.29325] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/06/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS This scoping review aims to map out existing disparities research within the subspecialty of laryngology in order to highlight gaps in knowledge and guide future research. STUDY DESIGN Scoping Review. METHODS We completed a scoping review of PubMed, Ovid Embase, and the Cochrane Library for primary research focused on evaluating the existence and impact of disparities in race/ethnicity, sex/gender, insurance status, education level, income, geography, and LGBTQ identity in the context of various laryngological conditions. Publications of any design and date, performed in the United States, and focusing on the adult population exclusively were included. RESULTS Of the 4,999 unique abstracts identified, 51 articles were ultimately included. The most frequently examined condition in relation to disparities was laryngeal cancer (27 of 51), followed by voice disorders (15 of 51), deglutitive disorders (eight of 51), and airway disorders (one of 51). Sources of inequity evaluated from most common to least common were race/ethnicity (43 of 51), sex/gender (39 of 51), insurance status (23 of 51), geography (23 of 51), income (21 of 51), and education level (16 of 51). No study examined the association of LGBTQ identity with inequity. CONCLUSIONS This scoping review highlights the limited extent of disparities research in laryngology and establishes the need for further scholarship on the impact of disparities in laryngology care. The pathologies studied were, in decreasing order of frequency: laryngeal cancer, voice disorders, deglutitive disorders, and airway disorders. Race/ethnicity and sex/gender were the most common disparities examined, with no evaluation of LGBTQ-related care inequity. LEVEL OF EVIDENCE NA Laryngoscope, 2020.
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Affiliation(s)
- Noah Z Feit
- Otolaryngology Department, Weill Cornell Medical College, New York, New York, U.S.A
| | - Zhaorui Wang
- Otolaryngology Department, Weill Cornell Medical College, New York, New York, U.S.A
| | - Michelle R Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medical College, New York, New York, U.S.A
| | - Sotirios Drenis
- Department of Otolaryngology, Head & Neck Surgery, Weill Cornell Medical College, New York, New York, U.S.A
| | - Katerina Andreadis
- Department of Otolaryngology, Head & Neck Surgery, Weill Cornell Medical College, New York, New York, U.S.A.,Sean Parker Institute for the Voice, Weill Cornell Medical College, New York, New York, U.S.A
| | - Anaïs Rameau
- Department of Otolaryngology, Head & Neck Surgery, Weill Cornell Medical College, New York, New York, U.S.A.,Sean Parker Institute for the Voice, Weill Cornell Medical College, New York, New York, U.S.A
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Jones RC, Creutzfeldt CJ, Cox CE, Haines KL, Hough CL, Vavilala MS, Williamson T, Hernandez A, Raghunathan K, Bartz R, Fuller M, Krishnamoorthy V. Racial and Ethnic Differences in Health Care Utilization Following Severe Acute Brain Injury in the United States. J Intensive Care Med 2020; 36:1258-1263. [PMID: 32912070 DOI: 10.1177/0885066620945911] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine racial and ethnic differences in the utilization of 3 interventions (tracheostomy placement, gastrostomy tube placement, and hospice utilization) among patients with severe acute brain injury (SABI). DESIGN Retrospective cohort study. SETTING Data from the National Inpatient Sample, from 2002 to 2012. PATIENTS Adult patients with SABI defined as a primary diagnosis of stroke, traumatic brain injury, or post-cardiac arrest who received greater than 96 hours of mechanical ventilation. EXPOSURE Race/ethnicity, stratified into 5 categories (white, black, Hispanic, Asian, and other). MEASUREMENTS AND MAIN RESULTS Data from 86 246 patients were included in the cohort, with a mean (standard deviation) age of 60 (18) years. In multivariable analysis, compared to white patients, black patients had an 20% increased risk of tracheostomy utilization (relative risk [RR]: 1.20, 95% CI: 1.16-1.24, P < .001), Hispanic patients had a 10% increased risk (RR: 1.10, 95% CI: 1.06-1.14, P < .001), Asian patients had an 8% increased risk (RR: 1.08, 95% CI: 1.01-1.16, P = .02), and other race patients had an 10% increased risk (RR: 1.10, 95% CI: 1.04-1.16, P < .001). A similar relationship was observed for gastrostomy utilization. In multivariable analysis, compared to white patients, black patients had a 25% decreased risk of hospice discharge (RR: 0.75, 95% CI: 0.67-0.85, P < .001), Hispanic patients had a 20% decreased risk (RR: 0.80, 95% CI: 0.69-0.94, P < .01), and Asian patients had a 47% decreased risk (RR: 0.53, 95% CI: 0.39-0.73, P < .001). There was no observed relationship between race/ethnicity and in-hospital mortality. CONCLUSIONS Minority race was associated with increased utilization of tracheostomy and gastrostomy, as well as decreased hospice utilization among patients with SABI. Further research is needed to better understand the mechanisms underlying these race-based differences in critical care.
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Affiliation(s)
- Rayleen C Jones
- School of Nursing, Duke University, NC, USA.,Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA
| | | | | | - Krista L Haines
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Surgery, Duke University, NC, USA
| | | | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, WA, USA
| | | | | | - Karthik Raghunathan
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Raquel Bartz
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Matt Fuller
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
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Nagaraja N, Olasoji EB, Patel UK. Sex and racial disparity in utilization and outcomes of t-PA and thrombectomy in acute ischemic stroke. J Stroke Cerebrovasc Dis 2020; 29:104954. [PMID: 32807414 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104954] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/19/2020] [Accepted: 05/10/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/PURPOSE Racial/ethnic and sex disparity may occur in stroke throughout the continuum of care. Endovascular therapy (EVT) became standard of care in 2015 for eligible patients with acute ischemic stroke (AIS). We evaluated for racial and sex differences in t-PA and EVT utilization and outcomes in 2016 in the National Inpatient Sample. METHODS Treatment rates for t-PA, EVT, and t-PA+EVT and outcomes including home discharge, in-hospital mortality and prolonged length of stay (pLOS) were evaluated by sex and race. Multivariate survey-logistic regression was performed to evaluate outcomes. RESULTS The study had 468,630 patients - 49.3% men, 50.7% women; 69.3% whites, and 30.7% non-whites. There was no difference in treatment utilization by sex, women vs men for t-PA (7.65% vs 7.76%; aOR:1.02; 95% CI:0.97-1.07), EVT (1.74% vs 1.67%; aOR:1.09; 95% CI:0.99-1.20) and t-PA+EVT (0.57% vs 0.57%; aOR:1.01; 95% CI:0.85-1.21); and by race, non-white vs white for t-PA (7.62% vs 7.74%; aOR:0.98; 95% CI:0.93-1.05), EVT (1.62% vs 1.74%; aOR:0.91; 95% CI:0.78-1.07), and t-PA+EVT(0.59% vs 0.56%; aOR:1.05; 95% CI:0.84-1.30). Compared to men, women treated with t-PA had less home discharge (37.2% vs 46.3%; aOR:0.81; 95% CI:0.72-0.90), more in-hospital mortality (5.7% vs 3.9%; aOR:1.37; 95% CI:1.06-1.77) and less pLOS (8.3% vs 9.6%; aOR:0.82; 95% CI:0.69-0.98); women treated with EVT had less home discharge (15.8% vs 23.7%; aOR:0.69; 95% CI:0.52-0.91). Compared to whites, non-whites treated with t-PA had lower odds of home discharge (42.1% vs 41.6%; aOR:0.79; 95% CI:0.69-0.90), less in-hospital mortality (3.7% vs 5.3%; aOR:0.65; 95% CI:0.49-0.87), and higher pLOS (11.4% vs 7.9%; aOR:1.3; 95% CI:1.07-1.56); non-whites treated with EVT had less home discharge (18%vs 20.2%; aOR:0.70; 95% CI:0.51-0.97) and higher pLOS (35.1% vs 24%; aOR:1.52; 95% CI:1.16-1.99). CONCLUSION Sex and racial disparity exists for outcomes of t-PA and EVT despite no difference in utilization rates.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, 1149 Newell Drive Room L3-100 PO BOX 100236, Gainesville, FL 32610, USA.
| | - Esther B Olasoji
- Department of Neurology, University of Florida College of Medicine, 1149 Newell Drive Room L3-100 PO BOX 100236, Gainesville, FL 32610, USA
| | - Urvish K Patel
- Department of Neurology and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Swallowing Outcomes and Discharge Destinations in Acute Stroke Tube-Feeding Dependent Dysphagia Patients Treated With Neuromuscular Electrical Stimulation During Inpatient Rehabilitation. Am J Phys Med Rehabil 2020; 99:487-494. [DOI: 10.1097/phm.0000000000001353] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Skolarus LE, Feng C, Burke JF. Exploring Factors Contributing to Race Differences in Poststroke Disability. Stroke 2020; 51:1813-1819. [PMID: 32404036 DOI: 10.1161/strokeaha.119.027700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Cross sectional analyses have found large race differences in poststroke disability, yet these analyses do not account for prestroke disability, hospitalization factors, postacute care, transitions, or mortality. In this context, we explore mortality, nursing home placement, and disability in a longitudinal analysis of older stroke survivors who survived at least 90 days poststroke. Methods- A prospective cohort of black or white stroke survivors from the National Health and Aging Trends Study (2009-2016) linked to Medicare were used. Disability was assessed during in-person interviews with validated scales (0-7). We used cox proportional hazards models to separately assess mortality and nursing home admission adjusting for age, sex, sociodemographics (marital status, education, income, insurance status, social network size), comorbidities, hospitalization factors, postacute care, and 90-day readmissions. To estimate racial differences in disability, we used a multilevel linear regression model initially adjusting for age and sex and then compared with a model adjusted for sociodemographics, comorbidities, hospitalization factors, postacute care, and 90-day readmissions. Results- There were 282 stroke survivors, of which 76 (12.6%) were black. There were no race differences in long-term mortality (hazard ratio for black, 1.2 [95% CI, 0.7-2.2]; P=0.5) or nursing home placement (hazard ratio for black, 0.7 [95% CI, 0.2-2.4]; P=0.5). The largest race differences in disability were observed immediately prestroke, estimated age- and sex-adjusted activity limitations were (2.6 [2.0-3.2] in blacks versus 1.4 [1.0-1.8] in whites, mean difference, 1.2 [0.5-1.9], P<0.001) and immediately poststroke (2.6 [2.0-3.3] in blacks versus 1.7 [1.2-2.1] in whites, mean difference, 1.0 [0.2-1.7], P<0.01). Full adjustment did not substantially change the associations between race and disability. Conclusions- Race differences in nursing home placement, long-term mortality, sociodemographics, comorbidities, hospitalization factors, postacute care, and readmissions are unlikely to be large contributors to race differences in poststroke disability. Further research is needed to understand the drivers of race differences in poststroke disability.
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Affiliation(s)
- Lesli E Skolarus
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.)
| | - Chunyang Feng
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.)
| | - James F Burke
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.).,Department of Neurology, Ann Arbor VA, MI (J.F.B.)
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23
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Everett EA, Everett W, Brier MR, White P. Appraisal of Health States Worse Than Death in Patients With Acute Stroke. Neurol Clin Pract 2020; 11:43-48. [PMID: 33968471 DOI: 10.1212/cpj.0000000000000856] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/21/2020] [Indexed: 12/14/2022]
Abstract
Objective To identify health states that patients with acute stroke deem worse than death and to explore potential predictors for these ratings. Methods This was a cross-sectional study involving patients admitted to an urban comprehensive stroke center with acute stroke. Participants were asked to rate 10 possible health states/functional outcomes as better or worse than death using a 5-point Likert scale. Principal component analysis (PCA) was used to reduce clusters of correlated ratings to summary components (factors). These components were then analyzed using linear regression to identify possible predictive variables. Results Eighty patients participated. The states deemed equal to or worse than death by the majority of participants were relying on a breathing machine (66%) or feeding tube (66%), persistent confusion (62%), inability to communicate with others (58%), and bowel/bladder incontinence (50%). PCA revealed 2 factors of correlated variables: factor 1 composed primarily of relying on a feeding tube or breathing machine, incontinence, chronic pain, and persistent confusion, and factor 2 composed primarily of using a wheelchair, being bedbound, living in a nursing home, and requiring help for activities of daily living. The only significant predictor found was race for factor 1, with black participants finding these states more preferable to death than white participants. Discussion A substantial number of patients found multiple common outcomes of stroke to be the same as or worse than death. This highlights the importance of realistic discussions about expected functional outcomes with patients and/or their surrogate decision makers when considering goals of care after stroke.
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Affiliation(s)
- Elyse A Everett
- Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO
| | - William Everett
- Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO
| | - Matthew R Brier
- Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO
| | - Patrick White
- Department of Medicine (EAE, PW) and Department of Neurology (WE, MRB), Washington University in St. Louis, MO
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24
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Galovic M, Stauber AJ, Leisi N, Krammer W, Brugger F, Vehoff J, Balcerak P, Müller A, Müller M, Rosenfeld J, Polymeris A, Thilemann S, De Marchis GM, Niemann T, Leifke M, Lyrer P, Saladin P, Kahles T, Nedeltchev K, Sarikaya H, Jung S, Fischer U, Manno C, Cereda CW, Sander JW, Tettenborn B, Weder BJ, Stoeckli SJ, Arnold M, Kägi G. Development and Validation of a Prognostic Model of Swallowing Recovery and Enteral Tube Feeding After Ischemic Stroke. JAMA Neurol 2020; 76:561-570. [PMID: 30742198 DOI: 10.1001/jamaneurol.2018.4858] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Predicting the duration of poststroke dysphagia is important to guide therapeutic decisions. Guidelines recommend nasogastric tube (NGT) feeding if swallowing impairment persists for 7 days or longer and percutaneous endoscopic gastrostomy (PEG) placement if dysphagia does not recover within 30 days, but, to our knowledge, a systematic prediction method does not exist. Objective To develop and validate a prognostic model predicting swallowing recovery and the need for enteral tube feeding. Design, Setting, and Participants We enrolled participants with consecutive admissions for acute ischemic stroke and initially severe dysphagia in a prospective single-center derivation (2011-2014) and a multicenter validation (July 2015-March 2018) cohort study in 5 tertiary stroke referral centers in Switzerland. Exposures Severely impaired oral intake at admission (Functional Oral Intake Scale score <5). Main Outcomes and Measures Recovery of oral intake (primary end point, Functional Oral Intake Scale ≥5) or return to prestroke diet (secondary end point) measured 7 (indication for NGT feeding) and 30 (indication for PEG feeding) days after stroke. Results In total, 279 participants (131 women [47.0%]; median age, 77 years [interquartile range, 67-84 years]) were enrolled (153 [54.8%] in the derivation study; 126 [45.2%] in the validation cohort). Overall, 64% (95% CI, 59-71) participants failed to recover functional oral intake within 7 days and 30% (95% CI, 24-37) within 30 days. Prolonged swallowing recovery was independently associated with poor outcomes after stroke. The final prognostic model, the Predictive Swallowing Score, included 5 variables: age, stroke severity on admission, lesion location, initial risk of aspiration, and initial impairment of oral intake. Predictive Swallowing Score prediction estimates ranged from 5% (score, 0) to 96% (score, 10) for a persistent impairment of oral intake on day 7 and from 2% to 62% on day 30. Model performance in the validation cohort showed a discrimination (C statistic) of 0.84 (95% CI, 0.76-0.91; P < .001) for predicting the recovery of oral intake on day 7 and 0.77 (95% CI, 0.67-0.87; P < .001) on day 30, and a discrimination for a return to prestroke diet of 0.94 (day 7; 95% CI, 0.87-1.00; P < .001) and 0.71 (day 30; 95% CI, 0.61-0.82; P < .001). Calibration plots showed high agreement between the predicted and observed outcomes. Conclusions and Relevance The Predictive Swallowing Score, available as a smartphone application, is an easily applied prognostic instrument that reliably predicts swallowing recovery. It will support decision making for NGT or PEG insertion after ischemic stroke and is a step toward personalized medicine.
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Affiliation(s)
- Marian Galovic
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland.,National Institute for Health Research University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, England.,Magnetic Resonance Imaging Unit, Chalfont Centre for Epilepsy, Chalfont St Peter, England
| | - Anne Julia Stauber
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Natascha Leisi
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Werner Krammer
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Florian Brugger
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Philipp Balcerak
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Anna Müller
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Marlise Müller
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Jochen Rosenfeld
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Alexandros Polymeris
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thorsten Niemann
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Maren Leifke
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Petra Saladin
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland.,Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Concetta Manno
- Stroke Center, Department of Neurology, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Carlo W Cereda
- Stroke Center, Department of Neurology, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Josemir W Sander
- National Institute for Health Research University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, England.,Magnetic Resonance Imaging Unit, Chalfont Centre for Epilepsy, Chalfont St Peter, England.,Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands
| | - Barbara Tettenborn
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Bruno J Weder
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland.,Support Centre for Advanced Neuroimaging, Institute of Diagnostic and Interventional Neuroradiology, University Hospital Inselspital, University of Bern, Bern, Switzerland
| | - Sandro J Stoeckli
- Department of Otorhinolaryngology, Head and Neck Surgery, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
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Krishnamoorthy V, Hough CL, Vavilala MS, Komisarow J, Chaikittisilpa N, Lele AV, Raghunathan K, Creutzfeldt CJ. Tracheostomy After Severe Acute Brain Injury: Trends and Variability in the USA. Neurocrit Care 2020; 30:546-554. [PMID: 30919303 DOI: 10.1007/s12028-019-00697-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND/OBJECTIVE Severe acute brain injury (SABI) is responsible for 12 million deaths annually, prolonged disability in survivors, and substantial resource utilization. Little guidance exists regarding indication or optimal timing of tracheostomy after SABI. Our aims were to determine national trends in tracheostomy utilization among mechanically ventilated patients with SABI in the USA, as well as to examine factors associated with tracheostomy utilization following SABI. METHODS We conducted a population-based retrospective cohort study using the National Inpatient Sample from 2002 to 2011. We identified adult patients with SABI, defined as a primary diagnosis of stroke, traumatic brain injury or post-cardiac arrest who received mechanical ventilation for greater than 96 h. We analyzed trends in tracheostomy utilization over time and used multilevel mixed-effects logistic regression to analyze factors associated with tracheostomy utilization. RESULTS There were 94,082 hospitalizations for SABI during the study period, with 30,455 (32%) resulting in tracheostomy utilization. The proportion of patients with SABI who received a tracheostomy increased during the study period, from 28.0% in 2002 to 32.1% in 2011 (p < 0.001). Variation in tracheostomy utilization was noted based on patient and facility characteristics, including higher odds of tracheostomy in large hospitals (OR 1.34, 95% CI 1.18-1.53, p < 0.001, compared to small hospitals), teaching hospitals (OR 1.15, 95% CI 1.06-1.25, p = 0.001, compared to non-teaching hospitals), and urban hospitals (OR 1.60, 95% CI 1.33-1.92, p < 0.001, compared to rural hospitals). CONCLUSIONS Tracheostomy utilization has increased in the USA among patients with SABI, with wide variation by patient and facility-level factors.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, 2301 Erwin Rd., Durham, NC, 27710, USA. .,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA.
| | - Catherine L Hough
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | | | | | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University, 2301 Erwin Rd., Durham, NC, 27710, USA
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26
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Affiliation(s)
- Cathy M Stinear
- From the Department of Medicine (C.M.S., M.-C.S.), University of Auckland, New Zealand.,Centre for Brain Research (C.M.S., M.-C.S., W.D.B.), University of Auckland, New Zealand
| | - Marie-Claire Smith
- From the Department of Medicine (C.M.S., M.-C.S.), University of Auckland, New Zealand.,Centre for Brain Research (C.M.S., M.-C.S., W.D.B.), University of Auckland, New Zealand
| | - Winston D Byblow
- Centre for Brain Research (C.M.S., M.-C.S., W.D.B.), University of Auckland, New Zealand.,Department of Exercise Sciences (W.D.B.), University of Auckland, New Zealand
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Faigle R, Cooper LA. Explaining and addressing racial disparities in stroke care and outcomes: A puzzle to solve now. Neurology 2019; 93:773-775. [PMID: 31554651 DOI: 10.1212/wnl.0000000000008384] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Roland Faigle
- From the Departments of Neurology (R.F.) and Medicine (L.A.C.), Johns Hopkins University School of Medicine; and Center for Health Equity (R.F., L.A.C.), Johns Hopkins University, Baltimore, MD.
| | - Lisa A Cooper
- From the Departments of Neurology (R.F.) and Medicine (L.A.C.), Johns Hopkins University School of Medicine; and Center for Health Equity (R.F., L.A.C.), Johns Hopkins University, Baltimore, MD
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28
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Faigle R, Gottesman RF. Variability in Palliative Care Use after Intracerebral Hemorrhage at US Hospitals: A Multilevel Analysis. Neuroepidemiology 2019; 53:84-92. [PMID: 31238305 DOI: 10.1159/000500276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/09/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Palliative care (PC) is an essential component of comprehensive care of patients with intracerebral hemorrhage (ICH). In the present study, we sought to characterize the variability of PC use after ICH among US hospitals. METHODS ICH admissions from hospitals with at least 12 annual ICH cases were identified in the Nationwide Inpatient Sample between 2008 and 2011. We used multilevel logistic regression modeling to estimate between-hospital variance in PC use. We calculated the intraclass correlation coefficient (ICC), proportional variance change, and median OR after accounting for individual-level and hospital-level covariates. RESULTS Among 26,791 ICH admissions, 12.5% received PC (95% CI 11.5-13.5). Among the 629 included hospitals, the median rate of PC use was 9.1 (interquartile range 1.5-19.3) per 100 ICH admissions, and 150 (23.9%) hospitals had no recorded PC use. The ICC of the random intercept (null) model was 0.274, suggesting that 27.4% of the overall variability in PC use was due to between-hospital variability. Adding hospital-level covariates to the model accounted for 25.8% of the between-hospital variance observed in the null model, with 74.2% of between-hospital variance remaining unexplained. The median OR of the fully adjusted model was 2.62 (95% CI 2.41-2.89), indicating that a patient moving from 1 hospital to another with a higher intrinsic propensity of PC use had a 2.63-fold median increase in the odds of receiving PC, independent of patient and hospital factors. CONCLUSIONS Substantial variation in PC use after ICH exists among US hospitals. A substantial proportion of this between-hospital variability remains unexplained even after accounting for patient and hospital characteristics.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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29
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Factors Influencing Oral Intake Improvement and Feeding Tube Dependency in Patients with Poststroke Dysphagia. J Stroke Cerebrovasc Dis 2019; 28:1421-1430. [PMID: 30962081 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To assess ischemic stroke patients regarding the relationship between lesion locations, swallowing impairment, medical and demographic factors and (1) oral intake improvement and (2) feeding tube dependency at discharge from their acute hospital stay. METHODS We conducted an exploratory, retrospective observational longitudinal cohort study of acute, first-ever, ischemic stroke patients. Patients who had an initial nonoral feeding recommendation from a speech and language pathologist and who underwent a modified barium swallow study within their hospital stay were included. Oral intake status was measured with the Functional Oral Intake Scale (FOIS) as the change in FOIS during the hospital stay and as feeding tube dependency at hospital discharge. Associations were assessed with multiple linear regression modeling controlling for age, comorbidities, and hospital length of stay. RESULTS We included 44 stroke patients. At hospital discharge, 93% of patients had oral intake restrictions and 30% were feeding tube dependent. Following multiple linear regression modeling, age, damage to the left superior frontal gyrus, dorsal anterior cingulate gyrus, hypothalamus, and nucleus accumbens were significant predictors for FOIS change. Feeding tube dependency showed no significant associations with any prognostic variables when controlling for confounders. CONCLUSIONS The vast majority of patients with an initial nonoral feeding recommendation are discharged with oral intake restrictions indicating a continued need for swallowing assessments and treatment after discharge. Lesion locations associated with motivation, reward, and drive to consume food as well as swallowing impairment, higher age, and more comorbidities were related to less oral intake improvement.
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30
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Abstract
Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.
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Affiliation(s)
- Anjail Sharrief
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX, United States.
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Predictors of Direct Enteral Tube Placement After Acute Stroke. J Stroke Cerebrovasc Dis 2019; 28:191-197. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/10/2018] [Accepted: 09/19/2018] [Indexed: 01/22/2023] Open
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Brown K, Cai C, Barreto A, Shoemaker P, Woellner J, Vu K, Xavier A, Saeed U, Watkins J, Savitz S, Sharrief A. Predictors of Percutaneous Endoscopic Gastrostomy Placement in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2018; 27:3200-3207. [PMID: 30172678 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/05/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Dysphagia is a common complication of stroke and can have a lasting impact on morbidity and mortality; yet there are no standards to guide dysphagia management in stroke patients. We assessed predictors of percutaneous endoscopic gastrostomy (PEG) placement in an ischemic stroke cohort and sought to determine the utility of an objective scale in predicting PEG placement in a high-risk sub-set. METHODS Consecutive cases of ischemic stroke were retrospectively, identified and demographic and clinical variables were collected. Penetration-Aspiration (PAS) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) were calculated for patients undergoing Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Modified Barium Swallowing Studies (MBSS). Multiple logistic regression analysis was used to assess predictors of PEG placement. RESULTS Among 724 patients, 131 underwent PEG placement. In univariate analysis of the overall cohort, sex, age, insured payer status, arrival National Institute of Health Stroke Scale (NIHSS), NIHSS level of consciousness severity, NIHSS dysarthria severity, diabetes mellitus, and prior International Conference for Harmonization (ICH) were all significantly associated with PEG placement. Among 197 high-risk patients undergoing FEES or MBSS, the multivariate logistic regression analysis showed that PAS scores 6-8 versus 1-2 (odds ratio [OR] 13.2; 95% confidence interval [CI] 4.58, 38.2), PAS score 3-5 versus 1.2 (OR 33.8; 95% CI 11.6, 98.3), Hispanic race (OR, 5.73; 95% CI 1.82, 18.0), male sex (OR, 2.59; 95% CI 1.05, 6.34), and arrival NIHSS (OR, 1.11; 95% CI 1.05, 1.18) were associated with PEG placement. CONCLUSIONS Use of an objective dysphagia scale simplified the prediction model among acute ischemic stroke patients undergoing instrumental assessments of dysphagia with FEES or MBSS. Male sex and Hispanic race were also significantly associated with PEG placement in this analysis. These findings support the need for rigorously designed prospective studies to assess biological and social factors that influence PEG placement and to determine, how to best evaluate and manage patients with dysphagia.
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Affiliation(s)
- Kristin Brown
- Department of Neurology, McGovern Medical School, Houston, Texas.
| | - Chunyan Cai
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Andrew Barreto
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Paige Shoemaker
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Jade Woellner
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Kim Vu
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Andreaa Xavier
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Umair Saeed
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Jeffrey Watkins
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Sean Savitz
- Department of Neurology, McGovern Medical School, Houston, Texas
| | - Anjail Sharrief
- Department of Neurology, McGovern Medical School, Houston, Texas
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Creutzfeldt CJ, Kluger B, Kelly AG, Lemmon M, Hwang DY, Galifianakis NB, Carver A, Katz M, Curtis JR, Holloway RG. Neuropalliative care: Priorities to move the field forward. Neurology 2018; 91:217-226. [PMID: 29950434 DOI: 10.1212/wnl.0000000000005916] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/06/2018] [Indexed: 11/15/2022] Open
Abstract
Neuropalliative care is an emerging subspecialty in neurology and palliative care. On April 26, 2017, we convened a Neuropalliative Care Summit with national and international experts in the field to develop a clinical, educational, and research agenda to move the field forward. Clinical priorities included the need to develop and implement effective models to integrate palliative care into neurology and to develop and implement informative quality measures to evaluate and compare palliative approaches. Educational priorities included the need to improve the messaging of palliative care and to create standards for palliative care education for neurologists and neurology education for palliative specialists. Research priorities included the need to improve the evidence base across the entire research spectrum from early-stage interventional research to implementation science. Highest priority areas include focusing on outcomes important to patients and families, developing serious conversation triggers, and developing novel approaches to patient and family engagement, including improvements to decision quality. As we continue to make remarkable advances in the prevention, diagnosis, and treatment of neurologic illness, neurologists will face an increasing need to guide and support patients and families through complex choices involving immense uncertainty and intensely important outcomes of mind and body. This article outlines opportunities to improve the quality of care for all patients with neurologic illness and their families through a broad range of clinical, educational, and investigative efforts that include complex symptom management, communication skills, and models of care.
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Affiliation(s)
- Claire J Creutzfeldt
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle.
| | - Benzi Kluger
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Adam G Kelly
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Monica Lemmon
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - David Y Hwang
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Nicholas B Galifianakis
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Alan Carver
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Maya Katz
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - J Randall Curtis
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
| | - Robert G Holloway
- From the Department of Neurology (C.J.C.), University of Washington, Harborview Medical Center, Seattle; Department of Neurology (B.K.), University of Colorado Anschutz Medical Center, Denver; Department of Neurology (A.G.K., R.G.H.), University of Rochester Medical Center, NY; Department of Pediatrics (M.L.), Division of Child Neurology, Duke University Hospital, Durham, NC; Division of Neurocritical Care and Emergency Neurology (D.Y.H.) and Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology (N.B.G., M.K.), University of California in San Francisco; Department of Neurology (A.C.), Memorial Sloan Kettering Cancer Center, New York, NY; and Cambia Palliative Care Center of Excellence (J.R.C.), University of Washington, Seattle
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Faigle R, Cooper LA, Gottesman RF. Race Differences in Gastrostomy Tube Placement After Stroke in Majority-White, Minority-Serving, and Racially Integrated US Hospitals. Dysphagia 2018; 33:636-644. [PMID: 29468269 DOI: 10.1007/s00455-018-9882-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/15/2018] [Indexed: 02/02/2023]
Abstract
We sought to determine individual and system contributions to race disparities in percutaneous endoscopic gastrostomy (PEG) tube placement after stroke. Ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic/racial minority stroke patients (< 25% ethnic/racial minorities ["majority-white hospitals"], 25-50% ethnic/racial minorities ["racially integrated hospitals"], or > 50% ethnic/racial minorities ["minority-serving hospitals"]). Logistic regression was used to evaluate the association between ethnicity/race and PEG utilization within and between the different hospital strata. Among 246,825 stroke admissions, patients receiving care in minority-serving hospitals had higher odds of PEG compared to patients in majority-white hospitals, regardless of individual patient race (adjusted odds ratio [OR] 1.24, 95% CI 1.12-1.38). Ethnic/racial minorities had higher odds of PEG than whites in any hospital strata; however, this discrepancy was largest in majority-white hospitals (OR 1.62, 95% CI 1.48-1.76), and smallest in minority-serving hospitals (OR 1.22, 95% CI 1.11-1.33; p for interaction < 0.001). Ethnic/racial minority patients had similar odds of PEG in any hospital strata, while white patients had increasing odds of PEG in racially integrated and minority-serving compared to majority-white hospitals (OR 1.28, 95% CI 1.15-1.43 in racially integrated, and OR 1.39, 95% CI 1.23-1.57 in minority-serving, compared to majority-white hospitals, p for trend < 0.001). The likelihood of PEG after ischemic stroke was increased in minority-serving compared to majority-white hospitals. White patients had higher odds of PEG in minority-serving compared to majority-white hospitals, indicating a systemic difference in PEG placement across hospitals.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA.
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, 2024 East Monument Street, Baltimore, MD, 21287, USA
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
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Galovic M. Comparing nasogastric and direct tube feeding in stroke: Enteral feeding going down the tube. Neurology 2018; 90:305-306. [PMID: 29367445 DOI: 10.1212/wnl.0000000000004970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Marian Galovic
- From the Department of Clinical and Experimental Epilepsy, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, UCL Institute of Neurology, London; Chalfont Centre for Epilepsy, Chalfont St. Peter, UK; and Department of Neurology, Kantonsspital St. Gallen, Switzerland.
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Wilmskoetter J, Simpson AN, Logan SL, Simpson KN, Bonilha HS. Impact of Gastrostomy Feeding Tube Placement on the 1-Year Trajectory of Care in Patients After Stroke. Nutr Clin Pract 2018; 33:553-566. [DOI: 10.1002/ncp.10015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/25/2017] [Indexed: 02/06/2023] Open
Affiliation(s)
- Janina Wilmskoetter
- Department of Health Sciences and Research; College of Health Professions; Medical University of South Carolina; Charleston South Carolina USA
| | - Annie N. Simpson
- Department of Healthcare Leadership and Management; College of Health Professions; Medical University of South Carolina; Charleston South Carolina USA
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina USA
| | - Sarah L. Logan
- Department of Neurosciences; College of Medicine; Medical University of South Carolina; Charleston South Carolina USA
| | - Kit N. Simpson
- Department of Healthcare Leadership and Management; College of Health Professions; Medical University of South Carolina; Charleston South Carolina USA
| | - Heather S. Bonilha
- Department of Health Sciences and Research; College of Health Professions; Medical University of South Carolina; Charleston South Carolina USA
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina USA
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One-Year Risk of Pneumonia and Mortality in Patients with Poststroke Dysphagia: A Nationwide Population-Based Study. J Stroke Cerebrovasc Dis 2018; 27:1311-1317. [PMID: 29395642 DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/21/2017] [Accepted: 12/13/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In the early stages of stroke, the use of a nasogastric tube can reduce complications such as malnutrition, dehydration, and pneumonia. However, its long-term efficacy is controversial. METHODS This retrospective cohort study used Taiwan's National Health Insurance Research Database to investigate associations among dysphagia, rate of readmission due to pneumonia, and mortality 1 year after stroke. Patients who had received their first stroke diagnosis and inpatient rehabilitation from January 1, 2006, to December 31, 2010, were enrolled. The presence of dysphagia was determined by the number of nasogastric tubes received (≥2 was classified as dysphagia, <2 as control). Kaplan-Meier plots with log-rank tests revealed differences between the 2 groups, and a Cox regression model was used to estimate the hazard ratio. RESULTS There were 5032 patients in the dysphagia group and 52,323 patients in the control group. The dysphagia group had a higher probability and incidence of pneumonia (18.78% versus 6.52%, P < .001 and adjusted hazard ratio [AHR] = 2.00, 95% confidence interval [CI] = 1.84-2.16) and a higher mortality rate (10.45% versus 4.77%, P < .001; AHR = 1.61, 95% CI = 1.46-1.79) 1 year after stroke. CONCLUSIONS The association persisted until the 5-year poststroke time point. Our results suggest that prolonged nasogastric tube use has negative effects. Intensive evaluation of dysphagia and removal of the nasogastric tube in the early stages of stroke might reduce pneumonia incidence and mortality.
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Joundi RA, Saposnik G, Martino R, Fang J, Porter J, Kapral MK. Outcomes among patients with direct enteral vs nasogastric tube placement after acute stroke. Neurology 2018; 90:e544-e552. [PMID: 29367443 DOI: 10.1212/wnl.0000000000004962] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/16/2017] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To compare complications, disability, and long-term mortality of patients who received direct enteral tube vs nasogastric tube feeding alone after acute stroke. METHODS We used the Ontario Stroke Registry to identify patients who received direct enteral tubes (DET; gastrostomy or jejunostomy) or temporary nasogastric tubes (NGT) alone during hospital stay after acute ischemic stroke or intracerebral hemorrhage from July 1, 2003, to March 31, 2013. We used propensity matching to compare groups from discharge and evaluated discharge disability, institutionalization, complications, and mortality, with follow-up over 2 years, and with cumulative incidence functions used to account for competing risks. RESULTS Among 1,448 patients with DET placement who survived until discharge, 1,421 were successfully matched to patients with NGT alone. Patients with DET had reduced risk of death within 30 days after discharge (9.7% vs 15.3%; hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.49-0.75), but this difference was eliminated after matching on length of stay and discharge disability (HR 0.90, 95% CI 0.70-1.17). Patients with DET had higher rates of severe disability at discharge (modified Rankin Scale score 4-5; 89.6% vs 78.4%), discharge to long-term care (38.0% vs 16.1%), aspiration pneumonia (14.4% vs 5.1%) and other complications, and mortality at 2 years (41.1% vs 35.9%). CONCLUSIONS Patients with DET placement after acute stroke have more severe disability at discharge compared to those with NGT placement alone, and associated higher rates of institutionalization, medical complications, and long-term mortality. These findings may inform goals of care discussions and decisions regarding long-term tube feeding after acute stroke.
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Affiliation(s)
- Raed A Joundi
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Gustavo Saposnik
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Rosemary Martino
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Jiming Fang
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Joan Porter
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada
| | - Moira K Kapral
- From the Division of Neurology (R.A.J.), Department of Medicine, Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital (G.S.), Institute of Health Policy, Management and Evaluation (G.S., M.K.K.), Department of Speech-Language Pathology (R.M.), Graduate Department of Rehabilitation Science (R.M.), and Division of General Internal Medicine (M.K.K.), Department of Medicine, University of Toronto; Health Care and Outcomes Research, Krembil Research Institute (R.M.), University Health Network; and Institute for Clinical Evaluative Sciences (ICES) (J.F., J.P., M.K.K., G.S.), Toronto, Canada.
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Hwang DY, George BP, Kelly AG, Schneider EB, Sheth KN, Holloway RG. Variability in Gastrostomy Tube Placement for Intracerebral Hemorrhage Patients at US Hospitals. J Stroke Cerebrovasc Dis 2017; 27:978-987. [PMID: 29221969 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/11/2017] [Accepted: 11/01/2017] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE We sought to characterize the variability among US hospitals with regard to gastrostomy tube placement for inpatients with intracerebral hemorrhage (ICH). METHODS Using the Nationwide Inpatient Sample, we examined variations in the annual rate of gastrostomy tube placement from 2002 to 2011 for ICH patients admitted to hospitals with 30 or more annual ICH admissions. We then directly compared, among these hospitals, their individual frequencies of gastrostomy tube placement for ICH patients over the same time period. To quantify variability among hospitals, we used multilevel multivariable regression models accounting for a hospital random effect, adjusted for patient-level and hospital-level factors predictors of placement. RESULTS Gastrostomy tube placement rates did not significantly change from 2002 to 2011 (9.8 to 8.7 per 100 admissions; P trend = .57). Among 690 hospitals with 38,080 ICH hospitalizations during this period, 10.4% of patients had a gastrostomy tube placed (n = 3976). Variation in the rate of placement among individual hospitals was large, from 0% to 34.4% (interquartile range 5.7%-13.6%). For a regression model controlling for patient and hospital covariates, the median odds ratio was 1.36 (95% confidence interval 1.28-1.44), indicating that if a patient moved from one hospital to another with a higher intrinsic propensity of placement, there was a 1.36-fold median increase in the odds of receiving a gastrostomy tube, independent of patient and hospital factors. CONCLUSIONS Variation in gastrostomy tube placement rates across hospitals is large and may in part reflect differences in local practice patterns or patient and surrogate preferences.
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Affiliation(s)
- David Y Hwang
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut; Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut.
| | - Benjamin P George
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Adam G Kelly
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Eric B Schneider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut; Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Singh T, Peters SR, Tirschwell DL, Creutzfeldt CJ. Palliative Care for Hospitalized Patients With Stroke: Results From the 2010 to 2012 National Inpatient Sample. Stroke 2017; 48:2534-2540. [PMID: 28818864 PMCID: PMC5571885 DOI: 10.1161/strokeaha.117.016893] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Substantial variability exists in the use of life-prolonging treatments for patients with stroke, especially near the end of life. This study explores patterns of palliative care utilization and death in hospitalized patients with stroke across the United States. METHODS Using the 2010 to 2012 nationwide inpatient sample databases, we included all patients discharged with stroke identified by International Classification of Diseases-Ninth Revision codes. Strokes were subclassified as ischemic, intracerebral, and subarachnoid hemorrhage. We compared demographics, comorbidities, procedures, and outcomes between patients with and without a palliative care encounter (PCE) as defined by the International Classification of Diseases-Ninth Revision code V66.7. Pearson χ2 test was used for categorical variables. Multivariate logistic regression was used to account for hospital, regional, payer, and medical severity factors to predict PCE use and death. RESULTS Among 395 411 patients with stroke, PCE was used in 6.2% with an increasing trend over time (P<0.05). We found a wide range in PCE use with higher rates in patients with older age, hemorrhagic stroke types, women, and white race (all P<0.001). Smaller and for-profit hospitals saw lower rates. Overall, 9.2% of hospitalized patients with stroke died, and PCE was significantly associated with death. Length of stay in decedents was shorter for patients who received PCE. CONCLUSIONS Palliative care use is increasing nationally for patients with stroke, especially in larger hospitals. Persistent disparities in PCE use and mortality exist in regards to age, sex, race, region, and hospital characteristics. Given the variations in PCE use, especially at the end of life, the use of mortality rates as a hospital quality measure is questioned.
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Affiliation(s)
- Tarvinder Singh
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle.
| | - Steven R Peters
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - David L Tirschwell
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - Claire J Creutzfeldt
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
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Abstract
Clinicians caring for patients with severe stroke in intensive care units often grapple with requests from surrogate decision makers for life-prolonging treatment that members of the care team may believe to be futile. An example is a surrogate decision maker's request to place a tracheostomy and feeding tube in a patient who, in the clinical judgment of the neurocritical care team, is very unlikely to recover interactive capacity. This article presents a case, discusses definitions of medical futility, and summarizes recommended steps for mediating conflict regarding potentially inappropriate treatment.
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George BP, Kelly AG, Albert GP, Hwang DY, Holloway RG. Timing of Percutaneous Endoscopic Gastrostomy for Acute Ischemic Stroke. Stroke 2017; 48:420-427. [DOI: 10.1161/strokeaha.116.015119] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/07/2016] [Accepted: 11/18/2016] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Stroke guidelines recommend time-limited trials of nasogastric feeding prior to percutaneous endoscopic gastrostomy (PEG) tube placement. We sought to describe timing of PEG placement and identify factors associated with early PEG for acute ischemic stroke.
Methods—
We designed a retrospective observational study to examine time to PEG for ischemic stroke admissions in the Nationwide Inpatient Sample, 2001 to 2011. We defined early PEG placement as 1 to 7 days from admission. Using multivariable regression analysis, we identified the effects of patient and hospital characteristics on PEG timing.
Results—
We identified 34 623 admissions receiving a PEG from 2001 to 2011, 53% of which received the PEG 1 to 7 days from admission. Among hospitals placing ≥10 PEG tubes, median time to PEG for individual hospitals ranged from 3 days to over 3 weeks (interquartile range 6–8.5 days). Older adult age groups were associated with early PEG (≥85 years versus 18–54 years: adjusted odds ratio 1.68, 95% confidence interval 1.50–1.87). Those receiving a PEG and tracheostomy were more likely to receive the PEG beyond 7 days, and these patients were more often younger compared with PEG only recipients. Those admitted to high-volume hospitals were more likely to receive their PEG early (≥350 versus <150 hospitalizations; adjusted odds ratio 1.26, 95% confidence interval 1.17–1.35).
Conclusions—
More than half of the PEG recipients received their surgical feeding tube within 7 days of admission. The oldest old, who may benefit most from time-limited trials of nasogastric feeding for ≥2 to 3 weeks, were most likely to receive a PEG within 7 days.
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Affiliation(s)
- Benjamin P. George
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
| | - Adam G. Kelly
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
| | - George P. Albert
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
| | - David Y. Hwang
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
| | - Robert G. Holloway
- From the Department of Neurology, University of Rochester Medical Center, NY (B.P.G., A.G.K., R.G.H.); College of Arts and Science, University of Rochester, NY (G.P.A.); and Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT (D.Y.H.)
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Wilmskoetter J, Simpson AN, Simpson KN, Bonilha HS. Practice Patterns of Percutaneous Endoscopic Gastrostomy Tube Placement in Acute Stroke: Are the Guidelines Achievable? J Stroke Cerebrovasc Dis 2016; 25:2694-2700. [PMID: 27475521 DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 06/09/2016] [Accepted: 07/04/2016] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Our objectives were to evaluate trends in percutaneous endoscopic gastrostomy (PEG) tube placement rate and timing in acute stroke patients. We hypothesized that noncompliance with clinical practice guidelines for timing of tube placement and an increase in placement occurred because of a decrease in length of hospital stay. METHODS We conducted a retrospective observational study of archival hospital billing data from the Florida state inpatient healthcare cost and utilization project database from 2001 to 2012 for patients with a primary diagnosis of stroke. Outcome measures were timing of PEG tube placements by year (2006-2012), rate of placements by year (2001-2012), and length of hospital stay. Univariate analyses and simple and multivariable logistic regression analyses were conducted. RESULTS The timing of gastrostomy tube placement remained stable with a median of 7 days post admission from 2006 through 2012. The proportion of tubes that were placed at or after 14 days and thereby met the guideline recommendations varied from 14.09% in 2006 to 13.41% in 2012. The rate of tube placement in stroke patients during the acute hospital stay decreased significantly by 25% from 6.94% in 2001 to 5.22% in 2012 (P < .0001). The length of hospital stay for all stroke patients decreased over the study period (P < .0001). CONCLUSIONS The vast majority of PEG tube placements happen earlier than clinical practice guidelines recommend. Over the study period, the rate of tubes placed in stroke patients decreased during the acute hospital stay despite an overall reduced length of stay.
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Affiliation(s)
- Janina Wilmskoetter
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Annie N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Heather S Bonilha
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Wilmskoetter J, Simpson KN, Bonilha HS. Hospital Readmissions of Stroke Patients with Percutaneous Endoscopic Gastrostomy Feeding Tubes. J Stroke Cerebrovasc Dis 2016; 25:2535-42. [PMID: 27423366 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 06/25/2016] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES A critical mission of acute care hospitals is to reduce hospital readmissions to improve patient care and avoid monetary penalties. We speculated that stroke patients with enteral tube feeding are high-risk patients and sought to evaluate their hospital readmissions. METHODS We analyzed archival hospital billing data from stroke patients discharged from acute care hospitals in Florida in 2012 for 30- and 60-day readmission rates, 30-day readmission rates by discharge destination, most frequent primary readmission diagnoses, and predictors of 30-day readmissions. We conducted univariate and multivariable logistic regression analyses. RESULTS We analyzed 26,774 discharge records. Within 30 days after discharge, 21.06% (N = 299) of stroke patients with percutaneous endoscopic gastrostomy (PEG) tube placement were rehospitalized. Of those readmissions, 11.71% (N = 35) were preventable. Among stroke patients with a PEG tube placement, 53.80% were discharged to skilled nursing facilities and 27.88% were rehospitalized within 30 days. Septicemia was the most frequent primary readmission diagnosis. Comorbidities, stroke type, length of hospital stay, and discharge destinations were predictive for 30-day readmissions (area under the receiver operating characteristic curve was .81). CONCLUSIONS Stroke patients with a PEG tube placement during their index hospital stay are twice as likely to be readmitted within 30 days compared to stroke patients without PEG tube placements. The primary readmission diagnosis for some patients was directly linked to PEG tube complications. We have identified risk factors that can be used to focus resources for readmission prevention.
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Affiliation(s)
- Janina Wilmskoetter
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - Heather S Bonilha
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina; Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Patient Age and the Outcomes after Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis. Neurocrit Care 2016; 25:371-383. [DOI: 10.1007/s12028-016-0287-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Faigle R, Bahouth MN, Urrutia VC, Gottesman RF. Racial and Socioeconomic Disparities in Gastrostomy Tube Placement After Intracerebral Hemorrhage in the United States. Stroke 2016; 47:964-70. [PMID: 26892281 DOI: 10.1161/strokeaha.115.011712] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 01/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Percutaneous endoscopic gastrostomy (PEG) tubes are widely used for enteral feeding of patients after intracerebral hemorrhage (ICH). We sought to determine whether PEG placement after ICH differs by race and socioeconomic status. METHODS Patient discharges with ICH as the primary diagnosis from 2007 to 2011 were queried from the Nationwide Inpatient Sample. Logistic regression was used to evaluate the association between race, insurance status, and household income with PEG placement. RESULTS Of 49 946 included ICH admissions, a PEG was placed in 4464 (8.94%). Among PEG recipients, 47.2% were minorities and 15.6% were Medicaid enrollees, whereas 33.7% and 8.2% of patients without a PEG were of a race other than white and enrolled in Medicaid, respectively (P<0.001). Compared with whites, the odds of PEG were highest among Asians/Pacific Islanders (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.32-1.99) and blacks (OR 1.42, 95% CI 1.28-1.59). Low household income (OR 1.25, 95% CI 1.09-1.44 in lowest compared with highest quartile) and enrollment in Medicaid (OR 1.36, 95% CI 1.17-1.59 compared with private insurance) were associated with PEG placement. Racial disparities (minorities versus whites) were most pronounced in small/medium-sized hospitals (OR 1.77, 95% CI 1.43-2.20 versus OR 1.31, 95% CI 1.17-1.47 in large hospitals; P value for interaction 0.011) and in hospitals with low ICH case volume (OR 1.58, 95% CI 1.38-1.81 versus OR 1.29, 95% CI 1.12-1.50 in hospitals with high ICH case volume; P value for interaction 0.007). CONCLUSIONS Minority race, Medicaid enrollment, and low household income are associated with PEG placement after ICH.
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Affiliation(s)
- Roland Faigle
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Mona N Bahouth
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor C Urrutia
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca F Gottesman
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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Maeda T, Babazono A, Nishi T, Yasui M, Harano Y. Investigation of the Existence of Supplier-Induced Demand in use of Gastrostomy Among Older Adults: A Retrospective Cohort Study. Medicine (Baltimore) 2016; 95:e2519. [PMID: 26844459 PMCID: PMC4748876 DOI: 10.1097/md.0000000000002519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study is to clarify whether there is small area variation in the use of gastrostomy that is explained by hospital physician density, so as to detect the existence of supplier-induced demand (SID).The study design is a retrospective cohort using claim data of Fukuoka Late Elders' Health Insurance, submitted from 2010 to 2013. Study participants included 51,785 older adults who had been diagnosed with eating difficulties. We designated use of gastrostomy as an event. Multilevel logistic analyses were then used to investigate the existence of SID.After controlling for patient factors, we found significant regional level variance in gastrectomy use (median odds ratio [MOR]: 1.72, 1.37-2.51). Hospital physician density was significantly positively related with gastrostomy (adjusted OR of hospital physician density: 1.75, 1.25-2.45; P < 0.001). MORs were largely reduced for the input variable of hospital physician density.We found that the small area variation in use of gastrostomy among older adults could be explained by hospital physician density, which might indicate the existence of SID.
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Affiliation(s)
- Toshiki Maeda
- From the Department of Healthcare Administration and Management, Graduate School of Healthcare Sciences, Kyushu University, Japan
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Creutzfeldt CJ, Holloway RG, Curtis JR. Palliative Care: A Core Competency for Stroke Neurologists. Stroke 2015; 46:2714-9. [PMID: 26243219 DOI: 10.1161/strokeaha.115.008224] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/01/2015] [Indexed: 12/28/2022]
Affiliation(s)
- Claire J Creutzfeldt
- From the Harborview Medical Center, Department of Neurology, University of Washington, Seattle, WA (C.J.C.); Department of Neurology, University of Rochester Medical Center, Rochester, NY (R.G.H.); and Cambia Palliative Care Center of Excellence, Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA (J.R.C.).
| | - Robert G Holloway
- From the Harborview Medical Center, Department of Neurology, University of Washington, Seattle, WA (C.J.C.); Department of Neurology, University of Rochester Medical Center, Rochester, NY (R.G.H.); and Cambia Palliative Care Center of Excellence, Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA (J.R.C.)
| | - J Randall Curtis
- From the Harborview Medical Center, Department of Neurology, University of Washington, Seattle, WA (C.J.C.); Department of Neurology, University of Rochester Medical Center, Rochester, NY (R.G.H.); and Cambia Palliative Care Center of Excellence, Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA (J.R.C.)
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Cai X, Robinson J, Muehlschlegel S, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Patient Preferences and Surrogate Decision Making in Neuroscience Intensive Care Units. Neurocrit Care 2015; 23:131-41. [PMID: 25990137 PMCID: PMC4816524 DOI: 10.1007/s12028-015-0149-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In the neuroscience intensive care unit (NICU), most patients lack the capacity to make their own preferences known. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preference-based treatment decisions, oftentimes in challenging situations where prognosis is uncertain. The neurointensivist has a large responsibility and role to play in this shared decision-making process. This review covers how NICU patient preferences are determined through existing advance care documentation or surrogate decision makers and how the optimum roles of the physician and surrogate decision maker are addressed. We outline the process of reaching a shared decision between family and care team and describe a practice for conducting optimum family meetings based on studies of ICU families in crisis. We review challenges in the decision-making process between surrogate decision makers and medical teams in neurocritical care settings, as well as methods to ameliorate conflicts. Ultimately, the goal of shared decision making is to increase knowledge amongst surrogates and care providers, decrease decisional conflict, promote realistic expectations and preference-centered treatment strategies, and lift the emotional burden on families of neurocritical care patients.
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Affiliation(s)
- Xuemei Cai
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA,
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Abstract
PURPOSE OF REVIEW This review addresses current controversies regarding appropriate indications for percutaneous endoscopic gastrostomy (PEG) insertion. We address specific indications, namely, dementia, stroke, aspiration, motor neurone disease/amyotrophic lateral sclerosis, and head and neck cancer. We recommend practical strategies for improving patient selection. RECENT FINDINGS There is now a general consensus in the United States that PEG feeding does not benefit patients with advanced dementia. 'Early' PEG insertion following stroke is similarly of no benefit. It is currently unclear whether patients with amyotrophic lateral sclerosis and head and neck tumors should have PEG or radiologically inserted gastrostomy. SUMMARY Decisions relating to PEG insertion remain difficult. The gastroenterologist, working as a member of a multidisciplinary nutrition team, needs to take a lead role in this regard, rather than functioning as a technician.
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Affiliation(s)
- Carthage Moran
- aDepartment of Medicine bDepartment of Gastroenterology, Cork University Hospital, Wilton, Cork, Ireland
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