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Abstract
IMPORTANCE Efforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses. OBJECTIVE To compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses. DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was conducted in all 146 inpatient facilities within the Veteran Affairs health system among patients who died in inpatient facilities between October 1, 2009, and September 30, 2012, with clinical diagnoses categorized as end-stage renal disease (ESRD), cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions. Data analysis was conducted from April 1, 2014, to February 10, 2016. MAIN OUTCOMES AND MEASURES Palliative care consultations, do-not-resuscitate orders, death in inpatient hospices, death in the intensive care unit, and family-reported quality of end-of-life care. RESULTS Among 57 753 decedents, approximately half of the patients with ESRD, cardiopulmonary failure, or frailty received palliative care consultations (adjusted proportions, 50.4%, 46.7%, and 43.7%, respectively) vs 73.5% of patients with cancer and 61.4% of patients with dementia (P < .001). Approximately one-third of patients with ESRD, cardiopulmonary failure, or frailty (adjusted proportions, 32.3%, 34.1%, and 35.2%, respectively) died in the intensive care unit, more than double the rates among patients with cancer and those with dementia (13.4% and 8.9%, respectively) (P < .001). Rates of excellent quality of end-of-life care reported by 34 005 decedents' families were similar for patients with cancer and those with dementia (adjusted proportions, 59.2% and 59.3%; P = .61), but lower for patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02 vs patients with cancer). This quality advantage was mediated by palliative care consultation, setting of death, and a code status of do-not-resuscitate; adjustment for these variables rendered the association between diagnosis and overall end-of-life care quality nonsignificant. CONCLUSIONS AND RELEVANCE Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and those with dementia. Increasing access to palliative care and goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the overall quality of end-of-life care for Americans dying of these illnesses.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts2Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer
| | - Corey Pilver
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts5Tufts Health Plan, Watertown, Massachusetts
| | - Dawn Smith
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania7University of Pennsylvania School of Nursing, Philadelphia
| | - Stuart R Lipsitz
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nancy L Keating
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts8Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Chen Q, Mull HJ, Rosen AK, Borzecki AM, Pilver C, Itani KM. Measuring readmissions after surgery: do different methods tell the same story? Am J Surg 2016; 212:24-33. [DOI: 10.1016/j.amjsurg.2015.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 07/27/2015] [Accepted: 08/08/2015] [Indexed: 11/29/2022]
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Rosen AK, Chen Q, Shwartz M, Pilver C, Mull HJ, Itani KFM, Borzecki A. Does Use of a Hospital-wide Readmission Measure Versus Condition-specific Readmission Measures Make a Difference for Hospital Profiling and Payment Penalties? Med Care 2016; 54:155-61. [PMID: 26595224 DOI: 10.1097/mlr.0000000000000455] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) use public reporting and payment penalties as incentives for hospitals to reduce readmission rates. In contrast to the current condition-specific readmission measures, CMS recently developed an all-condition, 30-day all-cause hospital-wide readmission measure (HWR) to provide a more comprehensive view of hospital performance. OBJECTIVES We examined whether assessment of hospital performance and payment penalties depends on the readmission measure used. RESEARCH DESIGN We used inpatient data to examine readmissions for patients discharged from VA acute-care hospitals from Fiscal Years 2007-2010. We calculated risk-standardized 30-day readmission rates for 3 condition-specific measures (heart failure, acute myocardial infarction, and pneumonia) and the HWR measure, and examined agreement between the HWR measure and each of the condition-specific measures on hospital performance. We also assessed the effect of using different readmission measures on hospitals' payment penalties. RESULTS We found poor agreement between the condition-specific measures and the HWR measure on those hospitals identified as low or high performers (eg, among those hospitals classified as poor performers by the heart failure readmission measure, only 28.6% were similarly classified by the HWR measure). We also found differences in whether a hospital would experience payment penalties. The HWR measure penalized only 60% of those hospitals that would have received penalties based on at least 1 of the condition-specific measures. CONCLUSIONS The condition-specific measures and the HWR measure provide a different picture of hospital performance. Future research is needed to determine which measure aligns best with CMS's overall goals to reduce hospital readmissions and improve quality.
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Affiliation(s)
- Amy K Rosen
- *Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System †Department of Surgery, Boston University School of Medicine ‡Boston University Questrom School of Business, Operations and Technology Management Department §VA Boston Healthcare System ∥Department of Health Law, Policy and Management, Boston University School of Public Health ¶Department of General Medicine, Boston University School of Medicine, Boston, MA
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Erez G, Pilver C, Potenza M. Gender-related differences in the associations between sexual impulsivity, psychiatric disorders and trauma. Eur Psychiatry 2016. [DOI: 10.1016/j.eurpsy.2016.01.893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IntroductionSexual impulsivity (SI) has been associated with conditions that have substantial public health costs, such as sexually transmitted infections and unintended pregnancies. However, SI has not been examined systematically with respect to its relationships to psychopathology. The literature regarding associations between SI and history of different types of trauma also scarce.AimsWe aimed to deepen the understanding of the roots of SI, both through the prism of history of trauma and through the prism of psychopathology as an explanation for SI.ObjectivesWe intended to investigate associations between SI and psychopathology, and between SI and personal history of trauma of different types, including gender-related differences.MethodsWe performed a secondary data analysis of Wave-2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national sample of 34,653 adults in the United States. DSM-IV based diagnoses of mood; anxiety, drug and personality disorders were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Scheduled DSM-IV Version.ResultsFor both women and men, SI was positively associated with most Axis-I and Axis-II psychiatric disorders. Significant gender-related differences (GRD) were observed. Among women as compared to men, SI was more strongly associated with social phobia, alcohol abuse/dependence and most personality disorders. As for trauma, SI was positively associated with any trauma for both women and men. Among women as compared to men, SI was more strongly associated with sexual assault and kidnapping.Disclosure of interestThe authors have not supplied their declaration of competing interest.
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Kong G, Smith PH, Pilver C, Hoff R, Potenza MN. Problem-gambling severity and psychiatric disorders among American-Indian/Alaska native adults. J Psychiatr Res 2016; 74:55-62. [PMID: 26741278 PMCID: PMC4744487 DOI: 10.1016/j.jpsychires.2015.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 11/23/2015] [Accepted: 12/03/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Little is known about the association between problem-gambling severity and psychiatric disorders among American-Indian/Alaska-Native (AI/AN) individuals. Thus, we examined these factors among a nationally representative sample of AI/AN and other American adults in the USA. METHOD Using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data, we conducted separate Wald tests and multinomial logistic regression analyses comparing AI/AN to black/African American, white/Caucasian, and all other racial/ethnic groups, respectively. RESULTS Relative to other American adults, AI/AN adults were least likely to report non-/low-frequency gambling (NG: AI/AN 66.5%, white/Caucasian 70.5%, black/African American 72.8%, other racial/ethnic group 72.3%) and most likely to report low-risk gambling (LRG: AI/AN 30.1%, white/Caucasian 26.5%, black/African American 23.4%, other racial/ethnic group 24.7%). The association between at-risk/problem-gambling (ARPG) and any past-year Axis-I disorder was stronger among AI/AN versus other American adults. Although ARPG and LRG were associated with multiple past-year Axis-I and lifetime Axis-II psychiatric disorders in both AI/AN and other American adults, LRG was more strongly associated with both Axis-I disorders (particularly major depression, generalized anxiety disorder and nicotine dependence) and Cluster-B Axis-II (particularly antisocial personality disorder) disorders in AI/AN versus other American adults. DISCUSSION A stronger association between problem-gambling severity and past-year psychiatric disorders among AI/AN relative to other American adults suggests the importance of enhancing mental health and problem-gambling prevention and treatment strategies that may help AI/AN individuals.
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Affiliation(s)
- Grace Kong
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States.
| | - Philip H. Smith
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Corey Pilver
- Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, United States
| | - Rani Hoff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Marc N. Potenza
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States,Department of Neurobiology, Yale University School of Medicine, New Haven, CT, United States,Child Study Center, Yale University, School of Medicine, New Haven, CT, United States,CASA Columbia, Yale University School of Medicine, New Haven, CT, United States
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Weinberger AH, Franco CA, Hoff RA, Pilver C, Steinberg MA, Rugle L, Wampler J, Cavallo DA, Krishnan-Sarin S, Potenza MN. Cigarette smoking, problem-gambling severity, and health behaviors in high-school students. Addict Behav Rep 2015. [PMID: 29531978 PMCID: PMC5845975 DOI: 10.1016/j.abrep.2015.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Introduction Smoking and gambling are two significant public health concerns. Little is known about the association of smoking and gambling in adolescents. The current study of high-school adolescents examined: (1) smoking behavior by problem-gambling severity and (2) health-related variables by problem-gambling severity and smoking status. Methods Analyses utilized survey data from 1591 Connecticut high-school students. Adolescents were classified by problem-gambling severity (Low-Risk Gambling [LRG], At-Risk/Problem Gambling [ARPG]) and smoking status (current smoker, non-smoker). Analyses examined the smoking behavior of ARPG versus LRG adolescents as well as the smoking-by-problem-gambling-severity interactions for health and well-being measures (e.g., grades, substance use). Chi-square and logistic regression analyses were used; the latter controlled for gender, race/ethnicity, school grade, and family structure. Results More adolescents with ARPG than LRG reported regular smoking, heavy smoking, early smoking onset, no smoking quit attempts, and parental approval of smoking. ARPG and LRG adolescents who smoked were more likely to report poor grades, lifetime use of marijuana and other drugs, current heavy alcohol use, current caffeine use, depression, and aggressive behaviors and less likely to report participation in extracurricular activities. The association between not participating in extracurricular activities and smoking was statistically stronger in the LRG compared to the ARPG groups. Post-hoc analyses implicated a range of extracurricular activities including team sports, school clubs, and church activities. Conclusions Smoking was associated with poorer health-related behaviors in both ARPG and LRG groups. Interventions with adolescents may benefit from targeting both smoking and gambling. We examined adolescent health behaviors by smoking status and gambling severity. Smoking was associated with poorer health behaviors for adolescent gamblers. Considering smoking may be helpful in interventions with adolescent gamblers.
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Affiliation(s)
- Andrea H Weinberger
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA.,Cancer Prevention and Control Research Program, Yale Cancer Center, New Haven, CT 06520, USA.,Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY 10461, USA
| | - Christine A Franco
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Rani A Hoff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA.,Department of Public Health, Yale University School of Medicine, New Haven, CT 06520, USA.,National Center for PTSD, Evaluation Division, VA CT Healthcare Center, West Haven, CT 06516, USA
| | - Corey Pilver
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06520, USA
| | | | - Loreen Rugle
- Connecticut Department of Mental Health and Addiction Services Problem Gambling Services, Middletown, CT 06457, USA
| | - Jeremy Wampler
- Connecticut Department of Mental Health and Addiction Services Problem Gambling Services, Middletown, CT 06457, USA
| | - Dana A Cavallo
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
| | | | - Marc N Potenza
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA.,Child Study Center, Yale University School of Medicine, New Haven, CT 06519, USA.,Department of Neurobiology, Yale University School of Medicine, New Haven, CT 06519, USA.,CASAColumbia, Yale University School of Medicine, New Haven, CT 06519, USA
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Levy BR, Pilver C, Chung PH, Slade MD. Subliminal strengthening: improving older individuals' physical function over time with an implicit-age-stereotype intervention. Psychol Sci 2014; 25:2127-35. [PMID: 25326508 DOI: 10.1177/0956797614551970] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Negative age stereotypes that older individuals assimilate from their culture predict detrimental outcomes, including worse physical function. We examined, for the first time, whether positive age stereotypes, presented subliminally across multiple sessions in the community, would lead to improved outcomes. Each of 100 older individuals (age=61-99 years, M=81) was randomly assigned to an implicit-positive-age-stereotype-intervention group, an explicit-positive-age-stereotype-intervention group, a combined implicit- and explicit-positive-age-stereotype-intervention group, or a control group. Interventions occurred at four 1-week intervals. The implicit intervention strengthened positive age stereotypes, which strengthened positive self-perceptions of aging, which, in turn, improved physical function. The improvement in these outcomes continued for 3 weeks after the last intervention session. Further, negative age stereotypes and negative self-perceptions of aging were weakened. For all outcomes, the implicit intervention's impact was greater than the explicit intervention's impact. The physical-function effect of the implicit intervention surpassed a previous study's 6-month-exercise-intervention's effect with participants of similar ages. The current study's findings demonstrate the potential of directing implicit processes toward physical-function enhancement over time.
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Affiliation(s)
- Becca R Levy
- Social and Behavioral Sciences Division, School of Public Health, Yale University
| | - Corey Pilver
- Department of Biostatistics, School of Public Health, Yale University
| | - Pil H Chung
- Department of Demography, University of California, Berkeley Department of Sociology, University of California, Berkeley
| | - Martin D Slade
- Department of Internal Medicine, School of Medicine, Yale University
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Cook JM, Pilver C, Dinnen S, Schnurr PP, Hoff R. Prevalence of physical and sexual assault and mental health disorders in older women: findings from a nationally representative sample. Am J Geriatr Psychiatry 2013; 21:877-86. [PMID: 23567392 DOI: 10.1016/j.jagp.2013.01.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 09/22/2011] [Accepted: 11/30/2011] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study presents prevalence and characteristics of physical and sexual assaults, and their relationship to posttraumatic stress disorder (PTSD), and mood and anxiety disorders in a nationally representative sample of older women. DESIGN AND SETTING Face-to-face interviews conducted with adult participants from wave 2 of the National Epidemiological Survey on Alcohol and Related Conditions. PARTICIPANTS A total of 3,354 community-residing women of age 65 years and older. MEASUREMENT Alcohol Use Disorder and Associated Disabilities Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, current mood and anxiety disorders. RESULTS Almost 14% of participants reported a history of physical or sexual assault or both during their lifetimes. Assaults were often repeated rather than isolated events. Although the majority of participants did not identify interpersonal violence as their "worst" traumatic event, those who experienced interpersonal violence were generally more likely than those without such history to meet the criteria for past-year and lifetime PTSDs, depression, and anxiety. CONCLUSIONS Some women who have been physically or sexually assaulted decades earlier continue to report significant levels of mood and anxiety disorders into late adulthood. Several ways to increase the identification and treatment of older female trauma survivors by healthcare providers are suggested.
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Affiliation(s)
- Joan M Cook
- Yale School of Medicine, New Haven, CT; National Center for PTSD, U.S. Department of Veterans Affairs, Washington, DC.
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