Elayne Livote

Hospital-Based Palliative Care Consultation: Effects on Hospital Cost

CONTEXT Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs. OBJECTIVE To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease. DESIGN, SETTING, AND PATIENTS An observational study of 3321 veterans hospitalized with advanced disease between October 1, 2004 and September 30, 2006. The sample includes 606 (18%) veterans who received palliative care and 2715 (82%) who received usual hospital care. October 1, 2004 and September 30, 2006. MAIN OUTCOME MEASURES We studied the costs and intensive care unit (ICU) use of palliative versus usual care for patients in five Veterans Affairs hospitals over a 2-year period. We used an instrumental variable approach to control for unmeasured characteristics that affect both treatment and outcome. RESULTS The average daily total direct hospital costs were

Brief Communication: Management of Implantable Cardioverter-Defibrillators in Hospice: A Nationwide Survey

464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care (p < 0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients (p < 0.001). COMMENTS Palliative care for patients hospitalized with advanced disease results in lower costs of care and less utilization of intensive care compared to similar patients receiving usual care. Selection on unobserved characteristics plays an important role in the determination of costs of care.

Effect of Admission Medication Reconciliation on Adverse Drug Events From Admission Medication Changes

BACKGROUND Communication about the deactivation of implantable cardioverter-defibrillators (ICDs) in patients near the end of life is rare. OBJECTIVE To determine whether hospices are admitting patients with ICDs, whether such patients are receiving shocks, and how hospices manage ICDs. DESIGN Cross-sectional survey. SETTING Randomly selected hospice facilities. PARTICIPANTS 900 hospices, 414 of which responded fully. MEASUREMENTS Frequency of admission of patients with ICDs, frequency with which patients received shocks, existence of ICD deactivation policies, and frequency of deactivation. RESULTS 97% of hospices admitted patients with ICDs, and 58% reported that in the past year, a patient had been shocked. Only 10% of hospices had a policy that addressed deactivation. On average, 42% (95% CI, 37% to 48%) of patients with ICDs had the shocking function deactivated. LIMITATION The study relied on the knowledge of hospice administrators. CONCLUSION Hospices are admitting patients with ICDs, and patients are being shocked at the end of life. Ensuring that hospices have policies in place to address deactivation may improve the care for patients with these devices. The authors provide a sample deactivation policy. PRIMARY FUNDING SOURCE National Institute of Aging and National Institute of Nursing Research.

Meeting standards of high-quality intensive care unit palliative care: Clinical performance and predictors

M edication reconciliation, a process by which a health care provider obtains and documents a thorough medication history with specific attention to comparing current and previous medication use, has been a focus of major patient safety initiatives. Evaluations of medication reconciliation programs have reported factors associated with successful implementation and its effect on prescribing outcomes such as medication errors and potential adverse drug events but not its effect on actual adverse drug events (ADEs). The objective of this study was to estimate the effectiveness of inpatient medication reconciliation at the time of hospital admission on ADEs caused by admission prescribing changes.

Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events.

Objectives:High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality’s National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance. Design:Prospective, multisite, observational study of performance of key intensive care unit palliative care processes. Settings:A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital. Patients:Consecutive adult patients with length of intensive care unit stay ≥5 days. Interventions:None. Measurements and Main Results:Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: Identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance. Conclusions:Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers. (Crit Care Med 2012; 40:–1112)

Long-term associations between cholinesterase inhibitors and memantine use and health outcomes among patients with Alzheimer's disease

BACKGROUND Medication reconciliation (MR) has proven to be a problematic task for many hospitals to accomplish. It is important to know the clinical impact of physician- versus pharmacist-initiated MR in the resource-limited hospital environment. METHODS This quasi-experimental study took place from December 2005 to February 2006 at an urban US Veterans Affairs hospital. MR was implemented on 2 similar general medical units: one received physician-initiated MR and the other received pharmacist-initiated MR. Adverse drug events (ADEs) and a 72-hour medication-prescribing risk score were ascertained by research pharmacists for all admitted patients by structured record review. Multivariable models were tested for intervention effect, accounting for quasi-experimental design and clustered observations, and were adjusted for patient and encounter covariates. RESULTS Pharmacists completed the MR process in 102 admissions and physicians completed the process in 116 admissions. In completing the MR process, pharmacists documented statistically more admission medication changes than physicians (3.6 vs 0.8; P < 0.001). The adjusted odds of an ADE caused by an admission prescribing change with pharmacist-initiated MR compared with a physician-initiated MR were 1.04 with a 95% CI of 0.53 to 2.0. The adjusted odds of an ADE caused by an admission prescribing change that was a prescribing error with pharmacist-initiated MR compared with a physician-initiated MR were 0.38 with a confidence interval of 0.14 to 1.05. No difference was observed in 72-hour prescribing risk score (coefficient = 0.10; 95% CI, -0.54 to 0.75). CONCLUSION MR performed by pharmacists versus physicians was more comprehensive and was followed by lower odds of ADEs from admission prescribing errors but with similar odds of all types of ADEs. Further research is warranted to examine how MR tasks may be optimally divided among clinicians and the mechanisms by which MR affects the likelihood of subsequent ADEs.

Electronic health records and adverse drug events after patient transfer

To examine in an observational study (1) relationships between cholinesterase inhibitors (ChEI) and memantine use, and functional and cognitive end points and mortality in patients with Alzheimers disease (AD); (2) relationships between other patient characteristics and these clinical end points; and (3) whether effects of the predictors change across time.

A retrospective chart review of heart rate and blood pressure abnormalities in veterans with spinal cord injury

Background Our objective was to examine the frequencies of medication error and adverse drug events (ADEs) at the time of patient transfer in a system with an electronic health record (EHR) as compared with a system without an EHR. It was hypothesised that the frequencies of these events would be lower in the EHR system because of better information exchange across sites of care. Methods 469 patients transferred between seven nursing homes and three hospitals in New York and Connecticut between 1999 and 2005 were followed retrospectively. Two groups of patients were compared: US Veterans Affairs (VA) patients, with an EHR, and non-VA patients, without an EHR, on the following measures: (1) medication prescribing discrepancies at nursing home/hospital transfer, (2) high-risk medication discrepancies and (3) ADEs caused by medication discrepancies according to structured medical record review by pairs of physician and pharmacist raters. Results The overall incidence of ADE caused by medication discrepancies was 0.20 per hospitalisation episode. After controlling for demographic and clinical covariates, there were no significant differences between VA and non-VA groups in medication discrepancies (mean difference 0.02; 95% CI −0.81 to 0.85), high-risk medication discrepancies (−0.18; 95%CI −0.22 to 0.58) or occurrence of an ADE caused by a medication discrepancy (OR 0.96; 95% CI 0.18 to 5.01). Conclusions There was no difference, with and without an EHR, in the occurrence of medication discrepancies or ADEs caused by medication discrepancies at the time of transfer between sites of care. Reducing such problems may require specialised computer tools to facilitate medication review.

Development of and Recovery From Difficulty With Activities of Daily Living: An Analysis of National Data

Abstract Objective Autonomic impairment may lead to increased prevalence of heart rate (HR) and blood pressure (BP) abnormalities in veterans with spinal cord injury (SCI). In addition, comorbid medical conditions and prescription medication use may influence these abnormalities, including bradycardia, and tachycardia, hypotension, hypertension as well as autonomic dysreflexia (AD), and orthostatic hypotension (OH). Design A retrospective review of clinical and administrative datasets in veterans with SCI and compared the prevalence rates between clinical values and ICD-9 diagnostic codes in individuals with tetraplegia (T: C1–C8), high paraplegia (HP: T1–T6), and low paraplegia (LP: T7 and below). Results The prevalence of clinical values indicative of a HR ≥ 80 beats per minute was higher in the HP compared to the LP and T groups. A systolic BP (SBP) ≤ 110 mmHg was more common in the T compared to the HP and LP groups, whereas the prevalence of a SBP ≥ 140 mmHg was increased in the LP compared to the HP and T groups. Diagnosis of hypertension was 39–60% whereas the diagnosis of hypotension was less than 1%. Diagnosis of AD and OH was highest in the T group, but remained below 10%, regardless of categorical lesion level. Antihypertensive medications were commonly prescribed (55%), and patients on these medications were less likely to have high BP. The odds ratio of higher SBP and DBP increased with age and body mass index (BMI). Conclusion In veterans with SCI, the prevalence of HR and BP abnormalities varied depending on level of lesion, age, BMI, and prescription medication use.

Longitudinal medication usage in Alzheimer disease patients.

Background: National-level data are needed on predictors of mild physical impairment among older adults to assist policy makers with resource allocation. Method: We analyzed data on adults above age 64 from the Medicare Current Beneficiary Survey (MCBS) with no activity of daily living (ADL) difficulties at baseline ( n = 14,226). Five ADLs were measured annually and recovery was defined as regaining complete ADL function at follow-up. Results: The strongest correlates of ADL difficulty were use of antipsychotic medications (adjusted odds ratio [AOR] = 1.93, 95% confidence interval [CI] = 1.44 to 2.58), instrumental ADL difficulty (AOR = 1.90, 95% CI = 1.74 to 2.07), and fair-poor general health (AOR = 1.59, 95% CI = 1.42 to 1.78). Only the number of incident ADL difficulties was associated with recovery (AOR = 0.02, 95% CI = 0.01 to 0.02). Conclusion: Identifying factors associated with development of mild physical impairment could help direct patients toward preventive care programs to preempt decline in physical function.