Ji Won Yoo

Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis

OBJECTIVEnHospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality.nnnMETHODnA systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I 2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence.nnnRESULTSnOf the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI 95%] = -2.22-2.61 days; p = 0.87; I 2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI 95% = 0.52-0.84; p < 0.01; I 2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively.nnnSIGNIFICANCE OF RESULTSnHospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.

Effects of the 2009 Medical Cannabinoid Legalization Policy on Hospital Use for Cannabinoid Dependency and Persistent Vomiting

BACKGROUND & AIMS: In 2009, the U.S. Department of Justice issued a memo stating that it would not prosecute users and sellers who complied with the state laws allowing for medical use of marijuana. There are growing concerns about legalization of marijuana use and its related public health effects. We performed an interrupted time series analysis to evaluate these effects. METHODS: We collected a representative sample of hospital discharge data from the Healthcare Cost and Utilization Project, from January 1993 to December 2014. We divided the data in to 3 groups: the prelegalization period (1993–2008), the legalization period (2009), and the postlegalization period (2010–2014). The disease variables were International Classification of Disease‐Ninth Revision‐Clinical Modification 304.30 cannabinoid dependency unspecified (CDU), 536.2 persistent vomiting, and an aggregate of CDU and persistent vomiting. We performed interrupted time series and Poisson‐Gamma regression analysis to calculate each year’s incidence rate of unspecified and persistent vomiting and CDU per 100,000 hospital discharges. CDU, persistent vomiting, and aggregate of CDU and persistent vomiting were modeled separately to estimate average incidence rate ratio and 95% confidence interval for each study phase. RESULTS: We observed an increasing trend of CDU or an aggregate of CDU and persistent vomiting during the prelegalization period. The legalization of marijuana significantly increased the incidence rate during the legalization period (by 17.9%) and the yearly average increase in rate by 6% after policy implementation, compared to the prelegalization period. The increase in rate of persistent vomiting after policy implementation increased significantly (by about 8%), although there were no significant trends in increase prior to or during marijuana legalization in 2009. CONCLUSIONS: In an interrupted time series analysis of before, during, and after medical marijuana legalization, we estimated levels and rate changes in CDU and persistent vomiting. We found persistent increases in rates of CDU and persistent vomiting during and after legalization of marijuana.

Association between residual teeth number in later life and incidence of dementia: A systematic review and meta-analysis

BackgroundIt has been suggested that tooth loss in later life might increase dementia incidence. The objective of this analysis is to systematically review the current evidence on the relationship between the number of remaining teeth and dementia occurrence in later life.MethodsA search of multiple databases of scientific literature was conducted with relevant parameters for articles published up to March 25th, 2017. Multiple cohort studies that reported the incidence of dementia and residual teeth in later life were found with observation periods ranging from 2.4 to 32xa0years. Random-effects pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated to examine whether high residual tooth number in later life was associated with a decreased risk of dementia. Heterogeneity was measured by I2. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the overall quality of evidence.ResultsThe literature search initially yielded 419 articles and 11 studies (aged 52 to 75 at study enrollment, nu2009=u200928,894) were finally included for analysis. Compared to the low residual teeth number group, the high residual teeth number group was associated with a decreased risk of dementia by approximately 50% (pooled ORu2009=u20090.483; 95% CI 0.315 to 0.740; pu2009<u20090.001; I2u2009=u200992.421%). The overall quality of evidence, however, was rated as very low.ConclusionDespite limited scientific strength, the current meta-analysis reported that a higher number of residual teeth was associated with having a lower risk of dementia occurrence in later life.

Cancer, depression, and health care coverage in the state of Nevada: A retrospective cross-sectional study.

42 Background: The prevalence of depressive disorders in patients with malignancies is estimated at 20-50%, significantly greater than the general population. Existing literature reports a negative impact of depression on both the patient and their families. There is limited information regarding the impact of healthcare coverage on the prevalence of depression in such patients both in the state of Nevada and nationwide.nnnMETHODSnA retrospective cross-sectional study was performed using the Behavioral Risk Surveillance System (BRFSS) database from 2010 to 2014. All adult subjects with a history of malignancy were included. Demographic factors and health care coverage were reviewed. Individuals with skin cancer as well as those with missing data were excluded. Patients were assigned to two groups based on their insurance coverage status. Study population was further stratified into Nevada and non-Nevada residents and analyzed. Association between depression and health care coverage across the study groups were assessed using Pearson chi-square test and regression models.nnnRESULTSn183,530 subjects nationwide met our inclusion criteria. The Nevada population represented 1% (1676) of the total study sample. In Nevada, the prevalence of cancer patients without healthcare coverage was 7.5% (N = 126) compared to individuals with coverage 92% (N = 1550). This is significantly higher when compared to the national average of 4.9 % without coverage (p = 0.001). Overall, the rate of depression in cancer patients with no healthcare coverage nationally was notably higher compared to those with coverage (37.5% vs 22.7%, p = 0.001). Similarly, statistically higher rates of depression were noted in non-insured Nevada patients compared to those insured [49 (38.8%) vs. 357 (23%), p 0.001)].nnnCONCLUSIONSnThis study demonstrates significant association between depression and lack of insurance coverage; both nationwide as well as in the state of Nevada. The proportion of uninsured Nevada residents with malignancies were higher compared to the national average. Improved and early screening for depression is crucial in mitigating the potential complications and morbidity associated with depression in patients with cancer.

Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals: 2010-2014

Aim: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. Materials and Methods: A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Results: Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and −9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Conclusions: Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.

Ten-year trends of palliative care utilization associated with multiple sclerosis patients in the United States from 2005 to 2014

Multiple sclerosis (MS) is a chronic neuro-inflammatory disease of the central nervous system, associated with accumulation of irreversible neurological disabilities through both inflammatory relapses and progressive neurodegeneration. Patients with debilitating MS could benefit from palliative care perspectives both during relapses that lead to transient disability as well as later in the disease course when significant physical and cognitive disability have accrued. However, no data about palliative care utilization trends of MS patients are available. We examined 10-year temporal trends of palliative care and assessed independent associations of palliative care with hospital utilization and cost using the 2005-2014 national inpatient sample. The national trends of palliative care utilization in MS patients increased by 120 times from 0.2% to 6.1% during 2005-2014, particularly with the dramatic single-year increase between 2010 (1.5%) and 2011 (4.5%). Moreover, the proportion of receiving palliative care in in-hospital death gradually increased from 7.7% in 2005 to 58.8% in 2014. Palliative care in MS inpatients may affect hospital utilization and charges in different ways. Hospital palliative care was associated with increased length of stay (LOS) (βu202f=u202f0.444u202fdays, pu202f<u202f0.001) and in-hospital death (ORu202f=u202f15.35, 95% CI [13.76, 17.12]), but associated with decreased hospital charges (βu202f=u202f-

Societal perspectives analysis for evaluating direct‐acting antiviral affordability while awaiting liver transplant

2261, pu202f<u202f0.001). In conclusion, the temporal trends of palliative care use in MS inpatients gradually increased with an exponential increase between 2010 and 2011 during 2005-2014, which is mostly attributed to patients with higher risk of in-hospital death. Moreover, palliative care was associated with reduced hospital charge with increased LOS and in-hospital death.

Literacy activity and health among older adults in the USA

We read with interest the study by Ahmed et al. identifying the cost-effectiveness of all direct-acting antivirals (DAAs) for patients with hepatitis C virus (HCV) awaiting liver transplant (LT) in the United States. A few things should be considered before applying the findings of Ahmed et al. to clinical practice. There are possible selection biases in the base case scenario, for example, the ASTRAL-4 cohort, which may not reflect the full spectrum of the US population. The ASTRAL-4 study included a predominantly white population (90%) compared to patients on the actual United Network of Organ Sharing waitlist (white 70%) in year 2012. According to Beckman et al., <1% of inmates with HCV were treated with DAAs. This inequality in DAAs for HCV treatment is not limited to the United States and is a common dilemma in other developed countries even under universal health care systems such as those of the United Kingdom and Korea. Kieslich et al. identified the limitations of payers’ perspectives that were applied by Ahmed et al., which might not fully reflect vulnerable populations as stated above. According to the United Network of Organ Sharing database in year 2016, approximately 20% of LT waitlist cases resulted in death or removal from the waitlist. The proportion of DAA users among HCV patients awaiting LT is largely unknown. Uncertainty remains regarding the Trump administration’s actions on DAA coverage for patients with HCV waiting LT. In these contexts, Kieslich et al. suggested that both the patient and the public should be proactively engaged to promote DAA coverage for HCV treatment as an urgent agenda for the media and policymakers. Simultaneously, newer costeffectiveness analyses of DAA coverage should be tested again, ideally by two reference case perspectives—the societal and payers’ perspectives—and should be put forward to identify the most affordable ways to cover DAAs for US patients with HCV awaiting LT.

Social determinants of mortality in U.S. lupus patients

ABSTRACT Health literacy skills are known to be a key mediator of the relationship between education and health in the general population. However, one aspect of health literacy skills—individuals’ actual literacy activities—remains understudied, especially among older adults. Health disparities that are driven by inequalities in education and level of health literacy skills are particularly problematic for older adults since they are exacerbated in old age by disadvantages that accumulate over the life course. This study examined a nationally representative sample of US adults age 50 years and older (n = 2,573) using data from the 2014 Program for International Assessment of Adult Competencies (PIAAC). Parallel mediation analysis was conducted to examine the partial mediation effects of health literacy skills and literacy activity (i.e., reading at home) on the relationship between education and health. Results showed that both health literacy skills and literacy activity mediated the education–health relationship. On average, literacy skills mediated 31.89% and literacy activities mediated 9.59% of the effect of education of self-rated health. Literacy activity, such as reading, is an easily accessible, autonomous, and sustainable option for promoting health in later life. Policies that support the intersection of public health and education may promote lifelong learning and well-being among US adults.

Interrupted Time Series Needed to Analyze Effects of Propoxyphene Withdrawal From Market and Health Outcome Trend Estimates: Comment on the Article by Curtis et al

We read with interest the study by Yelin etxa0al.1 that poverty results in higher mortality in lupus patients by increasing disease damage accumulation. We suggest some alternative mechanisms for the contribution of poverty to higher mortality. First, cardiovascular disease (CVD) is the leading cause of death in lupus patients, and lupus itself is an independent CVD risk factor.2 Risk of CVD-specific death has declined and is projected to continue declining due to better control of risk factors such as hypertension and diabetes.3 Second, according to recent guidelines of American College of Cardiology/American Heart Association (ACC/AHA)4 , health insurance is a key enabling factor promoting CVD risk factor management and in turn reducing the likelihood of life-threatening CV conditions (e.g., acute coronary syndrome). This article is protected by copyright. All rights reserved.