Journal of the American Geriatrics Society, May 1, 2000
Few studies describe the end of life in very old people. To characterize the last 6 months of lif... more Few studies describe the end of life in very old people. To characterize the last 6 months of life and dying in patients 80 years and older by describing demographic characteristics, functional state and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden. A retrospective analysis for patients enrolled in a prospective cohort study. Four teaching hospitals who participated in the Hospitalized Elderly Longitudinal Project (HELP). 417 patients who died within 1 year of their enrollment hospitalization. Chart reviews and interview data with patients and surrogates at several points in time. We constructed four observational time windows backward in time beginning with the patients' death. Before hospitalization, two out of three patients reported fair quality of life, and patients averaged 2.4 impairments in activities of daily living. Seventy percent preferred comfort care on the third day of hospitalization. During the last month of life, three of five patients interviewed in the hospital and four of five interviewed out of the hospital preferred not to be resuscitated. At the time of death, four of five patients had a do not resuscitate (DNR) order and two of five had an order to withhold a ventilator. During the last month of life, one out of four patients reported severe pain. Patients reported increasing functional impairments and limited quality of life. The majority preferred comfort care. The number of patients in severe pain was substantial. Before death, the majority had measures in place to limit aggressive care.
BackgroundWe previously reported reduction in the rate of hospitalisations with medication harm a... more BackgroundWe previously reported reduction in the rate of hospitalisations with medication harm among older adults with our ‘Pharm2Pharm’ intervention, a pharmacist-led care transition and care coordination model focused on best practices in medication management. The objectives of the current study are to determine the extent to which medication harm among older inpatients is ‘community acquired’ versus ‘hospital acquired’ and to assess the effectiveness of the Pharm2Pharm model with each type.MethodsAfter a 3-year baseline, six non-federal general acute care hospitals with 50 or more beds in Hawaii implemented Pharm2Pharm sequentially. The other five such hospitals served as the comparison group. We measured frequencies and quarterly rates of admissions among those aged 65 and older with ‘community-acquired’ (International Classification of Diseases-coded as present on admission) and ‘hospital-acquired’ (coded as not present on admission) medication harm per 1000 admissions from 2...
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 2017
Medicare and other payers have launched initiatives to reduce hospital utilization, especially ta... more Medicare and other payers have launched initiatives to reduce hospital utilization, especially targeting readmissions within 30 days of discharge. Hospital managers have traditionally contended that hospitals would prosper better by ignoring the penalties for high readmission rates and keeping the beds more full. We aimed to test the financial effects of admissions and readmissions by persons with and without specified chronic conditions in one regional hospital. This is a management case study with a descriptive brief report. This study was conducted at Winchester Memorial Hospital, a general hospital in a largely rural area of Virginia, 2010-2015. The total margin per admission varied by diagnosis, with the average patient diagnosed with chronic obstructive pulmonary disease, heart failure, pneumonia, or chronic renal disease having negative margins. The largest per-patient losses were in diagnostic categories coinciding with the highest readmission rates. The margin declined into...
Policymakers have been slow to support family caregivers, and political agendas mostly fail to ad... more Policymakers have been slow to support family caregivers, and political agendas mostly fail to address the cost burdens, impact on employment and productivity, and other challenges in taking on long-term care tasks. This project set out to raise policymakers' awareness of family caregivers through proposals to Republican and Democratic party platforms during the 2016 political season. The Family Caregiver Platform Project (FCPP) reviewed the state party platform submission process for Democratic and Republican parties in all 50 states and the District of Columbia. We built a website to make each process understandable by caregiver advocates. We designed model submissions to help volunteers tailor a proposal and recruited caregiver advocates participating in their state process. Finally, we mobilized a ground operation in many states and followed the progress of submissions in each state, as well as the formation of the national platforms. In 39 states, at least one party, Republ...
ObjectivesTo evaluate the association between a system of medication management services provided... more ObjectivesTo evaluate the association between a system of medication management services provided by specially trained hospital and community pharmacists (Pharm2Pharm) and rates and costs of medication‐related hospitalization in older adults.DesignQuasi‐experimental interrupted time series design comparing intervention and nonintervention hospitals using a mixed‐effects analysis that modeled the intervention as a time‐dependent variable.SettingSequential implementation of Pharm2Pharm at six general nonfederal acute care hospitals in Hawaii with more than 50 beds in 2013 and 2014. All five other such hospitals served as a contemporaneous comparison group.ParticipantsAdult inpatients who met criteria for being at risk for medication problems (N = 2,083), 62% of whom were aged 65 or older.InterventionA state‐wide system of medication management services provided by specially trained hospital and community pharmacists serving high‐risk individuals from hospitalization through transition...
When implantable cardioverter-defibrillators (ICDs) were first in broad use, about 20 years ago,1... more When implantable cardioverter-defibrillators (ICDs) were first in broad use, about 20 years ago,1 they often seemed like a nearmagical way to kick a troublesome heart back into doing its job. Without the serious risks and low yield of external cardiopulmonary resuscitation, a person could be resuscitated without even having lost consciousness. When I gave a talk to the Heart Failure Society of America a dozen years ago, only 1 team in the assembly regularly told patients as part of their initial consent process that they might someday want to turn off their device, and that team was from Canada. Already, those of us serving hospices had our horror stories circulating—of patients whose last days were marked by multiple shocks, of difficulties getting the devices turned off, and of patients whose last hours were spent anguishing over whether turning the ICD off would be suicide. In 2012, the American Heart Association promulgated a set of guidelines that stated that a person getting an ICD should know that they could turn it off and that they might want to do so.2 The statement went on to say, “For a device near its endof-battery life, the generator should not be changed without careful review of whether or not active defibrillation is consistent with overall goals of care and anticipated duration of good-quality survival.”2 No longer did the clinicians sell their device as an unalloyed good. We were coming to terms with the implacable fact of mortality and recognizing that some treatments caused more harm than good, perhaps especially when an ICD converted a peaceful dying into a cacophony of shocks and prolonged suffering. Diaconis, in this issue of JAMA Internal Medicine, tells the unfortunate story of her father who had only 1 evident shock and found it quite disorienting.3 Fortunately, she was able to get the device turned off and his heart had a peaceful course through a period of dementing illness until his natural death. Her claim is that the decision should have been made not to replace the device when the battery failed and that replacing it yielded only suffering—and she is right. Discussing the inevitability of death and the ways to make dying worse through technology is complicated and often difficult4,5; but it is essential to providing good care for persons coming to the end of life. The patient should have known at the time of initial implantation of the ICD that it could be stopped. That fact should have been part of the discussions with him and his family as his cognition began to decline. The failing battery gave an easy stopping point, but it should be easy to stop an ICD at any point. Diaconis justifiably feels wronged by the care system that imposed unnecessary suffering on her father. Helping to support persons who must live with disabilities and illnesses in old age is part of our health care mission; and, as she recounts it, the replacement of the ICD was an error. Reviewing the desirability of an ICD is part of managing a person with one, and knowing how to stop it when that is the better course is also obligatory. We should know the rate of this sort of error and test the strategies that reduce it, perhaps starting with those consent documents. We are doing better over time in recognizing the limits of our technologies. We should monitor progress and performance and, as warranted, celebrate our growing maturity in supporting patients who must deal with death.
Policy Points: At age 65, the average man and woman can respectively expect 1.5 years and 2.5 yea... more Policy Points: At age 65, the average man and woman can respectively expect 1.5 years and 2.5 years of requiring daily help with “activities of daily living.” Available services fail to match frail elders’ needs, thereby routinely generating errors, unreliability, unwanted services, unmet needs, and high costs. The number of elderly Medicare beneficiaries likely to be frail will triple between 2000 and 2050. Low retirement savings, rising medical and long‐term care costs, and declining family caregiver availability portend gaps in badly needed services. The financial simulation reported here for 4 diverse MediCaring Communities shows lower per capita costs. Program savings are substantial and can improve coverage and function of local supportive services within current overall Medicare spending levels. ContextThe Altarum Institute Center for Elder Care and Advanced Illness has developed a reform model, MediCaring Communities, to improve services for frail elderly Medicare beneficiar...
Journal of the American Geriatrics Society, May 1, 2000
Few studies describe the end of life in very old people. To characterize the last 6 months of lif... more Few studies describe the end of life in very old people. To characterize the last 6 months of life and dying in patients 80 years and older by describing demographic characteristics, functional state and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden. A retrospective analysis for patients enrolled in a prospective cohort study. Four teaching hospitals who participated in the Hospitalized Elderly Longitudinal Project (HELP). 417 patients who died within 1 year of their enrollment hospitalization. Chart reviews and interview data with patients and surrogates at several points in time. We constructed four observational time windows backward in time beginning with the patients' death. Before hospitalization, two out of three patients reported fair quality of life, and patients averaged 2.4 impairments in activities of daily living. Seventy percent preferred comfort care on the third day of hospitalization. During the last month of life, three of five patients interviewed in the hospital and four of five interviewed out of the hospital preferred not to be resuscitated. At the time of death, four of five patients had a do not resuscitate (DNR) order and two of five had an order to withhold a ventilator. During the last month of life, one out of four patients reported severe pain. Patients reported increasing functional impairments and limited quality of life. The majority preferred comfort care. The number of patients in severe pain was substantial. Before death, the majority had measures in place to limit aggressive care.
BackgroundWe previously reported reduction in the rate of hospitalisations with medication harm a... more BackgroundWe previously reported reduction in the rate of hospitalisations with medication harm among older adults with our ‘Pharm2Pharm’ intervention, a pharmacist-led care transition and care coordination model focused on best practices in medication management. The objectives of the current study are to determine the extent to which medication harm among older inpatients is ‘community acquired’ versus ‘hospital acquired’ and to assess the effectiveness of the Pharm2Pharm model with each type.MethodsAfter a 3-year baseline, six non-federal general acute care hospitals with 50 or more beds in Hawaii implemented Pharm2Pharm sequentially. The other five such hospitals served as the comparison group. We measured frequencies and quarterly rates of admissions among those aged 65 and older with ‘community-acquired’ (International Classification of Diseases-coded as present on admission) and ‘hospital-acquired’ (coded as not present on admission) medication harm per 1000 admissions from 2...
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 2017
Medicare and other payers have launched initiatives to reduce hospital utilization, especially ta... more Medicare and other payers have launched initiatives to reduce hospital utilization, especially targeting readmissions within 30 days of discharge. Hospital managers have traditionally contended that hospitals would prosper better by ignoring the penalties for high readmission rates and keeping the beds more full. We aimed to test the financial effects of admissions and readmissions by persons with and without specified chronic conditions in one regional hospital. This is a management case study with a descriptive brief report. This study was conducted at Winchester Memorial Hospital, a general hospital in a largely rural area of Virginia, 2010-2015. The total margin per admission varied by diagnosis, with the average patient diagnosed with chronic obstructive pulmonary disease, heart failure, pneumonia, or chronic renal disease having negative margins. The largest per-patient losses were in diagnostic categories coinciding with the highest readmission rates. The margin declined into...
Policymakers have been slow to support family caregivers, and political agendas mostly fail to ad... more Policymakers have been slow to support family caregivers, and political agendas mostly fail to address the cost burdens, impact on employment and productivity, and other challenges in taking on long-term care tasks. This project set out to raise policymakers' awareness of family caregivers through proposals to Republican and Democratic party platforms during the 2016 political season. The Family Caregiver Platform Project (FCPP) reviewed the state party platform submission process for Democratic and Republican parties in all 50 states and the District of Columbia. We built a website to make each process understandable by caregiver advocates. We designed model submissions to help volunteers tailor a proposal and recruited caregiver advocates participating in their state process. Finally, we mobilized a ground operation in many states and followed the progress of submissions in each state, as well as the formation of the national platforms. In 39 states, at least one party, Republ...
ObjectivesTo evaluate the association between a system of medication management services provided... more ObjectivesTo evaluate the association between a system of medication management services provided by specially trained hospital and community pharmacists (Pharm2Pharm) and rates and costs of medication‐related hospitalization in older adults.DesignQuasi‐experimental interrupted time series design comparing intervention and nonintervention hospitals using a mixed‐effects analysis that modeled the intervention as a time‐dependent variable.SettingSequential implementation of Pharm2Pharm at six general nonfederal acute care hospitals in Hawaii with more than 50 beds in 2013 and 2014. All five other such hospitals served as a contemporaneous comparison group.ParticipantsAdult inpatients who met criteria for being at risk for medication problems (N = 2,083), 62% of whom were aged 65 or older.InterventionA state‐wide system of medication management services provided by specially trained hospital and community pharmacists serving high‐risk individuals from hospitalization through transition...
When implantable cardioverter-defibrillators (ICDs) were first in broad use, about 20 years ago,1... more When implantable cardioverter-defibrillators (ICDs) were first in broad use, about 20 years ago,1 they often seemed like a nearmagical way to kick a troublesome heart back into doing its job. Without the serious risks and low yield of external cardiopulmonary resuscitation, a person could be resuscitated without even having lost consciousness. When I gave a talk to the Heart Failure Society of America a dozen years ago, only 1 team in the assembly regularly told patients as part of their initial consent process that they might someday want to turn off their device, and that team was from Canada. Already, those of us serving hospices had our horror stories circulating—of patients whose last days were marked by multiple shocks, of difficulties getting the devices turned off, and of patients whose last hours were spent anguishing over whether turning the ICD off would be suicide. In 2012, the American Heart Association promulgated a set of guidelines that stated that a person getting an ICD should know that they could turn it off and that they might want to do so.2 The statement went on to say, “For a device near its endof-battery life, the generator should not be changed without careful review of whether or not active defibrillation is consistent with overall goals of care and anticipated duration of good-quality survival.”2 No longer did the clinicians sell their device as an unalloyed good. We were coming to terms with the implacable fact of mortality and recognizing that some treatments caused more harm than good, perhaps especially when an ICD converted a peaceful dying into a cacophony of shocks and prolonged suffering. Diaconis, in this issue of JAMA Internal Medicine, tells the unfortunate story of her father who had only 1 evident shock and found it quite disorienting.3 Fortunately, she was able to get the device turned off and his heart had a peaceful course through a period of dementing illness until his natural death. Her claim is that the decision should have been made not to replace the device when the battery failed and that replacing it yielded only suffering—and she is right. Discussing the inevitability of death and the ways to make dying worse through technology is complicated and often difficult4,5; but it is essential to providing good care for persons coming to the end of life. The patient should have known at the time of initial implantation of the ICD that it could be stopped. That fact should have been part of the discussions with him and his family as his cognition began to decline. The failing battery gave an easy stopping point, but it should be easy to stop an ICD at any point. Diaconis justifiably feels wronged by the care system that imposed unnecessary suffering on her father. Helping to support persons who must live with disabilities and illnesses in old age is part of our health care mission; and, as she recounts it, the replacement of the ICD was an error. Reviewing the desirability of an ICD is part of managing a person with one, and knowing how to stop it when that is the better course is also obligatory. We should know the rate of this sort of error and test the strategies that reduce it, perhaps starting with those consent documents. We are doing better over time in recognizing the limits of our technologies. We should monitor progress and performance and, as warranted, celebrate our growing maturity in supporting patients who must deal with death.
Policy Points: At age 65, the average man and woman can respectively expect 1.5 years and 2.5 yea... more Policy Points: At age 65, the average man and woman can respectively expect 1.5 years and 2.5 years of requiring daily help with “activities of daily living.” Available services fail to match frail elders’ needs, thereby routinely generating errors, unreliability, unwanted services, unmet needs, and high costs. The number of elderly Medicare beneficiaries likely to be frail will triple between 2000 and 2050. Low retirement savings, rising medical and long‐term care costs, and declining family caregiver availability portend gaps in badly needed services. The financial simulation reported here for 4 diverse MediCaring Communities shows lower per capita costs. Program savings are substantial and can improve coverage and function of local supportive services within current overall Medicare spending levels. ContextThe Altarum Institute Center for Elder Care and Advanced Illness has developed a reform model, MediCaring Communities, to improve services for frail elderly Medicare beneficiar...
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