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Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. ClinicalTrials.gov NCT02689076. “Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization.” Registered 23 February 2016.

The Rural Interdisciplinary Team Training Program (RITT) is a team-based educational component of the Veterans Health Administration (VHA) Office of Rural Health Geriatric Scholars Program. It is a workforce development program to enhance the geriatrics knowledge and skills of VA primary care clinicians and staff caring for older veterans in rural communities. The RITT workshop, accredited for 6.5 hours, is interactive and multi-modal with didactic mini-lectures, interactive case discussions and role play demonstrations of assessments. Clinic teams also develop and implement a small quality improvement project based on common challenges faced by older persons. This report is an evaluation of the effect of the RITT Program on geriatrics knowledge and team development as well as success in developing and implementing the quality improvement projects in 80 VHA rural outpatient clinics in 38 states.

Palliative care is associated with improved patient and family outcomes and lower cost of care, but studies estimate that50% of hospitalized adults in the United States who are appropriate for palliative care receive it. Few studies have addressed demographic and clinical factors associated with receipt of palliative care.Our aim was to identify characteristics of hospitalized advanced cancer patients that are associated with referral to an interdisciplinary hospital-based palliative care team.The data are from a prospective observational study of hospitalized advanced cancer patients in five hospitals. We used multivariable logistic regression to estimate the relationship between patient characteristics and palliative care referral.The sample includes 3096 patients; 81% received usual care and 19% were referred to palliative care. Advanced cancer patients were twice as likely to receive palliative care referral if, at admission, they needed assistance with transfer from bed (p = 0.002) and about 1.5 times as likely if they were taking medication for pain (p = 0.002), nausea (p = 0.04), or constipation (p = 0.04). Patients with more comorbidities (p = 0.001) and higher symptom burden (p = 0.001) were more likely to be referred.Advanced cancer patients were more likely to be referred to the palliative care consultation team if they had high symptom burden at hospital admission. Overall a minority of advanced cancer patients were referred. Standardized screening for palliative care may be needed to ensure that advanced cancer patients receive the highest quality of evidence based care.

IMPORTANCE: Economics of care for adults with serious illness is a policy priority worldwide. Palliative care may lower costs for hospitalized adults, but the evidence has important limitations. OBJECTIVE: To estimate the association of palliative care consultation (PCC) with direct hospital costs for adults with serious illness. DATA SOURCES: Systematic searches of the Embase, PsycINFO, CENTRAL, PubMed, CINAHL, and EconLit databases were performed for English-language journal articles using keywords in the domains of palliative care (eg, palliative, terminal) and economics (eg, cost, utilization), with limiters for hospital and consultation. For Embase, PsycINFO, and CENTRAL, we searched without a time limitation. For PubMed, CINAHL, and EconLit, we searched for articles published after August 1, 2013. Data analysis was performed from April 8, 2017, to September 16, 2017. STUDY SELECTION: Economic evaluations of interdisciplinary PCC for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders. DATA EXTRACTION AND SYNTHESIS: Eight eligible studies were identified, all cohort studies, of which 6 provided sufficient information for inclusion. The study estimated the association of PCC within 3 days of admission with direct hospital costs for each sample and for subsamples defined by primary diagnoses and number of comorbidities at admission, controlling for confounding with an instrumental variable when available and otherwise propensity score weighting. Treatment effect estimates were pooled in the meta-analysis. MAIN OUTCOMES AND MEASURES: Total direct hospital costs. RESULTS: This study included 6 samples with a total 133 118 patients (range, 1020-82 273), of whom 93.2% were discharged alive (range, 89.0%-98.4%), 40.8% had a primary diagnosis of cancer (range, 15.7%-100.0%), and 3.6% received a PCC (range, 2.2%-22.3%). Mean Elixhauser index scores ranged from 2.2 to 3.5 among the studies. When patients were pooled irrespective of diagnosis, there was a statistically significant reduction in costs (−$3237; 95% CI, −$3581 to −$2893; P

BACKGROUND Inpatient hospital stays account for more than a third of direct medical cancer care costs. Evidence on factors driving these costs can inform planning of services, as well as consideration of equity in access. OBJECTIVE To measure the association between hospital costs, and demographic, clinical, and system factors, for a cohort of adults with advanced cancer. DESIGN Prospective multisite cohort study. SETTING Four medical and cancer centers. PATIENTS Adults with advanced cancer admitted to a participating hospital between 2007 and 2011, excluding those with dementia. Final analytic sample included 1020 patients. METHODS With receipt of palliative care controlled for, the associations between hospital cost and patient factors were estimated. Factors covered the domains of demographics (age, sex, race), socioeconomics and systems (education, insurance, living will, proxy), clinical care (diagnoses, complications deemed to pose a threat to life or bodily functions, comorbidities, symptom burden, activities of daily living), and prior healthcare utilization (home help, analgesic prescribing). OUTCOME MEASURE Direct hospital costs. RESULTS A major (markedly abnormal) complication (+$8267; P < 0.01), a minor but not a major complication (+$5289; P < 0.01), and number of comorbidities (+$852; P < 0.01) were associated with higher cost, and admitting diagnosis of electrolyte disorders (-$4759; P = 0.01) and increased age (-$53; P = 0.03) were associated with lower cost. CONCLUSIONS Complications and comorbidity burden drive inhospital utilization for adults with advanced cancer. There is little evidence of sociodemographic associations and no apparent impact of advance directives. Attempts to control growth of hospital cancer costs require consideration of how the most resource-intensive patients are identified promptly and prioritized for cost-effective care. Journal of Hospital Medicine 2017;12:407-413.

Psychosocial distress among patients with limited life expectancy influences treatment decisions, treatment adherence, and physical health. Veterans may be at elevated risk of psychosocial distress at the end of life, and understanding their mental healthcare needs may help identify hospitalized patients to whom psychiatric services should be targeted.To examine mental illness prevalence and mental health treatment rates among a national sample of hospitalized veterans with serious physical illnesses. Design, Subjects, and Measurements: This was a retrospective study of 11,286 veterans hospitalized in a Veterans Health Administration acute care facility in fiscal year 2011 with diagnoses of advanced cancer, congestive heart failure, chronic obstructive pulmonary disease, and/or advanced HIV/AIDS. Prevalent and incident mental illness diagnoses during and before hospitalization and rates of psychotherapy and psychotropic use among patients with incident depression and anxiety were measured.At least one-quarter of the patients in our sample had a mental illness or substance use disorder. The most common diagnoses at hospitalization were depression (11.4%), followed by alcohol abuse or dependence (5.5%), and post-traumatic stress disorder (4.9%). Of the 831 patients with incident past-year depression and 258 with incident past-year anxiety, nearly two-thirds received at least some psychotherapy or guideline-concordant medication within 90 days of diagnosis. Of 191 patients with incident depression and 47 with incident anxiety at time of hospitalization, fewer than half received mental healthcare before discharge.Many veterans hospitalized with serious physical illnesses have comorbid mental illnesses and may benefit from depression and anxiety treatment.

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.Prospective, multisite, observational study of performance of key intensive care unit palliative care processes.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.Consecutive adult patients with length of intensive care unit stay ≥5 days.None.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 for20% 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.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.

Critical care nurse communication training has largely been limited to didactic materials, interactive training for nurse supervisors, or brief participatory learning programs within the context of comprehensive end-of-life care educational seminars. Preliminary evidence suggests that an interactive approach can also be effective in communication skills training for intensive care unit (ICU) nurses.We implemented a 1-day educational intervention in five acute care hospitals within Veterans Integrated Service Network (VISN) 3 (New York-New Jersey region) of the Department of Veterans Affairs and focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients. A "learner centered" approach to skills training that has several integral components was employed. AMONG THESE ARE: a cognitive, evidence-based foundation upon which to build new skills; a method such as role-play that allows participants to practice newly learned skills; and an affective component, during which trainees can freely discuss their impressions of the exercise or explore difficulties that may have been encountered. Before and after the program we conducted a detailed assessment of participants' self-rated communication skills and of the techniques and materials we used.Post-program responses documented significant improvement in self-evaluated skills for each of the core tasks we assessed. Evidence suggests that communication with patients and families in the ICU can be most effectively approached in an interdisciplinary way. For nurses to fully realize their potential for optimal communication as members of the multidisciplinary team, they must be equipped with the necessary skills. We believe this new program helps to expand the range of approaches for training nurses in essential communication skills.

Background Intensive care unit (ICU) care could be improved by implementation of time-triggered evidence-based interventions including identification of a patient/family medical decision maker, the patient's advance directive status, and cardiopulmonary resuscitation preferences by Day 1; offer of social work and spiritual support by Day 3; and a family meeting establishing goals of care by Day 5. We implemented a program to improve care for ICU patients in five Department of Veterans Affairs' ICUs. Measures We measured the percent of ICU patients with lengths of stay of five or more days that received the care processes by the appropriate day. Intervention Critical care and palliative care providers trained ICU nurse teams to improve care through auditing, performance feedback, improvement tools, education, and monthly team meetings. Outcomes Pre- and postintervention care were compared. Offering social work and spiritual support, identification of the medical decision maker, and documentation of family meetings significantly improved. Conclusions/Lessons Learned ICU nurse teams can be engaged to improve care under the aegis of a collaborative quality improvement project.

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.

Most palliative care researchers want to demonstrate the effect of a treatment or intervention X on outcome Y. For example, we want to say that patients treated by the hospital-based palliative care team will have fewer intensive care unit (ICU) admissions than those not treated by the team (usual care patients). Randomized controlled trials (RCT) are the strongest design for making causal inferences about the effect of treatment X on outcome Y. Random assignment of patients to the treatment or control groups ensures there are no systematic differences between the groups in characteristics, observed and unobserved, that may affect outcome. Consequently differences between the groups on the outcome of interest can be attributed to the treatment. RCTs of palliative care treatments and interventions are difficult but not impossible to do. The difficulties arise from several sources, including enrollment bias, protocol adherence, and problems with external validity.1–3 Some physicians believe that palliative care is superior to usual care. Consequently, they believe it's unethical to encourage their patients to be in randomized trials of palliative care interventions.4 At the same, there are physicians who do not believe palliative care will benefit their patients and so, do not want them enrolled in a palliative care study. In addition, it may be unethical for researchers to take part in an RCT of palliative care. If palliative care was an additional service and researchers did not know if it provided benefit or harm then randomization might be an option. However, for palliative care researchers who believe the specialized care is beneficial, an RCT becomes an ethical issue. Adherence to the protocol can be challenging in an RCT of palliative care. Once patients are enrolled in an RCT, the crossover between treatment and usual care can be considerable.4 Physicians who gain direct or indirect positive experience with palliative care at the study hospital are likely to request palliative care consultation for their patients randomized to usual care. Similarly, family members and patients themselves may also request palliative care consultation. If these patients received palliative care as crossovers, “intent to treat,” or “as treated” analysis would produce biased estimates of the treatment effect.3,5 Finally, most RCTs sacrifice wide external validity for strong internal validity.6 That is to say, the trials are methodologically rigorous, but the results may not generalize to other more clinically relevant populations. For some program and policy research in palliative care, this trade-off may be inappropriate. For these reasons, many questions about the effects of palliative care on such outcomes as pain and other symptom management, family satisfaction with care, use of ICU care and costs will have to be answered using observational data. The analyses will have to use sophisticated methods that many of us in clinical research and practice may be less familiar with compared to the RCT. In this article we first explain what instrument variable estimation is and we show its use in a classic study of treatment of acute myocardial infarction (AMI).7 We then discuss how instrumental variable estimation is used in a recent study from geriatrics literature. Finally, we suggest possible instrumental variables for a recent palliative care study. Readers will find a thorough and modern introduction to instrumental variables models and their applications in Stock and Watson.8

BACKGROUND: Few studies of hip fracture have large enough samples of men, minorities, and persons with specific comorbidities to examine differences in their mortality and functional outcomes. To address this problem, we combined three cohorts of hip fracture patients to produce a sample of 2692 patients followed for 6 months. METHOD: Data on mortality, mobility, and other activities of daily living (ADLs) were available from all three cohorts. We used multiple regression to examine the association of race, gender, and comorbidity with 6-month survival and function, controlling for prefracture mobility and ADLs, age, fracture type, cohort, and admission year. RESULTS: The mortality rate at 6 months was 12%: 9% for women and 19% for men. Whites and women were more likely than were nonwhites and men to survive to 6 months, after adjusting for age, comorbidities, and prefracture mobility and function. Whites were more likely than were nonwhites to walk independently or with help at 6 months compared to not walking, after adjusting for age, comorbidities, and prefracture mobility and function. Dementia had a negative impact on survival, mobility, and ADLs at 6 months. The odds of survival to 6 months were significantly lower for people with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and/or cancer. Parkinson's disease and stroke had negative impacts on mobility and ADLs, respectively, among survivors at 6 months. CONCLUSIONS: The finding of higher mortality and worse mobility for nonwhite patients with hip fractures highlights the need for more research on race/ethnicity disparities in hip fracture care. Language: en

Background: Use of more than one health care system to obtain care is common among adults receiving care within the Veterans Affairs (VA) medical system. It is not known what effect using care from multiple sources has on the quality of care patients receive. Objectives: To examine whether use of recommended ambulatory care services differs between exclusive and dual VA users. Methods: Cross-sectional analysis of the 2004 Behavior Risk Factor Surveillance System, a nationally-representative survey of community-dwelling adults aged 18 years or older. Our outcome measures were self-reported use of 18 recommended services for cancer prevention, cardiovascular risk reduction, diabetes management, and infectious disease prevention. We used multivariable logistic regression to examine the association between exclusive and dual VA use and use of recommended ambulatory services. Results: There were 3470 exclusive VA users and 4523 dual VA users. Dual users were significantly more likely to be older and white, have higher incomes, have graduated from college, and be insured when compared with exclusive VA users. In unadjusted analyses, dual users received higher rates of recommended services. After adjustment for patient characteristics, use of recommended services was largely similar among exclusive and dual VA users. Exclusive VA users reported 14% greater use of breast cancer screening and 10% greater use of cholesterol monitoring among patients with hypercholesterolemia, and 6% lower use of prostate cancer screening and 7% lower use of influenza vaccination. Conclusions: After adjustment for patient characteristics, exclusive and dual VA users reported similar rates of recommended ambulatory service use.

Beta-blockers reduce mortality in patients with systolic chronic heart failure (CHF), yet prescription rates have remained low among primary care providers.To determine the beta-blocker prescription rate among patients with systolic CHF at primary care Veterans Affairs (VA) clinics, its change over time; and to determine factors associated with nonprescription.Retrospective chart review.Seven hundred and forty-five patients with diagnostic codes for CHF followed in primary care clinics at 3 urban VA Medical Centers.Rate of beta-blocker prescription and comparison of patient characteristics between those prescribed versus those not prescribed beta-blockers.Only 368 (49%) had documented systolic CHF. Eighty-two percent (303/368) of these patients were prescribed a beta-blocker. The prescription rate rose steadily over 3 consecutive 2-year time periods. Patients with more severely depressed ejection fractions were more likely to be on a beta-blocker than patients with less severe disease. Independent predictors of nonprescription included chronic obstructive pulmonary disease, asthma, depression, and age. Patients under 65 years old were 12 times more likely to receive beta-blockers than those over 85.Primary care providers at VA Medical Centers achieved high rates of beta-blocker prescription for CHF patients. Subgroups with relative contraindications had lower prescription rates and should be targeted for quality improvement initiatives.

We sought to examine the relationship between functional outcome and process of care for patients with hip fracture.We undertook a prospective cohort study in 4 hospitals of 554 patients treated with surgery for hip fracture.Information on patient characteristics and processes of hospital care collected from the medical record, interviews, and bedside observations. Follow-up information obtained at 6 months on function (using the Functional Independence Measure [FIM]), survival, and readmission.Individual processes of care were generally not associated with adjusted outcomes. A scale of 9 processes related to mobilization was associated with improved adjusted locomotion (P = 0.006), self care (P = 0.022), and transferring (P = 0.007) at 2 months, but the benefits were smaller and not significant by 6 months. These processes were not associated with mortality. The predicted value for the FIM locomotion measure (range, 2-14) at 2 months was 5.9 (95% confidence interval 5.4-6.4) for patients at the 10th percentile of performance on these processes compared with 7.1 (95% confidence interval 6.6, 7.6) at the 90th percentile. Patients who experienced no hospital complications and no readmissions retained the benefits in locomotion at 6 months. Anticoagulation processes were associated with improved transferring at 2 months (P = 0.046) but anticoagulation and other processes of care were not otherwise associated with improved function.Our findings indicate the need to attend to all steps in the care of patients with hip fracture. Additionally, functional outcomes were more sensitive markers of improved process of care, compared with 6-month mortality, in the case of hip fracture.

To compare per diem total direct, ancillary (laboratory and radiology) and pharmacy costs of palliative care (PC) compared to usual care (UC) patients during a terminal hospitalization; to examine the association between PC and ICU admission.Retrospective, observational cost analysis using a VA (payer) perspective.Two urban VA medical centers.Demographic and health characteristics of 314 veterans admitted during two years were obtained from VA administrative data. Hospital costs came from the VA cost accounting system.Generalized linear models (GLM) were estimated for total direct, ancillary and pharmacy costs. Predictors included patient age, principal diagnosis, comorbidity, whether patient stay was medical or surgical, site and whether the patient was seen by the palliative care consultation team. A probit regression was used to analyze probability of ICU admission. Propensity score matching was used to improve balance in observed covariates.PC patients were 42 percentage points (95% CI, -56% [corrected] to -31%) less likely to be admitted to ICU. Total direct costs per day were $239 (95% CI, -387 to -122) lower and ancillary costs were $98 (95% CI, -133 to -57) lower than costs for UC patients. There was no difference in pharmacy costs. The results were similar using propensity score matching.PC was associated with significantly lower likelihood of ICU use and lower inpatient costs compared to UC. Our findings coupled with those indicating better patient and family outcomes with PC suggest both a cost and quality incentive for hospitals to develop PC programs.

THE SPECIALTY OF PALLIATIVE CARE has experienced substantial growth and development over the past 10 years. Strong clinical palliative care programs are now firmly established in multiple settings and venues, education in palliative care has seen strong advances with increasing penetration of palliative care content in medical school and residency curricula and continuing medical and nursing education programs, a rigorous certifying board examination for physicians has been developed, and there has been steady growth in the number of physicians who are certified in palliative medicine. Whereas we can point to these many successes in palliative care, palliative care research remains relatively underdeveloped. The evidence base for much of what we do in clinical practice remains sparse compared to more established medical specialties and important research questions in palliative care have yet to be adequately addressed or answered. Dr. Storey’s poignant account of his difficulties in conducting high-quality rigorous research in palliative care—particularly his difficulty in conducting randomized controlled trials—is emblematic of the problems facing palliative care researchers. If we are to conduct high-quality research in palliative care (and indeed we must if the field is to advance), then our efforts must be focused equally on answering the important clinical questions of interest (the what) and on using the appropriate research instruments, designs, and analytic techniques (the how). In this article, we identify key challenges in each of these three research areas and discuss approaches to overcoming them.

Purpose The 2014 American Geriatrics Society's Choosing Wisely list cautions against the use of any benzodiazepines or other sedative-hypnotics (BSHs) as initial treatments for agitation, insomnia, or delirium in older adults. Because these symptoms are prevalent among hospitalized patients, seriously ill older adults are at risk of receiving these potentially inappropriate medications. The objectives of this study were to understand the extent to which potentially inappropriate BSHs are being used in hospitalized, seriously ill, older veterans and to understand what clinical and sociodemographic characteristics are associated with potentially inappropriate BSH use. Methods We reviewed medical records of 222 veterans aged ≥65 years who were hospitalized in an acute care facility in the New York–New Jersey metropolitan region in fiscal years 2009 and 2010. Veterans had diagnoses of advanced cancer, chronic obstructive pulmonary disease, congestive heart failure, and/or HIV/AIDS and received inpatient palliative care. Associations among potentially inappropriate BSH use (BSHs for indications other than alcohol withdrawal and current generalized anxiety disorder or one-time use before a medical procedure) and clinical and sociodemographic characteristics were examined with multivariable logistic regression. Findings One-fifth of the sample was prescribed a potentially inappropriate BSH during the index hospitalization during the study period (n = 47). The most commonly prescribed potentially inappropriate medications were zolpidem (n = 26 [11.7%]) and lorazepam (n = 19 [8.9%]). Hispanic ethnicity was significantly associated with prescription of potentially inappropriate BSHs among the entire sample (adjusted odds ratio [AOR] = 3.79; 95% CI, 1.32–10.88) and among patients who survived until discharge (n = 164; AOR=5.28; 95% CI, 1.64–17.07). Among patients who survived until discharge, black patients were less likely to be prescribed potentially inappropriate BSHs than white patients (AOR = 0.35; 95% CI, 0.13–0.997), and patients who had past-year BSH prescriptions were more likely to be prescribed a potentially inappropriate BSH than patients without past-year BSH use. Implications The potentially inappropriate BSHs documented in our sample included short- and intermediate-acting benzodiazepines, medications that were not identified as potentially inappropriate for older adults until after these data were collected. Few long-acting benzodiazepines were recorded, suggesting that the older veterans in our sample were receiving medications according to the guidelines in place at the time of hospitalization. Clinicians may be able to reduce prescriptions of newly identified inappropriate BSHs by being aware of medications patients received before hospitalization and by being cognizant of racial/ethnic disparities in symptom management. Future studies should explore reasons for disparities in BSH prescriptions.

Objective To determine whether inpatient palliative care teams' assessments of psychological distress affect receipt of in-hospital mental health care (psychotherapy, psychological support, and health and behavior interventions) for seriously ill veterans. Methods Retrospective review of medical records from 287 seriously ill veterans who received inpatient palliative care consults between 2008 and 2010 in the NY/NJ Veterans Healthcare Network. Results Of the veterans who were cognitively or physically able to answer questions on the Condensed Memorial Symptom Assessment Scale, 44% reported psychological distress. Of those with distress, 38% accessed mental health care. In logistic regression models adjusted for sociodemographic and health characteristics, there was no evidence that psychological distress reported during the palliative care consult was associated with subsequent mental health care receipt from any type of provider. Conclusions Efforts to increase mental health care to psychologically distressed palliative care patients need to convert assessments into receipt of needed care.

The informal care networks of 242 impaired older people were examined in terms of the primary caregiver and secondary helpers. Most primary caregivers had at least one secondary helper; 88% identified helpers who provided hands-on help, 19% reported that helpers contributed financially, and 44% had helpers involved in care decisions. The size of the network was larger for direct care compared to financial or decision-making assistance. Almost half of primary caregivers reported that their spouse helped. It was expected that after controlling for characteristics of the primary caregiver and of the older person, that characteristics of the secondary caregiver network would influence the amount and type of primary caregiver assistance and formal care used by the older person. However, both hours and type of care by the primary caregiver were independent of size, scope, and composition of the secondary helper network. This independence suggests that efforts to alter the secondary caregiver network may have limited effects on the primary caregiver.

Objective To compare methods of analyzing endogenous treatment effect models for nonlinear outcomes and illustrate the impact of model specification on estimates of treatment effects such as health care costs. Data Sources Secondary data on cost and utilization for inpatients hospitalized in five Veterans Affairs acute care facilities in 2005–2006. Study Design We compare results from analyses with full information maximum simulated likelihood (FIMSL); control function (CF) approaches employing different types and functional forms for the residuals, including the special case of two-stage residual inclusion; and two-stage least squares (2SLS). As an example, we examine the effect of an inpatient palliative care (PC) consultation on direct costs of care per day. Data Collection/Extraction Methods We analyzed data for 3,389 inpatients with one or more life-limiting diseases. Principal Findings The distribution of average treatment effects on the treated and local average treatment effects of a PC consultation depended on model specification. CF and FIMSL estimates were more similar to each other than to 2SLS estimates. CF estimates were sensitive to choice and functional form of residual. Conclusions When modeling cost or other nonlinear data with endogeneity, one should be aware of the impact of model specification and treatment effect choice on results.

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.To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease.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.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.The average daily total direct hospital costs were $464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care (p0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients (p0.001).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.

Although the majority of hospital deaths occur in the intensive care unit and virtually all critically ill patients and their families have palliative needs, we know little about how patients and families, the most important "stakeholders," define high-quality intensive care unit palliative care. We conducted this study to obtain their views on important domains of this care.Qualitative study using focus groups facilitated by a single physician.A 20-bed general intensive care unit in a 382-bed community hospital in Oklahoma; 24-bed medical-surgical intensive care unit in a 377-bed tertiary, university hospital in urban California; and eight-bed medical intensive care unit in a 311-bed Veterans' Affairs hospital in a northeastern city.Randomly-selected patients with intensive care unit length of stay=5 days in 2007 to 2008 who survived the intensive care unit, families of survivors, and families of patients who died in the intensive care unit.None.Focus group facilitator used open-ended questions and scripted probes from a written guide. Three investigators independently coded meeting transcripts, achieving consensus on themes. From 48 subjects (15 patients, 33 family members) in nine focus groups across three sites, a shared definition of high-quality intensive care unit palliative care emerged: timely, clear, and compassionate communication by clinicians; clinical decision-making focused on patients' preferences, goals, and values; patient care maintaining comfort, dignity, and personhood; and family care with open access and proximity to patients, interdisciplinary support in the intensive care unit, and bereavement care for families of patients who died. Participants also endorsed specific processes to operationalize the care they considered important.Efforts to improve intensive care unit palliative care quality should focus on domains and processes that are most valued by critically ill patients and their families, among whom we found broad agreement in a diverse sample. Measures of quality and effective interventions exist to improve care in domains that are important to intensive care unit patients and families.

Purpose of review To summarize recent research findings about the use and effects of integrated care pathways for end-of-life care. Recent findings Integrated care pathways designed for patients at the end of life include the Liverpool Care Pathway, used widely in the UK, and Palliative Care for Advanced Disease, developed in the USA. There is general consensus in the current literature that integrated care pathways improve standardization, continuity and collaboration among the interdisciplinary team. Although recent studies on integrated care pathways for dying patients have been predominantly descriptive, previous studies demonstrate improved symptom assessment, documentation of care goals, compliance with standardized guidelines and pain control. Summary The use of integrated care pathways for dying patients has the potential to improve care by promoting best practice and standardizing care. In addition, these pathways may improve documentation and provide a mechanism for measuring patient outcomes. Although recent studies on the use of these integrated care pathways are descriptive, some publications have demonstrated improved patient outcomes and processes of care. As their use expands, more studies on the effects and outcomes of these care pathways are anticipated.

Objectives. We compared use of preventive care among veterans receiving care through the Veterans Health Administration (VHA), Medicare fee-for-service (FFS) plans, and Medicare health maintenance organizations (HMOs). Methods. Using both the Costs and Use, and Access to Care files of the Medicare Current Beneficiary Survey (2000–2003), we performed a cross-sectional analysis examining self-reported use of influenza vaccination, pneumococcal vaccination, serum cholesterol screening, and serum prostate-specific antigen measurement among male veterans 65 years or older. Veterans’ care was categorized as received through VHA, Medicare FFS, Medicare HMOs, VHA and Medicare FFS, or VHA and Medicare HMOs. Results. Veterans receiving care through VHA reported 10% greater use of influenza vaccination (P Conclusions. Receiving care through VHA was associated with greater use of preventive care.

To report on implementation of a Veterans Affairs (VA) network-wide, standardized, high-quality palliative care (PC) program using a Web-based PC Report Card for performance monitoring and improvement.The PC director and coordinator and facility directors established interdisciplinary teams at five acute care and three nursing home sites. Teams were trained together and subsequently met quarterly for ongoing training. Additionally, the PC director and coordinator developed and implemented a Web-based PC Report Card on the network Intranet for PC coordinator to report performance data monthly to the PC teams.The number of patients in the network who received PC consults more than doubled in the first 4 years of the PC program. The percentage of deaths with PC consultation prior to death increased from 23% in fiscal year (FY) 2002 to 57% in FY06. Over the same period, the average days between the initial PC consultation and patients' death across all sites increased from 23 days to 106 days.All the sites established PC teams and the number of consultations showed a sustained increase over baseline in 2002. All sites improved on the key process measures captured by the Report Card.

To examine unidentified heterogeneity in hip fracture patients that may predict variation in functional outcomes.Observational, longitudinal, multisite cohort study.Three separate cohorts from five hospitals in the metropolitan New York area and eight hospitals in Baltimore.Two thousand six hundred ninety-two hip fracture patients treated at one of 13 hospitals and followed for 6 months postfracture.A mobility measure with three categories (independent (walks independently or with a device), limited independence (needs human assistance or supervision to walk 150 feet or one block or able only to walk indoors), and unable to walk) was developed for use with all three cohorts. A similar measure was developed for the other activities of daily living (ADLs): bathing, dressing, feeding, and using the toilet. Cluster analysis was used to form homogenous groups of patients based on baseline demographic characteristics, comorbid conditions, and baseline mobility and ADL independence.Seven homogeneous subgroups were identified based on prefracture age, health, and functional status, with measurably different 6-month functional outcomes. At least 90% of patients could be correctly classified into the seven groups using simple decision rules about age, ADLs, and dementia status at baseline. Dementia was the only comorbid condition that segmented the groups.The heterogeneous hip fracture population can be grouped into homogenous patient clusters based on prefracture characteristics. Differentially targeting services and interventions to these subgroups may improve functional status outcomes.

Hospital-based interdisciplinary palliative care teams (PCTs) are increasingly being established to meet the growing demand for high quality care for patients with life-limiting illnesses in which the goal is comfort rather than cure. Two recent studies suggest that PCTs teams are highly effective in influencing care of patients within large academic medical centers. The current study examines whether the previously demonstrated success of palliative care teams within subspecialty academic health centers could be replicated in an urban Veterans Affairs medical center (VAMC).To describe the characteristics of patients referred to, recommendations made by, and implementation rate of an interdisciplinary PCT in an urban VAMC.Retrospective, observational study.One hundred patients referred by inpatient doctor to the PCT between October 1999 and March 2002 in a 214-bed VA hospital in the New York City area.Patient demographics, prevalence of five types of recommendations by the PCT and implementation rate by primary physician: (1) advance directives; (2) discharge planning; (3) pain management; (4) symptom management of dyspnea, delirium, constipation, nausea, anxiety, and depression; and (5) consultation orders for other services.The average number of recommendations per patient was 2.84 and 84.2% were implemented. The most frequent recommendations concerned discharge plans. The reasons recommendations were not implemented included: (1) patient or family refusal noted in the medical record, (2) the patient's clinical status changed, including patient death, and (3) the attending physician chose a different dose, medication, or route of administration than was recommended.Overall, most recommendations were implemented by the referring physicians. This finding is consistent with several prior studies demonstrating that PCTs in acute care can and do influence processes of care for hospitalized patients. Well-designed observational studies and randomized controlled trials of specific palliative care interventions and their effect on patient, family, and health care system outcomes are needed.

Anemia is common in the elderly and has been associated with increased mortality.1–3 Among patients with chronic disease or malignancy, hemoglobin levels are often robust predictors of long term survival.4–7 The degree of anemia among patients admitted to the hospital for medical and surgical conditions is associated with higher short term mortality in many,8–12 though not all, studies.13–15 The relationship between hemoglobin levels and surgical outcomes is likely to be complex, and understanding it requires an ability to dissect out several interrelated issues. First, fluctuations in hemoglobin levels during a surgical patient’s hospital course are common, so it is important to distinguish measurements on admission from subsequent ones both before and after surgery.8,9,12–17 Anemia at different points during the hospital course may also reflect different problems with varying implications. Anemia on admission may carry a poor prognosis because it is a physiologic indicator of underlying comorbid illness burden, illness severity (anemia of chronic disease), or prehospital bleeding. For this reason, proper adjustment for comorbidities and severity of illness on admission is imperative. In addition, many elderly patients may be dehydrated on admission, and the initial fluid hydration may decrease hemoglobin levels.18 Many surgical patients who are admitted for urgent or emergent conditions also can have bleeding and fluid shifts before their operation. Drops in hemoglobin levels during surgery can be caused by bleeding and hemodilution from intravenous fluids or fluid shifts.18–20 Finally, inpatients may lose blood through repeated phlebotomy (“hospital-acquired anemia”), though this may be largely a problem of patients requiring intensive care or repeated surgery.21,22 Second, blood transfusions are common among surgical patients and need to be accounted for in studies of anemia.8,9,12–14,16 Indeed, most of the research in this area has predominantly focused on the impact of the blood transfusion itself on outcomes. Unfortunately, the literature examining the impact of transfusion on mortality is quite conflicted.23,24 The majority of studies have reported no effect of transfusion on mortality.13,16,25–34 However, several investigators have reported that transfusion was associated with lower risk of death,10,11 whereas others found it increased death rates.12,35,36 Finally, there has been little investigation of the impact of anemia on nonmortal outcomes.12,14 We sought to characterize variations in hemoglobin levels during the course of hospitalization and examine the prognostic significance of hemoglobin levels measured at different time points during hospitalization using data from a prospective cohort study of patients undergoing surgery for hip fracture in 4 hospitals. The aims of this study were to: 1) describe the epidemiology of anemia during hospitalization; 2) assess the relationship between hemoglobin measurements and clinical and functional outcomes; and 3) determine whether hemoglobin measurements add independent prognostic information after adjusting for risk factors known to influence hip fracture outcomes.

To examine the relationship between early physical therapy (PT), later therapy, and mobility 2 and 6 months after hip fracture.Prospective, multisite observational study.Four hospitals in the New York City area.Four hundred forty-three hospitalized older patients discharged after surgery for hip fracture in 1997-98.Patient demographics, fracture type, comorbidities, dementia, number of new impairments at discharge, amount of PT between day of surgery and postoperative day (POD) 3, amount of therapy between POD4 and 8 weeks later, and prefracture, 2-, and 6-month mobility measured using the Functional Independence Measure.More PT immediately after hip fracture surgery was associated with significantly better locomotion 2 months later. Each additional session from the day of surgery through POD3 was associated with an increase of 0.4 points (P=.032) on the 14-point locomotion scale, but the positive relationship between early PT and mobility was attenuated by 6 months postfracture. There was no association between later therapy and 2- or 6-month mobility.PT immediately after hip fracture surgery is beneficial. The effects of later therapy on mobility were difficult to assess because of limitations of the data. Well-designed randomized, controlled trials of the effect of varying schedules and amounts of therapy on functional status after hip fracture would be informative.

OBJECTIVES: To examine the causes of hospital readmission after hip fracture and the relationships between hospital readmission and 6-month physical function and mortality. DESIGN: Prospective, multisite, observational cohort study. SETTING: Four hospitals in the New York City metropolitan area. PARTICIPANTS: Five hundred sixty-two patients hospitalized for hip fracture aged 50 and older and discharged alive in 1997–1998. MEASUREMENTS: Patient demographic characteristics, type of fracture and repair, comorbid conditions, postoperative complications, do not resuscitate status, and active clinical problems at the time of hospital discharge. Prefracture and 6-month mobility were measured using the Functional Independence Measure. Hospital readmissions and International Classification of Diseases, Ninth Revision principal diagnoses were ascertained from hospital admission/discharge databases, the New York Statewide Planning and Research Cooperative System, medical record review, and patient self-report. RESULTS: Eighty-two percent of participants were women, and 93% were white. Within 6 months after hospital discharge, 178 (32%) patients were readmitted to the hospital, with 45 (8%) readmitted more than once. Forty-seven of 233 readmissions (20%) occurred within the first 2 weeks after discharge, and 80 (34%) occurred within 4 weeks. Over 6 months, 89% of readmissions were for nonsurgical problems, of which infectious (21%) and cardiac (12%) diseases were the most common. In multivariate analyses, patients who were readmitted were more likely to require total assistance with ambulation at 6 months (odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6–4.6) and to die (OR = 4.0, 95% CI = 2.2–7.3) than those not readmitted. CONCLUSION: Hospital readmissions after hip fracture are largely due to nonsurgical illness and are associated with increased morbidity and mortality.

To estimate the impact of the Balanced Budget Act of 1997 (BBA), which changed the way Medicare reimbursed for home health services, on a range of home health utilization measures, and to examine whether particular subgroups of beneficiaries were differentially impacted in the post-BBA period.Secondary data from the Centers for Medicare and Medicaid Services (CMS) Standard Analytic Files for the 1 percent sample of Medicare beneficiaries for fiscal years 1997 and 1999, linked with information from CMS eligibility, provider, and cost report files as well as the Area Resources File.Logistic regression was used to estimate the effects of being in the post-BBA period on the incidence of home health service use and ordinary least squares (OLS) regression was used to estimate the effects of being in the post-BBA period on the amount and type of use by home health service users. Interaction terms we reincluded for all the independent variables to assess whether the effect was disproportionate among particular beneficiary subgroups.Results show a 22 percent decrease in the percentage using home health services post-BBA and a 39 percent decrease in the number of visits per user. Stronger reductions, though not very large, were found in the incidence of use for beneficiaries aged 85 and older, those in states with high historical Medicare home health use, and those with Medicaid buy-in. More intensive reductions in the number of services were found for those aged 85 and older, in high historical Medicare use states, nonwhites, females, those using for-profit agencies, and those treated for certain diagnoses. Less intensive reductions were associated with hospital-based agencies.This research demonstrates that public program expenditures can be sharply curtailed with financial incentives. As reimbursement shifts to a prospective payment system legislated by the BBA, utilization should be closely monitored, especially for vulnerable subgroups.

This study's objective was to examine the relationships between rural residence and availability of nursing home and home health care to functional disability at the time of nursing home admission. Secondary data were obtained from the Minimum Data Set (MDS) 2.0 for Nebraska for 3,443 rural and 1,296 urban older people admitted to nursing facilities. Data from the MDS were merged with county-level data on home health agencies and nursing homes in Nebraska. The relationship of rurality of nursing home residents' prior residence and availability of nursing home and home health care to functional status at admission, controlling for demographic and health characteristics of older people, was estimated using multiple linear regression with robust variance estimates. After taking account of demographic and health status characteristics, rural residence and availability of home health and nursing home care had nonsignificant effects on functional status at admission. The findings indicate that functional disability at admission is associated with specific diseases and medical conditions, cognitive status, gender, living arrangements and marital arrangements. Rural older people are not at higher risk of admission at lower levels of functional disability compared to their urban counterparts.

Hospital palliative care consultation teams have been shown to improve care for adults with serious illness. This study examined the effect of palliative care teams on hospital costs.We analyzed administrative data from 8 hospitals with established palliative care programs for the years 2002 through 2004. Patients receiving palliative care were matched by propensity score to patients receiving usual care. Generalized linear models were estimated for costs per admission and per hospital day.Of the 2966 palliative care patients who were discharged alive, 2630 palliative care patients (89%) were matched to 18,427 usual care patients, and of the 2388 palliative care patients who died, 2278 (95%) were matched to 2124 usual care patients. The palliative care patients who were discharged alive had an adjusted net savings of $1696 in direct costs per admission (P = .004) and $279 in direct costs per day (P.001) including significant reductions in laboratory and intensive care unit costs compared with usual care patients. The palliative care patients who died had an adjusted net savings of $4908 in direct costs per admission (P = .003) and $374 in direct costs per day (P.001) including significant reductions in pharmacy, laboratory, and intensive care unit costs compared with usual care patients. Two confirmatory analyses were performed. Including mean costs per day before palliative care and before a comparable reference day for usual care patients in the propensity score models resulted in similar results. Estimating costs for palliative care patients assuming that they did not receive palliative care resulted in projected costs that were not significantly different from usual care costs.Hospital palliative care consultation teams are associated with significant hospital cost savings.

Veterans Affairs medical centers (VAMCs) provide better preventive and chronic disease care when compared with other health care organizations, although recent health care quality improvement initiatives outside the VAMC sector may have narrowed quality differences.Using the nationally representative 2000 and 2004 surveys of the Behavior Risk Factor Surveillance System, which included 152,310 community-dwelling insured adults in 2000 and 251,570 in 2004, we compared self-reported use of 17 recommended ambulatory care services for cancer prevention, cardiovascular risk reduction, diabetes mellitus management, and infectious disease prevention among insured adults receiving and not receiving care at VAMCs.A total of 2852 insured adults (1.9%) received care at VAMCs in 2000 and 7155 (2.4%) received care at VAMCs in 2004. Use of 9 of the 17 services was greater in 2004 when compared with 2000 (Por = .05). In 2000, receiving VAMC care was associated with greater use of 6 of the 17 services; in 2004, receiving VAMC care was associated with greater use of 12 of the 17 services (Por = .05). In 2004, greater use among these 12 services ranged from 10% greater use of cholesterol screening to 40% greater use of colorectal cancer screening. For 13 of the 17 services, the likelihood of service use among adults receiving VAMC care when compared with adults not receiving VAMC care was not significantly different in 2004 than in 2000. However, this likelihood was significantly greater (for VAMC vs non-VAMC use) in 2004 than in 2000 for breast cancer screening (relative risk [RR], 1.21 [95% confidence interval {CI}, 1.15-1.25] vs 0.80 [95% CI, 0.58-0.98]; P.001), dilated eye examination among adults with diabetes (RR, 1.12 [95% CI, 1.07-1.15] vs 1.01 [95% CI, 0.88-1.09]; P = .04), and influenza (RR, 1.30 [95% CI, 1.24-1.36] vs 1.06 [95% CI, 0.89-1.21]; P = .006) and pneumococcal (RR, 1.27 [95% CI, 1.23-1.31] vs 1.04 [95% CI, 0.86-1.21]; P = .005) vaccinations.Despite increasing emphasis on quality of care and improved performance throughout the US health care system, adults receiving VAMC care remain more likely to receive recommended ambulatory care.