Objective-To explore the influence of contextual factors on health-related quality of life (HRQoL... more Objective-To explore the influence of contextual factors on health-related quality of life (HRQoL), which is sometimes used as an indicator of quality of care, we examined the association of neighborhood socioeconomic status (NSES) and trajectories of HRQoL after hospitalization for acute coronary syndromes (ACS). Methods-We studied 1,481patients hospitalized with ACS in Massachusetts and Georgia querying HRQoL via the mental and physical components of the SF-36 (MCS and PCS) and the physical limitations and angina-related HRQoL subscales of the Seattle Angina Questionnaire (SAQ) during hospitalization and at 1-, 3-, and 6-months post-discharge. We categorized participants by tertiles of the Neighborhood Deprivation Index (a residence-census tract-based measure) to examine the association of NSES with trajectories of HRQoL after adjusting for individual SES and clinical characteristics. Results-Participants had mean age 61.3 (SD: 11.4) years; 33% were female; 76%, non-Hispanic white; 11.2% had household income below the federal poverty level. During 6 months post-discharge, living in lower NSES neighborhoods was associated with lower mean PCS scores (1.5 points for intermediate NSES; 1.8 for low) and SAQ scores (2.4 and 4.2 points) versus living in high NSES neighborhoods. Neighborhood SES was more consequential for patients with lower individual SES. Individuals living below the federal poverty level had lower average MCS and SAQ physical scores (3.7 and 7.7 points, respectively) than those above. Conclusions-Neighborhood deprivation was associated with worse health status. Using HRQoL to assess quality of care without accounting for individual and neighborhood SES may unfairly penalize safety net hospitals.
IMPORTANCE Trauma centers improve outcomes for young patients with serious injuries. However, mos... more IMPORTANCE Trauma centers improve outcomes for young patients with serious injuries. However, most injury-related hospital admissions and deaths occur in older adults, and it is not clear whether trauma center care provides the same benefit in this population. OBJECTIVE To examine whether 30-and 365-day mortality of injured older adults is associated with the treating hospital's trauma center level. DESIGN, SETTING, AND PARTICIPANTS This prospective, population-based cohort study used Medicare claims data from January 1, 2013, to December 31, 2016, for all fee-for-service Medicare beneficiaries 66 years or older with inpatient admission for traumatic injury in 2014 to 2015. Data analysis was performed from January 1 to June 31, 2021. Preinjury health was measured using 2013 claims, and outcomes were measured through 2016. The population was stratified by anatomical injury pattern. Propensity scores for level I trauma center treatment were estimated using the Abbreviated Injury Scale, age, and residential proximity to trauma center and then used to match beneficiaries from each trauma level (I, II, III, and IV/non-trauma centers) by injury type. EXPOSURE Admitting hospital's trauma center level. MAIN OUTCOMES AND MEASURES Case fatality rates (CFRs) at 30 and 365 days after injury, estimated in the matched sample using multivariable, hierarchical logistic regression models. RESULTS A total of 433 169 Medicare beneficiaries (mean [SD] age, 82.9 [8.3] years; 68.4% female; 91.5% White) were included in the analysis. A total of 206 275 (47.6%) were admitted to non-trauma centers and 161 492 (37.3%) to level I or II trauma centers. Patients with isolated extremity fracture had the fewest deaths (365-day CFR ranged from 16.1% [95% CI, 11.2%-22.4%] to 17.4% [95% CI, 11.8%-24.6%] by trauma center status). Patients with both hip fracture and traumatic brain injury had the most deaths (365-day CFRs ranged from 33.4% [95% CI, 25.8%-42.1%] to 35.8% [95% CI, 28.9%-43.5%]). CONCLUSIONS AND RELEVANCE These findings suggest that older adults do not benefit from existing trauma center care, which is designed with younger patients in mind. There is a critical need to improve trauma care practices to address common injury mechanisms and types of injury in older adults.
IMPORTANCE Advance care planning (ACP) is intended to maximize the concordance of preferences wit... more IMPORTANCE Advance care planning (ACP) is intended to maximize the concordance of preferences with end-of-life (EOL) care and is assumed to lead to less intensive use of health care services. The Centers for Medicare & Medicaid Services began reimbursing clinicians for ACP discussions with patients in 2016. OBJECTIVE To determine whether billed ACP visits are associated with intensive use of health care services at EOL.
Background: Clinical trials in home hospice settings are important to build the evidence base for... more Background: Clinical trials in home hospice settings are important to build the evidence base for practice, but balancing the burden and benefit of clinical trial conduct for clinicians, patients, and family caregivers is challenging. A stakeholder-engaged process can help inform and refine key aspects of home hospice clinical trials. The aim of this study was to describe a stakeholder-engaged process to refine, design, and implement aspects of an educational intervention trial in home hospice, including recommendations for refining intervention content and delivery, recruitment and enrollment strategies, and content and frequency of outcome measurement. Methods: A panel of interprofessional (1 hospice administrator, 3 nurses, 2 physicians, 2 pharmacists) and 2 former family caregiver stakeholders was systematically selected and invited to participate based on expertise, representing 2 geographically distinct hospices who were participating in the clinical trial. Teleconferences followed a predetermined procedural sequence: 1. pre-meeting materials distribution and review; 2. pre-meeting email solicitation of concerns in response to materials; 3. teleconference with structured and guided discussion; and 4. documentation and distribution of minutes for accuracy review and future meeting guidance. Discussion topics were distinct for each panel meeting. Written reflections on the stakeholder engagement process were collected from panel members to further refine our process. Results: Five initial biweekly teleconferences resulted in recommendations for recruitment strategy, enrollment process, measurement frequency, patient inclusion, and primary care physician notification of the patient's trial involvement. The panel continues to participate in quarterly teleconferences to review progress and unexpected questions and concerns. Panelist reflections reveal personal and professional benefit from participation. Conclusions: An interprofessional stakeholder process is feasible and invaluable for developing home hospice intervention studies, contributing to better science, successful trial implementation, and relevant, valid outcomes. Trial registration: Clinicaltrials.gov,
Background: Little is known about the heterogeneous clinical profile of physical frailty and its ... more Background: Little is known about the heterogeneous clinical profile of physical frailty and its association with cognitive impairment in older U.S. nursing home (NH) residents. Methods: Minimum Data Set 3.0 at admission was used to identify older adults newly-admitted to nursing homes with life expectancy ≥6 months and length of stay ≥100 days (n = 871,801). Latent class analysis was used to identify physical frailty subgroups, using FRAIL-NH items as indicators. The association between the identified physical frailty subgroups and cognitive impairment (measured by Brief Interview for Mental Status/Cognitive Performance Scale: none/mild; moderate; severe), adjusting for demographic and clinical characteristics, was estimated by multinomial logistic regression and presented in adjusted odds ratios (aOR) and 95% confidence intervals (CIs). Results: In older nursing home residents at admission, three physical frailty subgroups were identified: "mild physical frailty" (prevalence: 7.6%), "moderate physical frailty" (44.5%) and "severe physical frailty" (47.9%). Those in "moderate physical frailty" or "severe physical frailty" had high probabilities of needing assistance in transferring between locations and inability to walk in a room. Residents in "severe physical frailty" also had greater probability of bowel incontinence. Compared to those with none/mild cognitive impairment, older residents with moderate or severe impairment had slightly higher odds of belonging to "moderate physical frailty" [aOR (95%CI) moderate cognitive impairment : 1.01 (0.99-1.03); aOR (95%CI) severe cognitive impairment : 1.03 (1.01-1.05)] and much higher odds to the "severe physical frailty" subgroup [aOR (95%CI) moderate cognitive impairment : 2.41 (2.35-2.47); aOR (95%CI) severe cognitive impairment : 5.74 (5.58-5.90)]. Conclusions: Findings indicate the heterogeneous presentations of physical frailty in older nursing home residents and additional evidence on the interrelationship between physical frailty and cognitive impairment.
Journal of the American Geriatrics Society, Feb 14, 2020
OBJECTIVESTo evaluate the prevalence and factors associated with statin pharmacotherapy in long‐s... more OBJECTIVESTo evaluate the prevalence and factors associated with statin pharmacotherapy in long‐stay nursing home residents with life‐limiting illness.DESIGNCross‐sectional.SETTINGUS Medicare‐ and Medicaid‐certified nursing home facilities.PARTICIPANTSLong‐stay nursing home resident Medicare fee‐for‐service beneficiaries aged 65 years or older with life‐limiting illness (n = 424 212).MEASUREMENTSPrevalent statin use was estimated as any low‐moderate intensity (daily dose low‐density lipoprotein‐cholesterol [LDL‐C] reduction <30%‐50%) and high‐intensity (daily dose LDL‐C reduction >50%) use via Medicare Part D claims for a prescription supply on September 30, 2016, with a 90‐day look‐back period. Life‐limiting illness was operationally defined to capture those near the end of life using evidence‐based criteria to identify progressive terminal conditions or limited prognoses (<6 mo). Poisson models provided estimates of adjusted prevalence ratios and 95% confidence intervals for resident factors.RESULTSA total of 34% of residents with life‐limiting illness were prescribed statins (65‐75 y = 44.0%, high intensity = 11.1%; >75 y = 31.1%, high intensity = 5.4%). Prevalence of statins varied by life‐limiting illness definition. Of those with a prognosis of less than 6 months, 23% of the 65 to 75 and 12% of the older than 75 age groups were on statins. Factors positively associated with statin use included minority race or ethnicity, use of more than five concurrent medications, and atherosclerotic cardiovascular disease or risk factors.CONCLUSIONDespite having a life‐limiting illness, more than one‐third of clinically compromised long‐stay nursing home residents remain on statins. Although recent national guidelines have expanded indications for statins, the benefit of continued therapy in an advanced age population near the end of life is questionable. Efforts to deprescribe statins in the nursing home setting may be warranted. J Am Geriatr Soc 68:708–716, 2020
American Journal of Emergency Medicine, Feb 1, 2017
Author Contributions: JPH, JT, and PLH conceived the study, designed the trial, and obtained rese... more Author Contributions: JPH, JT, and PLH conceived the study, designed the trial, and obtained research funding. JPH, EW, and TZ supervised the conduct of the trial and data collection. JPH, EW and TZ recruited participating centers and patients and managed the data, including collection and quality control. JPH and FLB provided statistical advice on study design and analyzed the data; JPH drafted the manuscript, and all authors contributed substantially to its revision. JPH takes responsibility for the paper as a whole.
Journal of Medical Education and Curricular Development
Objectives To describe the development and refinement of an implicit bias recognition and managem... more Objectives To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a “knowledge, awareness, and skill-building” bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results The initial tri...
BackgroundAlthough advance care planning (ACP) for persons with dementia (PWD) can promote patien... more BackgroundAlthough advance care planning (ACP) for persons with dementia (PWD) can promote patient‐centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians.MethodsQualitative study using semi‐structured interviews (August 2018–December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision‐making was approached, and how decision‐making capacity was assessed.ResultsOf 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as pos...
Language access is a challenge to advance care planning (ACP). Spanish-language speakers are the ... more Language access is a challenge to advance care planning (ACP). Spanish-language speakers are the largest non-English speaking population in the US. While ACP tools have been translated into Spanish, it is unclear how heterogeneity in country of origin may affect the generalizability of translations across diverse US Spanish-speaking populations. The study objective is to describe challenges and facilitators to ACP for diverse populations of Spanish-language speakers. We conducted 3 focus groups with a total of 29 participants from members of Spanish-language speaking communities whose countries of origin were predominantly from the Caribbean, Central, and South America. Eligibility included being 18 years or older, being a native Spanish-speaker, and having direct experience with ACP as a patient, caregiver, or medical interpreter. We conducted thematic analysis with axial coding. Themes include: 1. Linguistic Challenges with Current ACP Translations; 2. Effect of Country of Origin ...
recommended VAD over transplant for all racial/sex groups. Surveys demonstrated similar final rec... more recommended VAD over transplant for all racial/sex groups. Surveys demonstrated similar final recommendations. Conclusions: Despite identical clinical vignettes, the decision making process varied by patient sex and race. Women patients were judged more harshly by their appearance and adequacy of social support, particularly the African American woman. Implications for Policy or Practice: Future research should investigate whether objective assessments of social support lead to equity in advanced therapy allocation.
In the adjusted analysis, the odds of being penalized under the SNF VBP program for SNFs with neg... more In the adjusted analysis, the odds of being penalized under the SNF VBP program for SNFs with negative profit margins are 13% higher vs. SNFs with positive profit margins (OR: 1.13; 95% CI: 1.04-1.23). Conclusions: SNFs with negative profit margins are more likely to be penalized under the SNF-VBP. Implications for Policy or Practice: Although we want to incentivize quality improvement through programs like SNF-VBP, we need to ensure that SNFs with negative profit margins have the resources to improve. Facilities with negative profit margins that are penalized under SNF-VBP have an average loss of $24 400-an amount that roughly approximates average annual salary of a certified nursing assistant, one of the key nursing home direct care staffs. These losses may further exacerbate quality problems in facilities that are already struggling. Alternative approaches to assist financially struggling SNFs may help them improve quality and perform better under SNF-VBP.
Background: Little is known regarding differences between patients referred to hospice from diffe... more Background: Little is known regarding differences between patients referred to hospice from different care locations. Objective: The objective this study was to describe the associations between hospice referral locations and hospice patient and admission characteristics. Research Design: Cross-sectional analysis of hospice administrative data. Subjects: Adult (age older than 18 y) decedents of a national, for-profit, hospice chain across 19 US states who died between January 1, 2012, and December 31, 2016. Measures: Patients’ primary hospice diagnosis, hospice length stay, and hospice care site. We also determined the frequency of opioid prescriptions with and without a bowel regimen on hospice admission. Results: Among 78,647 adult decedents, the mean age was 79.2 (SD=13.5) years, 56.4% were female, and 69.9% were a non-Hispanic White race. Most hospice referrals were from the hospital (51.9%), followed by the community (21.9%), nursing homes (17.4%), and assisted living (8.8%). Cancer (33.6%) was the most prevalent primary hospice diagnosis; however, this varied significantly between referral locations (P<0.001). Similarly, home hospice (32.8%) was the most prevalent site; however, this also varied significantly between referral locations (P<0.001). More hospital-referred patients (55.6%) had a hospice length of stay <7 days compared with patients referred from nursing homes (30.3%), the community (28.9%), or assisted living (18.7%), P<0.001. Hospital-referred patients also had the lowest frequency (58.4%) of coprescribed opioids and bowel regimen on hospice admission compared with other referral locations. Conclusion: We observed significant differences in hospice patient and admission characteristics by referral location.
OBJECTIVESTo quantify the frequency and type of medication decisions on discharge from the hospit... more OBJECTIVESTo quantify the frequency and type of medication decisions on discharge from the hospital to hospice care.DESIGNRetrospective cohort study.SETTINGA 544‐bed academic tertiary care hospital in Portland, Oregon.PARTICIPANTSA total of 348 adult patients (age ≥18 y) discharged to hospice care between January 1, 2010, and December 31, 2016.MEASUREMENTSData were collected from an electronic repository of medical record data and a manual review of patients’ discharge summaries. Our outcomes of interest were the frequency and type of medication decisions documented in patients’ discharge summaries. Medication decisions were categorized as continuation, continuation but with changes in dose, route of administration, and/or frequency, discontinuation, and initiation of new medications. We also collected data on the frequency of patient/family in the participation of medication‐related decisions.RESULTSPatients were prescribed a mean of 7.1 medications (standard deviation [SD] = 4.8) ...
Author Contributions: JPH, JT, and PLH conceived the study, designed the trial, and obtained rese... more Author Contributions: JPH, JT, and PLH conceived the study, designed the trial, and obtained research funding. JPH, EW, and TZ supervised the conduct of the trial and data collection. JPH, EW and TZ recruited participating centers and patients and managed the data, including collection and quality control. JPH and FLB provided statistical advice on study design and analyzed the data; JPH drafted the manuscript, and all authors contributed substantially to its revision. JPH takes responsibility for the paper as a whole.
Objective-To explore the influence of contextual factors on health-related quality of life (HRQoL... more Objective-To explore the influence of contextual factors on health-related quality of life (HRQoL), which is sometimes used as an indicator of quality of care, we examined the association of neighborhood socioeconomic status (NSES) and trajectories of HRQoL after hospitalization for acute coronary syndromes (ACS). Methods-We studied 1,481patients hospitalized with ACS in Massachusetts and Georgia querying HRQoL via the mental and physical components of the SF-36 (MCS and PCS) and the physical limitations and angina-related HRQoL subscales of the Seattle Angina Questionnaire (SAQ) during hospitalization and at 1-, 3-, and 6-months post-discharge. We categorized participants by tertiles of the Neighborhood Deprivation Index (a residence-census tract-based measure) to examine the association of NSES with trajectories of HRQoL after adjusting for individual SES and clinical characteristics. Results-Participants had mean age 61.3 (SD: 11.4) years; 33% were female; 76%, non-Hispanic white; 11.2% had household income below the federal poverty level. During 6 months post-discharge, living in lower NSES neighborhoods was associated with lower mean PCS scores (1.5 points for intermediate NSES; 1.8 for low) and SAQ scores (2.4 and 4.2 points) versus living in high NSES neighborhoods. Neighborhood SES was more consequential for patients with lower individual SES. Individuals living below the federal poverty level had lower average MCS and SAQ physical scores (3.7 and 7.7 points, respectively) than those above. Conclusions-Neighborhood deprivation was associated with worse health status. Using HRQoL to assess quality of care without accounting for individual and neighborhood SES may unfairly penalize safety net hospitals.
IMPORTANCE Trauma centers improve outcomes for young patients with serious injuries. However, mos... more IMPORTANCE Trauma centers improve outcomes for young patients with serious injuries. However, most injury-related hospital admissions and deaths occur in older adults, and it is not clear whether trauma center care provides the same benefit in this population. OBJECTIVE To examine whether 30-and 365-day mortality of injured older adults is associated with the treating hospital's trauma center level. DESIGN, SETTING, AND PARTICIPANTS This prospective, population-based cohort study used Medicare claims data from January 1, 2013, to December 31, 2016, for all fee-for-service Medicare beneficiaries 66 years or older with inpatient admission for traumatic injury in 2014 to 2015. Data analysis was performed from January 1 to June 31, 2021. Preinjury health was measured using 2013 claims, and outcomes were measured through 2016. The population was stratified by anatomical injury pattern. Propensity scores for level I trauma center treatment were estimated using the Abbreviated Injury Scale, age, and residential proximity to trauma center and then used to match beneficiaries from each trauma level (I, II, III, and IV/non-trauma centers) by injury type. EXPOSURE Admitting hospital's trauma center level. MAIN OUTCOMES AND MEASURES Case fatality rates (CFRs) at 30 and 365 days after injury, estimated in the matched sample using multivariable, hierarchical logistic regression models. RESULTS A total of 433 169 Medicare beneficiaries (mean [SD] age, 82.9 [8.3] years; 68.4% female; 91.5% White) were included in the analysis. A total of 206 275 (47.6%) were admitted to non-trauma centers and 161 492 (37.3%) to level I or II trauma centers. Patients with isolated extremity fracture had the fewest deaths (365-day CFR ranged from 16.1% [95% CI, 11.2%-22.4%] to 17.4% [95% CI, 11.8%-24.6%] by trauma center status). Patients with both hip fracture and traumatic brain injury had the most deaths (365-day CFRs ranged from 33.4% [95% CI, 25.8%-42.1%] to 35.8% [95% CI, 28.9%-43.5%]). CONCLUSIONS AND RELEVANCE These findings suggest that older adults do not benefit from existing trauma center care, which is designed with younger patients in mind. There is a critical need to improve trauma care practices to address common injury mechanisms and types of injury in older adults.
IMPORTANCE Advance care planning (ACP) is intended to maximize the concordance of preferences wit... more IMPORTANCE Advance care planning (ACP) is intended to maximize the concordance of preferences with end-of-life (EOL) care and is assumed to lead to less intensive use of health care services. The Centers for Medicare & Medicaid Services began reimbursing clinicians for ACP discussions with patients in 2016. OBJECTIVE To determine whether billed ACP visits are associated with intensive use of health care services at EOL.
Background: Clinical trials in home hospice settings are important to build the evidence base for... more Background: Clinical trials in home hospice settings are important to build the evidence base for practice, but balancing the burden and benefit of clinical trial conduct for clinicians, patients, and family caregivers is challenging. A stakeholder-engaged process can help inform and refine key aspects of home hospice clinical trials. The aim of this study was to describe a stakeholder-engaged process to refine, design, and implement aspects of an educational intervention trial in home hospice, including recommendations for refining intervention content and delivery, recruitment and enrollment strategies, and content and frequency of outcome measurement. Methods: A panel of interprofessional (1 hospice administrator, 3 nurses, 2 physicians, 2 pharmacists) and 2 former family caregiver stakeholders was systematically selected and invited to participate based on expertise, representing 2 geographically distinct hospices who were participating in the clinical trial. Teleconferences followed a predetermined procedural sequence: 1. pre-meeting materials distribution and review; 2. pre-meeting email solicitation of concerns in response to materials; 3. teleconference with structured and guided discussion; and 4. documentation and distribution of minutes for accuracy review and future meeting guidance. Discussion topics were distinct for each panel meeting. Written reflections on the stakeholder engagement process were collected from panel members to further refine our process. Results: Five initial biweekly teleconferences resulted in recommendations for recruitment strategy, enrollment process, measurement frequency, patient inclusion, and primary care physician notification of the patient's trial involvement. The panel continues to participate in quarterly teleconferences to review progress and unexpected questions and concerns. Panelist reflections reveal personal and professional benefit from participation. Conclusions: An interprofessional stakeholder process is feasible and invaluable for developing home hospice intervention studies, contributing to better science, successful trial implementation, and relevant, valid outcomes. Trial registration: Clinicaltrials.gov,
Background: Little is known about the heterogeneous clinical profile of physical frailty and its ... more Background: Little is known about the heterogeneous clinical profile of physical frailty and its association with cognitive impairment in older U.S. nursing home (NH) residents. Methods: Minimum Data Set 3.0 at admission was used to identify older adults newly-admitted to nursing homes with life expectancy ≥6 months and length of stay ≥100 days (n = 871,801). Latent class analysis was used to identify physical frailty subgroups, using FRAIL-NH items as indicators. The association between the identified physical frailty subgroups and cognitive impairment (measured by Brief Interview for Mental Status/Cognitive Performance Scale: none/mild; moderate; severe), adjusting for demographic and clinical characteristics, was estimated by multinomial logistic regression and presented in adjusted odds ratios (aOR) and 95% confidence intervals (CIs). Results: In older nursing home residents at admission, three physical frailty subgroups were identified: "mild physical frailty" (prevalence: 7.6%), "moderate physical frailty" (44.5%) and "severe physical frailty" (47.9%). Those in "moderate physical frailty" or "severe physical frailty" had high probabilities of needing assistance in transferring between locations and inability to walk in a room. Residents in "severe physical frailty" also had greater probability of bowel incontinence. Compared to those with none/mild cognitive impairment, older residents with moderate or severe impairment had slightly higher odds of belonging to "moderate physical frailty" [aOR (95%CI) moderate cognitive impairment : 1.01 (0.99-1.03); aOR (95%CI) severe cognitive impairment : 1.03 (1.01-1.05)] and much higher odds to the "severe physical frailty" subgroup [aOR (95%CI) moderate cognitive impairment : 2.41 (2.35-2.47); aOR (95%CI) severe cognitive impairment : 5.74 (5.58-5.90)]. Conclusions: Findings indicate the heterogeneous presentations of physical frailty in older nursing home residents and additional evidence on the interrelationship between physical frailty and cognitive impairment.
Journal of the American Geriatrics Society, Feb 14, 2020
OBJECTIVESTo evaluate the prevalence and factors associated with statin pharmacotherapy in long‐s... more OBJECTIVESTo evaluate the prevalence and factors associated with statin pharmacotherapy in long‐stay nursing home residents with life‐limiting illness.DESIGNCross‐sectional.SETTINGUS Medicare‐ and Medicaid‐certified nursing home facilities.PARTICIPANTSLong‐stay nursing home resident Medicare fee‐for‐service beneficiaries aged 65 years or older with life‐limiting illness (n = 424 212).MEASUREMENTSPrevalent statin use was estimated as any low‐moderate intensity (daily dose low‐density lipoprotein‐cholesterol [LDL‐C] reduction &lt;30%‐50%) and high‐intensity (daily dose LDL‐C reduction &gt;50%) use via Medicare Part D claims for a prescription supply on September 30, 2016, with a 90‐day look‐back period. Life‐limiting illness was operationally defined to capture those near the end of life using evidence‐based criteria to identify progressive terminal conditions or limited prognoses (&lt;6 mo). Poisson models provided estimates of adjusted prevalence ratios and 95% confidence intervals for resident factors.RESULTSA total of 34% of residents with life‐limiting illness were prescribed statins (65‐75 y = 44.0%, high intensity = 11.1%; &gt;75 y = 31.1%, high intensity = 5.4%). Prevalence of statins varied by life‐limiting illness definition. Of those with a prognosis of less than 6 months, 23% of the 65 to 75 and 12% of the older than 75 age groups were on statins. Factors positively associated with statin use included minority race or ethnicity, use of more than five concurrent medications, and atherosclerotic cardiovascular disease or risk factors.CONCLUSIONDespite having a life‐limiting illness, more than one‐third of clinically compromised long‐stay nursing home residents remain on statins. Although recent national guidelines have expanded indications for statins, the benefit of continued therapy in an advanced age population near the end of life is questionable. Efforts to deprescribe statins in the nursing home setting may be warranted. J Am Geriatr Soc 68:708–716, 2020
American Journal of Emergency Medicine, Feb 1, 2017
Author Contributions: JPH, JT, and PLH conceived the study, designed the trial, and obtained rese... more Author Contributions: JPH, JT, and PLH conceived the study, designed the trial, and obtained research funding. JPH, EW, and TZ supervised the conduct of the trial and data collection. JPH, EW and TZ recruited participating centers and patients and managed the data, including collection and quality control. JPH and FLB provided statistical advice on study design and analyzed the data; JPH drafted the manuscript, and all authors contributed substantially to its revision. JPH takes responsibility for the paper as a whole.
Journal of Medical Education and Curricular Development
Objectives To describe the development and refinement of an implicit bias recognition and managem... more Objectives To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a “knowledge, awareness, and skill-building” bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results The initial tri...
BackgroundAlthough advance care planning (ACP) for persons with dementia (PWD) can promote patien... more BackgroundAlthough advance care planning (ACP) for persons with dementia (PWD) can promote patient‐centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians.MethodsQualitative study using semi‐structured interviews (August 2018–December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision‐making was approached, and how decision‐making capacity was assessed.ResultsOf 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as pos...
Language access is a challenge to advance care planning (ACP). Spanish-language speakers are the ... more Language access is a challenge to advance care planning (ACP). Spanish-language speakers are the largest non-English speaking population in the US. While ACP tools have been translated into Spanish, it is unclear how heterogeneity in country of origin may affect the generalizability of translations across diverse US Spanish-speaking populations. The study objective is to describe challenges and facilitators to ACP for diverse populations of Spanish-language speakers. We conducted 3 focus groups with a total of 29 participants from members of Spanish-language speaking communities whose countries of origin were predominantly from the Caribbean, Central, and South America. Eligibility included being 18 years or older, being a native Spanish-speaker, and having direct experience with ACP as a patient, caregiver, or medical interpreter. We conducted thematic analysis with axial coding. Themes include: 1. Linguistic Challenges with Current ACP Translations; 2. Effect of Country of Origin ...
recommended VAD over transplant for all racial/sex groups. Surveys demonstrated similar final rec... more recommended VAD over transplant for all racial/sex groups. Surveys demonstrated similar final recommendations. Conclusions: Despite identical clinical vignettes, the decision making process varied by patient sex and race. Women patients were judged more harshly by their appearance and adequacy of social support, particularly the African American woman. Implications for Policy or Practice: Future research should investigate whether objective assessments of social support lead to equity in advanced therapy allocation.
In the adjusted analysis, the odds of being penalized under the SNF VBP program for SNFs with neg... more In the adjusted analysis, the odds of being penalized under the SNF VBP program for SNFs with negative profit margins are 13% higher vs. SNFs with positive profit margins (OR: 1.13; 95% CI: 1.04-1.23). Conclusions: SNFs with negative profit margins are more likely to be penalized under the SNF-VBP. Implications for Policy or Practice: Although we want to incentivize quality improvement through programs like SNF-VBP, we need to ensure that SNFs with negative profit margins have the resources to improve. Facilities with negative profit margins that are penalized under SNF-VBP have an average loss of $24 400-an amount that roughly approximates average annual salary of a certified nursing assistant, one of the key nursing home direct care staffs. These losses may further exacerbate quality problems in facilities that are already struggling. Alternative approaches to assist financially struggling SNFs may help them improve quality and perform better under SNF-VBP.
Background: Little is known regarding differences between patients referred to hospice from diffe... more Background: Little is known regarding differences between patients referred to hospice from different care locations. Objective: The objective this study was to describe the associations between hospice referral locations and hospice patient and admission characteristics. Research Design: Cross-sectional analysis of hospice administrative data. Subjects: Adult (age older than 18 y) decedents of a national, for-profit, hospice chain across 19 US states who died between January 1, 2012, and December 31, 2016. Measures: Patients’ primary hospice diagnosis, hospice length stay, and hospice care site. We also determined the frequency of opioid prescriptions with and without a bowel regimen on hospice admission. Results: Among 78,647 adult decedents, the mean age was 79.2 (SD=13.5) years, 56.4% were female, and 69.9% were a non-Hispanic White race. Most hospice referrals were from the hospital (51.9%), followed by the community (21.9%), nursing homes (17.4%), and assisted living (8.8%). Cancer (33.6%) was the most prevalent primary hospice diagnosis; however, this varied significantly between referral locations (P<0.001). Similarly, home hospice (32.8%) was the most prevalent site; however, this also varied significantly between referral locations (P<0.001). More hospital-referred patients (55.6%) had a hospice length of stay <7 days compared with patients referred from nursing homes (30.3%), the community (28.9%), or assisted living (18.7%), P<0.001. Hospital-referred patients also had the lowest frequency (58.4%) of coprescribed opioids and bowel regimen on hospice admission compared with other referral locations. Conclusion: We observed significant differences in hospice patient and admission characteristics by referral location.
OBJECTIVESTo quantify the frequency and type of medication decisions on discharge from the hospit... more OBJECTIVESTo quantify the frequency and type of medication decisions on discharge from the hospital to hospice care.DESIGNRetrospective cohort study.SETTINGA 544‐bed academic tertiary care hospital in Portland, Oregon.PARTICIPANTSA total of 348 adult patients (age ≥18 y) discharged to hospice care between January 1, 2010, and December 31, 2016.MEASUREMENTSData were collected from an electronic repository of medical record data and a manual review of patients’ discharge summaries. Our outcomes of interest were the frequency and type of medication decisions documented in patients’ discharge summaries. Medication decisions were categorized as continuation, continuation but with changes in dose, route of administration, and/or frequency, discontinuation, and initiation of new medications. We also collected data on the frequency of patient/family in the participation of medication‐related decisions.RESULTSPatients were prescribed a mean of 7.1 medications (standard deviation [SD] = 4.8) ...
Author Contributions: JPH, JT, and PLH conceived the study, designed the trial, and obtained rese... more Author Contributions: JPH, JT, and PLH conceived the study, designed the trial, and obtained research funding. JPH, EW, and TZ supervised the conduct of the trial and data collection. JPH, EW and TZ recruited participating centers and patients and managed the data, including collection and quality control. JPH and FLB provided statistical advice on study design and analyzed the data; JPH drafted the manuscript, and all authors contributed substantially to its revision. JPH takes responsibility for the paper as a whole.
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