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Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia.

ABSTRACT: OBJECTIVE:To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life. DESIGN:Retrospective multicentre cohort study. SETTING:Three large, metropolitan tertiary hospitals in Australia. PARTICIPANTS:831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES:Odds ratios (ORs) of NBT derived from logistic regression models. RESULTS:Overall, 103 (12.4%) admissions involved NBTs. Admissions that involved conflict within a patient's family (OR 8.9, 95%?CI 4.1 to 18.9) or conflict within the medical team (OR 6.5, 95%?CI 2.4 to 17.8) had the strongest associations with NBTs in the all subsets regression model. A positive association was observed in older patients, with each 10-year increment in age increasing the likelihood of NBT by approximately 50% (OR 1.5, 95%?CI 1.2 to 1.9). There was also a statistically significant hospital effect. CONCLUSIONS:This paper presents the first statistical modelling results to assess the factors associated with NBT in hospital, beyond an intensive care setting. Our findings highlight potential areas for intervention to reduce the likelihood of NBTs.

SUBMITTER: Carter HE

PROVIDER: S-EPMC6858125 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia.

Carter Hannah Elizabeth HE Lee Xing Ju XJ Gallois Cindy C Winch Sarah S Callaway Leonie L Willmott Lindy L White Ben B Parker Malcolm M Close Eliana E Graves Nicholas N

BMJ open 20191104 11

<h4>Objective</h4>To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life.<h4>Design</h4>Retrospective multicentre cohort study.<h4>Setting</h4>Three large, metropolitan tertiary hospitals in Australia.<h4>Participants</h4>831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012.<h4>Main outcome measures</h4>Odds ratios (ORs) of NBT derived from logistic regression mo ...[more]

PMID: 31690607

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Project description:ObjectiveBlack patients are more likely than white patients to die in the hospital with intensive care and life-sustaining treatments and less likely to use hospice. Regional concentration of high end-of-life (EOL) treatment intensity practice patterns may disproportionately affect black patients. We calculated and compared race-specific hospital-level EOL treatment intensity in Pennsylvania.MethodsWe conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions, 2001-2007, among black and white admissions ≥21 years old at high probability of dying (HPD) (≥15% predicted probability of dying at admission). We calculated hospitals' race-specific observed, expected, and Bayes' shrunken observed-to-expected ratios of intensive care unit (ICU) admission, ICU length of stay (LOS), intubation/mechanical ventilation, hemodialysis, tracheostomy, and gastrostomy among HPD admissions; and an empirically weighted EOL treatment intensity index summing these ratios.ResultsThere were 35,609 black HPD admissions (27,576 unique patients) and 311,896 white HPD admissions (252,662 unique patients) to 182 hospitals. Among 95 hospitals with ≥30 black HPD admissions, 80% of black admissions were concentrated in 29 hospitals, where black-specific observed and expected EOL measures were usually higher than white-specific measures (p < 0.001 for all but 5/24 measures). Hospitals' black-specific and white-specific observed-to-expected ratios of ICU and life-sustaining treatment (LST) (rho 0.52-0.90) and EOL index (rho = 0.92) were highly correlated. However, black-specific observed-to-expected ratios and overall EOL intensity index were consistently lower than white-specific ratios (p < 0.001 for all except hemodialysis).ConclusionsIn Pennsylvania, black-serving hospitals have higher standardized EOL treatment intensity than nonblack-serving hospitals, contributing to black patients' relatively higher use of intensive treatment. However, conditional on being admitted to the same high-intensity hospital and after risk adjustment, blacks are less intensively treated than whites.

Project description:ObjectivesTo determine whether high performing hospitals with low 30 day risk standardized readmission rates have a lower proportion of readmissions from specific diagnoses and time periods after admission or instead have a similar distribution of readmission diagnoses and timing to lower performing institutions.DesignRetrospective cohort study.SettingMedicare beneficiaries in the United States.ParticipantsPatients aged 65 and older who were readmitted within 30 days after hospital admission for heart failure, acute myocardial infarction, or pneumonia in 2007-09.Main outcome measuresReadmission diagnoses were classified with a modified version of the Centers for Medicare and Medicaid Services' condition categories, and readmission timing was classified by day (0-30) after hospital discharge. Hospital 30 day risk standardized readmission rates over the three years of study were calculated with public reporting methods of the US federal government, and hospitals were categorized with bootstrap analysis as having high, average, or low readmission performance for each index condition. High and low performing hospitals had ≥ 95% probability of having an interval estimate respectively less than or greater than the national 30 day readmission rate over the three year period of study. All remaining hospitals were considered average performers.ResultsFor readmissions in the 30 days after the index admission, there were 320,003 after 1,291,211 admissions for heart failure (4041 hospitals), 102,536 after 517,827 admissions for acute myocardial infarction (2378 hospitals), and 208,438 after 1,135,932 admissions for pneumonia (4283 hospitals). The distribution of readmissions by diagnosis was similar across categories of hospital performance for all three conditions. High performing hospitals had fewer readmissions for all common diagnoses. Median time to readmission was similar by hospital performance for heart failure and acute myocardial infarction, though was 1.4 days longer among high versus low performing hospitals for pneumonia (P<0.001). Findings were unchanged after adjustment for other hospital characteristics potentially associated with readmission patterns.ConclusionsHigh performing hospitals have proportionately fewer 30 day readmissions without differences in readmission diagnoses and timing, suggesting the possible benefit of strategies that lower risk of readmission globally rather than for specific diagnoses or time periods after hospital stay.

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Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia.

Publications

Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia.

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