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Mapping health status measures to a utility measure in a study of nursing home residents with advanced dementia.

ABSTRACT: Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, hospitalization) of questionable clinical benefit. To facilitate cost-effectiveness analyses of these interventions, utility-based measures are needed in order to estimate quality-adjusted outcomes.Nursing home residents with advanced dementia in 22 facilities were followed for 18 months (N=319). Validated health status measures ascertained from nurses at baseline, quarterly, and death (N=1702 assessments) were mapped to the Health Utilities Index Mark 2 [range, 1 (perfect health) to 0 (death); scores below 0 indicate states worse than death]. To assess validity, utility scores were compared between residents who did and did not receive burdensome interventions (parenteral therapy, percutaneous endoscopic gastrostomy tubes, and hospital transfers), residents with and without pneumonia, and residents who did and did not die at the last assessment.Mean (±SD) Health Utilities Index Mark 2 utility score for the cohort was 0.165±0.060 (range, -0.005 to 0.215). Residents spent an average of 15.5% of their days with utilities <0.10. Lower utility scores were found among residents who received burdensome interventions (0.152±0.067 vs. 0.171±0.056; P=0.0003); had pneumonia (0.147±0.066 vs. 0.170±0.057; P=0.003); and were dying (0.163±0.057 vs. 0.180±0.055; P=0.006).It is feasible to map health status measures to utility-based measures for advanced dementia. This work will facilitate future cost-effectiveness analyses aimed at quantifying the cost of interventions relative to quality-based outcomes for patients with this condition.

SUBMITTER: Goldfeld KS

PROVIDER: S-EPMC3549579 | biostudies-other | 2012 May

REPOSITORIES: biostudies-other

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Mapping health status measures to a utility measure in a study of nursing home residents with advanced dementia.

Goldfeld Keith S KS Hamel Mary Beth MB Mitchell Susan L SL

Medical care 20120501 5

<h4>Background</h4>Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, hospitalization) of questionable clinical benefit. To facilitate cost-effectiveness analyses of these interventions, utility-based measures are needed in order to estimate quality-adjusted outcomes.<h4>Methods</h4>Nursing home residents with advanced dementia in 22 facilities were followed for 18 months (N=319). Validated health status measures ascertained from nurses at ...[more]

PMID: 22635251

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Project description:Nursing home residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve the quality of life. Fragmentation in health care has contributed to poor coordination of care for acutely ill nursing home residents.To compare patterns of care and quality outcomes for nursing home residents with advanced dementia covered by managed care with those covered by traditional fee-for-service Medicare.Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE) was a prospective cohort study including 22 nursing homes in the Boston, Massachusetts, area that monitored 323 nursing home residents for 18 months to better understand the course of advanced dementia at or near the end of life. Data from CASCADE and Medicare were linked to determine the health insurance status of study participants.The health insurance status of the resident, either managed care or traditional fee for service.The outcomes included survival, symptoms related to comfort, treatment of pain and dyspnea, presence of pressure ulcers, presence of a do-not-hospitalize order, treatment of pneumonia, hospital transfer (admission or emergency department visit) for an acute illness, hospice referral, primary care visits, and family satisfaction with care.Residents enrolled in managed care (n = 133) were more likely to have do-not-hospitalize orders compared with those in traditional Medicare fee for service (n = 158) (63.7% vs 50.9%; adjusted odds ratio, 1.9; 95% CI, 1.1-3.4), were less likely to be transferred to the hospital for acute illness (3.8% vs 15.7%; adjusted odds ratio, 0.2; 95% CI, 0.1-0.5), had more primary care visits per 90 days (mean [SD], 4.8 [2.6] vs 4.2 [5.0]; adjusted rate ratio, 1.3; 95% CI, 1.1-1.6), and had more nurse practitioner visits (3.0 [2.1] vs 0.8 [2.6]; adjusted rate ratio, 3.0; 95% CI, 2.2-4.1). Survival, comfort, and other treatment outcomes did not differ significantly across groups. CONCLUSIONS AND RELEVANCE Medicare managed-care programs may offer a promising approach to ensure that nursing homes are able to provide appropriate, less burdensome, and affordable care, especially at the end of life.

Project description:ImportancePrognostication in advanced dementia is challenging but may influence care.ObjectivesTo determine the accuracy of proxies' prognostic estimates for nursing home residents with advanced dementia, identify factors associated with those estimates, and examine the association between their estimates and use of burdensome interventions.Design, setting, and participantsData were combined from 2 studies that prospectively followed 764 residents with advanced dementia and their proxies in Boston-area nursing homes for 12 months: (1) the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia, conducted from September 2009 to November 2012 (362 resident/proxy dyads; 35 facilities); and (2) the Educational Video to Improve nursing home Care in End-Stage Dementia, conducted from March 2013 to July 2017 (402 resident/proxy dyads; 62 facilities). Proxies were the residents' formally or informally designated medical decision makers.Main outcomes and measuresDuring quarterly telephone interviews, proxies stated whether they believed the resident would live less than 1 month, 1 to 6 months, 7 to 12 months, or more than 12 months. Prognostic estimates were compared with resident survival. Resident and proxy characteristics associated with proxy prognostic estimates were determined. The association between prognostic estimates and whether residents experienced any of the following was determined: hospital transfers, parenteral therapy, tube feeding, venipunctures, and bladder catheterizations.ResultsThe residents' mean (SD) age was 86.6 (7.3) years; 631 (82.6%) were women and 133 (17.4%) were men. Of the 764 residents, 310 (40.6%) died later than 12 months. Proxies estimated survival with moderate accuracy (C statistic, 0.67). When proxies perceived the resident would die within 6 months, they were more likely to report being asked (183 [7.2%] of 2526) vs not being asked (126 [5.0%] of 2526) about goals of care by nursing home clinicians (adjusted odds ratio [AOR], 1.94; 95% CI, 1.50-2.52). Residents were less likely to experience burdensome interventions when the proxy prognostic estimate was less than 6 months (89 [4.4%] of 2031) vs greater than 6 months (1008 [49.6%] of 2031) (AOR, 0.46; 95% CI, 0.34-0.62).Conclusions and relevanceProxies estimated the prognosis of nursing home residents with advanced dementia with moderate accuracy. Having been asked about their opinion about the goal of care was associated with the proxies' perception that the resident had less than 6 months to live and that perception was associated with a lower likelihood the resident experienced burdensome interventions.

Project description:ObjectivesGiven an aging human immunodeficiency virus (HIV) population, we aimed to determine the prevalence of HIV for long-stay residents in US nursing homes (NHs) between 2001 and 2010 and to compare characteristics and diagnoses of HIV-positive (HIV+) and negative (HIV-) residents. Also, for residents with dementia diagnoses, we compared antipsychotic (APS) medication receipt by HIV status.DesignA cross-sectional comparative study.SettingNHs in the 14 states accounting for 75% of persons living with HIV.ParticipantsA total of 9 245 009 long-stay NH residents.MeasurementsUsing Medicaid fee-for-service claims data in the years 2001 to 2010, together with Medicare resident assessment and Chronic Condition Warehouse data, we identified long-stay (more than 89 days) NH residents by HIV status and dementia presence. We examined dementia presence by age groups and APS medication receipt by younger (aged younger than 65 years) vs older (aged 65 years or older) residents, using logistic regression.ResultsBetween 2001 and 2010, the prevalence of long-stay residents with HIV in NHs increased from 0.7% to 1.2%, a 71% increase. Long-stay residents with HIV were younger and less often female or white. For younger NH residents, rates of dementia were 20% and 16% for HIV+ and HIV- residents, respectively; they were 53% and 57%, respectively, for older residents. In adjusted analyses, younger HIV+ residents with dementia had greater odds of APS medication receipt than did HIV- residents (AOR = 1.3; 95% confidence interval [CI] = 1.2-1.4), but older HIV residents had lower odds (AOR = 0.9; 95% CI = 0.8-0.9).ConclusionThe prevalence of long-stay HIV+ NH residents has increased over time, and given the rapid aging of the HIV population, this increase is likely to have continued. This study raises concern about potential differential quality of care for (younger) residents with HIV in NHs, but not for those aged 65 years and older. These findings contribute to the evidence base needed to ensure high-quality care for younger and older HIV+ residents in NHs.

Project description:BackgroundApproximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life. We aimed to quantify the benefits and harms of anticoagulation in this population.MethodsUsing Minimum Data Set and Medicare claims, we conducted a retrospective cohort study with 14,877 long-stay nursing home residents aged ≥66 between 2013 and 2018 who had advanced dementia and AF. We excluded individuals with venous thromboembolism and valvular heart disease. We measured anticoagulant exposure quarterly, using Medicare Part D claims. The primary outcome was all-cause mortality; secondary outcomes were ischemic stroke and serious bleeding. We performed survival analyses with multivariable adjustment and inverse probability of treatment (IPT) weighting.ResultsIn the study sample, 72.0% were female, 82.7% were aged ≥80 years, and 13.5% were nonwhite. Mean CHA2 DS2 VASC score was 6.19 ± 1.58. In multivariable survival analysis, anticoagulation was associated with decreased risk of death (HR 0.71, 95% CI 0.67-0.75) and increased bleeding risk (HR 1.15, 95% CI 1.02-1.29); the association with stroke risk was not significant (HR 1.08, 95% CI 0.80-1.46). Results were similar in models with IPT weighting. While >50% of patients in both groups died within a year, median weighted survival was 76 days longer for anticoagulated individuals.ConclusionPersons with advanced dementia and AF derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding. The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.

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Mapping health status measures to a utility measure in a study of nursing home residents with advanced dementia.

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Mapping health status measures to a utility measure in a study of nursing home residents with advanced dementia.

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