Improving the accuracy and turn-around time of controlled drug prescribing for patients being discharged home for end-of-life care.
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ABSTRACT:
SUBMITTER: Daniel S
PROVIDER: S-EPMC4645883 | biostudies-other | 2014
REPOSITORIES: biostudies-other
Publications
Improving the accuracy and turn-around time of controlled drug prescribing for patients being discharged home for end-of-life care.
Daniel Suzanne S Patel Janki J Benson Debbie D
BMJ quality improvement reports 20141024 1
Many patients approaching the end of their life express the preference to die at home,[1] although unfortunately the majority of people will still die in hospital.[2] For patients approaching the end of their life, it was noted anecdotally that often those who have expressed a preference to go home from hospital for end of life care may have their discharge delayed due to problems in the prescribing of common medications used to alleviate distressing symptoms at the end of life. An initial audit ...[more]
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Project description:The aims of this study were to evaluate the effects on opioid medication prescribing, patient opioid safety education, and prescribing of naloxone following implementation of a Safer Opioid Prescribing Protocol (SOPP) as part of the electronic health record (EHR) system at a Level I trauma center. This was a prospective observational study of the EHR of trauma patients pre- (n = 191) and post-(n = 316) SOPP implementation between 2014 and 2016. At a comparison Level I trauma site not implementing SOPP, EHRs for the same time period were assessed for any historical trends in opioid and naloxone prescribing. After SOPP implementation, the implementation site increased the use of nonnarcotic pain medication, decreased dispensing high opioid dose (?100 MME [milligram morphine equivalent]), significantly increased the delivery of opioid safety education to patients, and initiated prescribing naloxone. These changes were not found in the comparison site. Opioid prescribing for acute pain can be effectively reduced in a busy trauma setting with a guideline intervention incorporated into an EHR. Guidelines can increase the use of nonnarcotic medications for the treatment of acute pain and increase naloxone coprescription for patients with a higher risk of overdose.
| S-EPMC6727973 | biostudies-literature
Project description:BackgroundMany people move in and out of hospital in the last few weeks of life. These care transitions can be distressing for family members because they signify the deterioration and impending death of their ill relative and forthcoming family bereavement. Whilst there is evidence about psychosocial support for family members providing end-of-life care at home, there is limited evidence about how this can be provided in acute hospitals during care transitions. Consequently, family members report a lack of support from hospital-based healthcare professionals.MethodsThe aim of the study was to implement research evidence for family support at the end-of-life in acute hospital care. Informed by Participatory Learning and Action Research and Normalization Process Theory (NPT) we co-designed a context-specific intervention, the Family-Focused Support Conversation, from a detailed review of research evidence. We undertook a pilot implementation in three acute hospital Trusts in England to assess the potential for the intervention to be used in clinical practice. Pilot implementation was undertaken during a three-month period by seven clinical co-researchers - nurses and occupational therapists in hospital specialist palliative care services. Implementation was evaluated through data comprised of reflective records of intervention delivery (n = 22), in-depth records of telephone implementation support meetings between research team members and co-researchers (n = 3), and in-depth evaluation meetings (n = 2). Data were qualitatively analysed using an NPT framework designed for intervention evaluation.ResultsClinical co-researchers readily incorporated the Family-Focused Support Conversation into their everyday work. The intervention changed family support from being solely patient-focused, providing information about patient needs, to family-focused, identifying family concerns about the significance and implications of discharge and facilitating family-focused care. Co-researchers reported an increase in family members' involvement in discharge decisions and end-of-life care planning.ConclusionThe Family-Focused Support Conversation is a novel, evidenced-based and context specific intervention. Pilot implementation demonstrated the potential for the intervention to be used in acute hospitals to support family members during end-of-life care transitions. This subsequently informed a larger scale implementation study.Trial registrationn/a.
| S-EPMC7507823 | biostudies-literature
Project description:BackgroundThe policy in a number of countries is to provide people with a terminal illness the choice of dying at home. This policy is supported by surveys indicating that the general public and people with a terminal illness would prefer to receive end-of-life care at home. This is the fourth update of the original review.ObjectivesTo determine if providing home-based end-of-life care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs, and caregivers, compared with inpatient hospital or hospice care.Search methodsWe searched the following databases until April 2015: Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), Ovid MEDLINE(R) (from 1950), EMBASE (from 1980), CINAHL (from 1982), and EconLit (from 1969). We checked the reference lists of potentially relevant articles identified and handsearched palliative care publications, clinical trials registries, and a database of systematic reviews for related trials (PDQ-Evidence 2015).Selection criteriaRandomised controlled trials, interrupted time series, or controlled before and after studies evaluating the effectiveness of home-based end-of-life care with inpatient hospital or hospice care for people aged 18 years and older.Data collection and analysisTwo review authors independently extracted data and assessed study quality. We combined the published data for dichotomous outcomes using fixed-effect Mantel-Haenszel meta-analysis. When combining outcome data was not possible, we reported the results from individual studies.Main resultsWe included four trials in this review and did not identify new studies from the search in April 2015. Home-based end-of-life care increased the likelihood of dying at home compared with usual care (risk ratio (RR) 1.33, 95% confidence interval (CI) 1.14 to 1.55, P = 0.0002; Chi(2) = 1.72, df = 2, P = 0.42, I(2) = 0%; 3 trials; N = 652; high quality evidence). Admission to hospital while receiving home-based end-of-life care varied between trials, and this was reflected by a high level of statistical heterogeneity in this analysis (range RR 0.62 to RR 2.61; 4 trials; N = 823; moderate quality evidence). Home-based end-of-life care may slightly improve patient satisfaction at one-month follow-up and reduce it at six-month follow-up (2 trials; low quality evidence). The effect on caregivers is uncertain (2 trials; low quality evidence). The intervention may slightly reduce healthcare costs (2 trials, low quality evidence). No trial reported costs to patients and caregivers.Authors' conclusionsThe evidence included in this review supports the use of home-based end-of-life care programmes for increasing the number of people who will die at home, although the numbers of people admitted to hospital while receiving end-of-life care should be monitored. Future research should systematically assess the impact of home-based end-of-life care on caregivers.
| S-EPMC7111432 | biostudies-literature
Project description:Importance:Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population. Objective:To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use. Design, Setting, and Participants:This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively. Exposures:Sepsis hospital discharge and 1 or more home health assessments within 1 week. Main Outcomes and Measures:Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use. Results:Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P < .001), multiple dependencies of activities of daily living or instrumental activities of daily living (OR, 2.80; 95% CI, 2.57-3.05; P < .001), and an overall poor health status (OR, 2.21; 95% CI, 2.01-2.44; P < .001) documented on home health assessment. Among the decedents, cancer was associated with hospice use (OR, 2.25; 95% CI, 2.11-2.41; P < .001), patients aged 85 years or older (OR, 1.49; 95% CI, 1.37-1.61; P < .001), and living in an assisted living setting (OR, 1.93; 95% CI, 1.69-2.19; P < .001). Conclusions and Relevance:The findings of this study suggest that death within 1 year after sepsis discharge may be common among Medicare beneficiaries discharged to home health care. Although 1 in 2 decedents used hospice, aggressive care near the end of life and late hospice referral were common. Readily identifiable risk factors suggest opportunities to target efforts to improve palliative and end-of-life care among high-risk sepsis survivors.
| S-EPMC7137683 | biostudies-literature
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| S-EPMC7582021 | biostudies-literature
Project description:ObjectiveTo examine long-term care facility (LTCF or nursing home) use and end-of-life care for individuals with Parkinson disease (PD).MethodsIn this nationwide retrospective cohort study, we compared LTCF and hospice utilization among Medicare beneficiaries diagnosed with PD by demographic, clinical, and physician characteristics. We also examined the impact of outpatient neurologist care for institutionalized patients with PD on end-of-life care.ResultsWe identified 469,055 individuals with PD who received Medicare benefits in 2002. Nearly 25% (more than 100,000 in total) resided in an LTCF. Women with PD had greater odds of nursing facility residence (adjusted odds ratio [AOR] 1.34, 95% confidence interval [CI] 1.30-1.38) compared with men. Black individuals with PD were 34% more likely than white individuals to reside in an LTCF (AOR 1.34, 95% CI 1.30-1.38), contrary to the race patterns typically observed for LTCF use. Hip fracture (AOR 2.10, 95% CI 2.04-2.15) and dementia (AOR 4.06, 95% CI 4.00-4.12) were the strongest clinical predictors of LTCF placement. Only 33% (n = 38,334) of nursing home residents with PD had outpatient neurologist care. Eighty-four percent (n = 80,877) of LTCF residents with PD died by December 31, 2005. Hospice utilization varied little by race and sex. LTCF residents who had outpatient neurologist care were twice as likely to utilize hospice services before death (AOR 2.35, 95% CI 2.24-2.47).Conclusions and relevanceA large proportion of the Medicare PD population resides in an LTCF. There is substantial unmet need for palliative care in the PD population. Increased efforts to provide specialist care to dependent individuals with PD may improve end-of-life care.
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Project description:BackgroundHigh-quality end-of-life care should be the right of every Canadian. The objective of this study was to identify aspects of end-of-life care that are high in priority as targets for improvement using feedback elicited from patients and their families.MethodsWe conducted a multicentre, cross-sectional survey involving patients with advanced, life-limiting illnesses and their family caregivers. We administered the Canadian Health Care Evaluation Project (CANHELP) questionnaire along with a global rating question to measure satisfaction with end-of-life care. We derived the relative importance of individual questions on the CANHELP questionnaire from their association with a global rating of satisfaction, as determined using Pearson correlation coefficients. To determine high-priority issues, we identified questions that had scores indicating high importance and low satisfaction.ResultsWe approached 471 patients and 255 family members, of whom 363 patients and 193 family members participated, with response rates of 77% for patients and 76% for families. From the perspective of patients, high-priority areas needing improvement were related to feelings of peace, to assessment and treatment of emotional problems, to physician availability and to satisfaction that the physician took a personal interest in them, communicated clearly and consistently, and listened. From the perspective of family members, similar areas were identified as high in priority, along with the additional areas of timely information about the patient's condition and discussions with the doctor about final location of care and use of end-of-life technology.InterpretationEnd-of-life care in Canada may be improved for patients and their families by providing better psychological and spiritual support, better planning of care and enhanced relationships with physicians, especially in aspects related to communication and decision-making.
| S-EPMC2972350 | biostudies-literature
Project description:Members of longevous families live longer than individuals from similar birth cohorts and delay/escape age-related diseases. Insight into this familial component of longevity can provide important knowledge about mechanisms protecting against age-related diseases. This familial component of longevity was studied in the Leiden Longevity Study which consists of 944 longevous siblings (participants), their parents (N = 842), siblings (N = 2,302), and spouses (N = 809). Family longevity scores were estimated to explore whether human longevity is transmitted preferentially through the maternal or paternal line. Standardized mortality ratios (SMRs) were estimated to investigate whether longevous siblings have a survival advantage compared with longevous singletons and we investigated whether parents of longevous siblings harbor a life-long sustained survival advantage compared with the general Dutch population by estimating lifetime SMRs (L-SMRs). We found that sibships with long-lived mothers and non-long-lived fathers had 0.41 (p = .024) less observed deaths than sibships with long-lived fathers and non-long-lived mothers and 0.48 (p = .008) less observed deaths than sibships with both parents non-long lived. Participants had 18.6 per cent less deaths compared with matched singletons and parents had a life-long sustained survival advantage (L-SMR = 0.510 and 0.688). In conclusion, genetic longevity studies may incorporate the maternal transmission pattern and genes influencing the entire life-course of individuals.
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Project description:ObjectiveUltrahigh therapy use has increased in SNFs without concomitant increases in residents' characteristics. It has been suggested that this trend may also have influenced the provision of high-intensity rehabilitation therapies to residents who are at the end of life (EOL). Motivated by lack of evidence, we examined therapy use and intensity among long-stay EOL residents.DesignAn observational study covering a time period 2012-2016.Setting and participantsNew York State nursing homes (N = 647) and their long-stay decedent residents (N = 55,691).MethodsData sources included Minimum Data Set assessments, vital statistics, Nursing Home Compare website, LTCfocus, and Area Health Resource File. Therapy intensity in the last month of life was the outcome measure. Individual-level covariates were used to adjust for health conditions. Facility-level covariates were the key independent variables of interest. Multinomial logistic regression models with facility random effects were estimated.ResultsOverall, 13.6% (n = 7600) of long-stay decedent residents had some therapy in the last month of life, 0% to 45% across facilities. Of those, almost 16% had very high/ultrahigh therapy intensity (>500 minutes) prior to death. Adjusting for individual-level covariates, decedents in the for-profit facilities had 18% higher risk of low/medium therapy [relative risk ratio (RRR) = 1.182, P < .001], and more than double the risk of high/ultrahigh therapy (RRR = 2.126, P < .001), compared to those with no therapy use in the last month of life. In facilities with higher physical therapy staffing, decedents had higher risk (RRR = 16.180, P = .002) of high/ultrahigh therapy, but not of low/medium therapy intensity. The use of high/ultrahigh therapy in this population has increased over time.Conclusions and relevanceThis is a first study to empirically demonstrate that facility characteristics are associated with the provision of therapy intensity to EOL residents. Findings suggest that facilities with a for-profit mission, and with higher staffing of therapists, may be more incentivized to maximize therapy use, even among the sickest of the residents.
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