6810 Montague Dr
Amarillo TX 79109
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Cost Savings Associated With an Inpatient Palliative Care Unit: Results From the First Two Years. - Journal of pain and symptom management
Palliative care consultation services (PCCS) decrease costs for patients by matching treatments received to patients' and families' goals of care. However, few studies have examined the costs of a specialized palliative care unit (PCU).To quantitatively describe Mount Sinai Hospital's PCU's first two years of operation; to examine how patient-related costs changed in the days before and after transfer to PCU; and to compare cost savings of PCU to those of PCCS.Cost and administrative data from PCU patients from the first 24.5 months of our PCU's operation were analyzed. To compare costs between PCU and PCCS patients, we matched PCU patients to similar PCCS patients and used propensity scores to adjust for differences across groups.The PCU admitted 1107 patients in its first 24.5 months. Over this time frame, there was a statistically significant (PÂ <Â 0.001) decrease in average daily direct costs per patient. The mean of patients' average cost per day was $687 less while on the PCU than before transfer to PCU. Among patients who died in the hospital, average daily direct cost per patient in the days after transfer to PCU was $240 lower as compared with patients being followed by PCCS on the general hospital wards (SEÂ =Â $45, PÂ <Â 0.001).Among patients who died in the hospital, transfer to a PCU is associated with significant cost savings as compared with patients on hospital wards who are seen by a PCCS.Published by Elsevier Inc.
A survey of bereaved family members to assess quality of care on a palliative care unit. - Journal of palliative medicine
More U.S. hospitals are adopting palliative care programs, prompting inquiry about the relationship of palliative care to patient and family satisfaction. This study compares the impact of palliative care units, palliative care consultation, and usual care on bereaved families' perceptions of care quality.Using the Bereaved Family Survey we conducted interviews with family members of patients who died at Mount Sinai Medical Center between March 2012 and March 2013.Of 108 completed surveys, 31 were in the palliative care unit group, 28 in the consultation service group, and 49 in the usual care group. Family members of patients who died on the palliative care unit were more likely to report that their loved one's end-of-life medical care had been "excellent" as compared to family members of patients who received palliative care consultation or usual care (adjusted OR, 2.06; 95% CI, 1.17-3.61). Family members of palliative care unit patients also reported greater satisfaction with emotional support before the patient's death (adjusted OR, 1.71; 95% CI, 1.01-2.90). We found no significant differences between the consultation service and usual care.Family members of patients who died while receiving care in a dedicated palliative care unit report higher overall satisfaction and emotional support before death as compared to the consultation service or usual care.
Dyadic psychosocial intervention for advanced lung cancer patients and their family caregivers: results of a randomized pilot trial. - Cancer
Advanced lung cancer (LC) patients and their families have reported low self-efficacy for self-care/caregiving and high rates of distress, yet few programs exist to address their supportive care needs during treatment. This pilot study examined the feasibility, acceptability, and preliminary efficacy of a 6-session, telephone-based dyadic psychosocial intervention that was developed for advanced LC patients and their caregivers. The program was grounded in self-determination theory (SDT), which emphasizes the importance of competence (self-efficacy), autonomy (sense of choice/volition), and relatedness (sense of belonging/connection) for psychological functioning. The primary outcomes were patient and caregiver psychological functioning (depression/anxiety) and caregiver burden. The secondary outcomes were the SDT constructs of competence, autonomy, and relatedness.Thirty-nine advanced LC patients who were within 1 month of treatment initiation (baseline) and their caregivers (51% spouses/partners) completed surveys and were randomized to the intervention or usual medical care. Eight weeks after baseline, they completed follow-up surveys.Solid recruitment (60%) and low attrition rates demonstrated feasibility. Strong program evaluations (mean, 8.6/10) and homework completion rates (88%) supported acceptability. Participants receiving the intervention evidenced significant improvements (Pâ€‰<â€‰.0001) in depression, anxiety, and caregiver burden in comparison with usual medical care. Large effect sizes (dâ€‰â‰¥â€‰1.2) favoring the intervention were also found for patient and caregiver competence and relatedness and for caregiver autonomous motivation for providing care.These findings support intervention feasibility, acceptability, and preliminary efficacy. By empowering families with the skills to coordinate care and meet the challenges of LC together, this intervention holds great promise for improving palliative/supportive care services in cancer.Â© 2014 American Cancer Society.
Engaging heart failure clinicians to increase palliative care referrals: overcoming barriers, improving techniques. - Journal of palliative medicine
Heart failure (HF) is the most common cause of hospitalization among adults over the age of 65. Hospital readmission rates, mortality rates, and Medicare costs for patients with this disease are high. Furthermore, patients with HF experience a number of symptoms that worsen as the disease progresses. However, a small minority of patients with HF receives hospice or palliative care. One possible reason for this may be that the HF and palliative care clinicians have differing perspectives on the role of palliative care for these patients.The goal of the article is to offer palliative care clinicians a roadmap for collaborating with HF clinicians by reviewing the needs of patients with HF.This article reviews the needs of patients with HF and their families, the barriers to referral to palliative care for patients with HF, and provides suggestions for improving collaboration between palliative care and HF clinicians.
A study to improve communication between clinicians and patients with advanced heart failure: methods and challenges behind the working to improve discussions about defibrillator management trial. - Journal of pain and symptom management
We report the challenges of the Working to Improve Discussions About Defibrillator Management trial, our novel, multicenter trial aimed at improving communication between cardiology clinicians and their patients with advanced heart failure (HF) who have implantable cardioverter defibrillators (ICDs). The study objectives are (1) to increase ICD deactivation conversations, (2) to increase the number of ICDs deactivated, and (3) to improve psychological outcomes in bereaved caregivers. The unit of randomization is the hospital, the intervention is aimed at HF clinicians, and the patient and caregiver are the units of analysis. Three hospitals were randomized to usual care and three to intervention. The intervention consists of an interactive educational session, clinician reminders, and individualized feedback. We enroll patients with advanced HF and their caregivers, and then we regularly survey them to evaluate whether the intervention has improved communication between them and their HF providers. We encountered three implementation barriers. First, there were institutional review board concerns at two sites because of the palliative nature of the study. Second, we had difficulty in creating entry criteria that accurately identified an HF population at high risk of dying. Third, we had to adapt our entry criteria to the changing landscape of ventricular assist devices and cardiac transplant eligibility. Here we present our novel solutions to the difficulties we encountered. Our work has the ability to enhance conduct of future studies focusing on improving care for patients with advanced illness.Published by Elsevier Inc.
The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors. - Journal of critical care
To determine whether frailty can be measured within 4 days prior to hospital discharge in older intensive care unit (ICU) survivors of respiratory failure and whether it is associated with post-discharge disability and mortality.We performed a single-center prospective cohort study of 22 medical ICU survivors age 65 years or older who had received noninvasive or invasive mechanical ventilation for at least 24 hours. Frailty was defined as a score of â‰¥3 using Fried's 5-point scale. We measured disability with the Katz Activities of Daily Living. We estimated unadjusted associations between Fried's frailty score and incident disability at 1-month and 6-month mortality using Cox proportional hazard models.The mean (SD) age was 77 (9) years, mean Acute Physiology and Chronic Health Evaluation II score was 27 (9.7), mean frailty score was 3.4 (1.3), and 18 (82%) were frail. Nine subjects (41%) died within 6 months, and all were frail. Each 1-point increase in frailty score was associated with a 90% increased rate of incident disability at 1-month (rate ratio: 1.9, 95% CI 0.7-4.9) and a threefold increase in 6-month mortality (rate ratio: 3.0, 95% CI 1.4-6.3).Frailty can be measured in older ICU survivors near hospital discharge and is associated with 6-month mortality in unadjusted analysis. Larger studies to determine if frailty independently predicts outcomes are warranted.Copyright Â© 2014 Elsevier Inc. All rights reserved.
High burden of palliative needs among older intensive care unit survivors transferred to post-acute care facilities. a single-center study. - Annals of the American Thoracic Society
Adults with chronic critical illness (tracheostomy after â‰¥ 10 d of mechanical ventilation) have a high burden of palliative needs, but little is known about the actual use and potential need of palliative care services for the larger population of older intensive care unit (ICU) survivors discharged to post-acute care facilities.To determine whether older ICU survivors discharged to post-acute care facilities have potentially unmet palliative care needs.We examined electronic records from a 1-year cohort of 228 consecutive adults â‰¥ 65 years of age who had their first medical-ICU admission in 2009 at a single tertiary-care medical center and survived to discharge to a post-acute care facility (excluding hospice). Use of palliative care services was defined as having received a palliative care consultation. Potential palliative care needs were defined as patient characteristics suggestive of physical or psychological symptom distress or anticipated poor prognosis. We examined the prevalence of potential palliative needs and 6-month mortality.The median age was 78 years (interquartile range, 71-84 yr), and 54% received mechanical ventilation for a median of 7 days (interquartile range, 3-16 d). Six subjects (2.6%) received a palliative care consultation during the hospitalization. However, 88% had at least one potential palliative care need; 22% had chronic wounds, 37% were discharged on supplemental oxygen, 17% received chaplaincy services, 23% preferred to not be resuscitated, and 8% were designated "comfort care." The 6-month mortality was 40%.Older ICU survivors from a single center who required postacute facility care had a high burden of palliative care needs and a high 6-month mortality. The in-hospital postcritical acute care period should be targeted for palliative care assessment and intervention.
Changes in ankle brachial pulse wave velocity during a five-year follow-up period in older Japanese adults: sub-analysis results of the health research volunteer study in Japan. - Internal medicine (Tokyo, Japan)
Brachial-ankle pulse wave velocity (baPWV) is a measure of arterial stiffness. However, precisely how aging, hypertension and other factors influence this in progressively stiffening large arteries, especially in older adults, remains uncertain. We examined changes in arterial stiffness in a population of active older Japanese adults using a five-year follow-up cohort study.Comprehensive geriatric assessments were performed in socially active adults over the age of 70 years at The Life Planning Center Clinic in Tokyo. Clinically acceptable baPWV measurements at baseline and at the end of the study were obtained in 257 individuals (115 men, baseline mean age of 78Â±4 years; 142 women, baseline mean age of 77Â±4 years) classified into four groups based on the use of antihypertensive interventions at the end of the study: Group 1 (112 normotensives), Group 2 (49 hypertensives without medication use), Group 3 (39 hypertensives with medication use initiated during the follow-up period) and Group 4 (57 hypertensives receiving medications throughout the follow-up period).During the follow-up period, Group 1 exhibited no changes in blood pressure with increases in baPWV. Group 2 exhibited increases in blood pressure and baPWV. Both Groups 3 and 4 exhibited decreases in blood pressure without any changes in baPWV. Other factors such as age, gender and the hemoglobin level could also have influenced baPWV.Arterial stiffness increases with aging; however, antihypertensive medications were found to provide protective effects against the development of arterial stiffness during a five-year follow-up period. Other factors that modify baPWV were also identified.
Educational and psychological interventions to improve outcomes for recipients of implantable cardioverter defibrillators and their families: a scientific statement from the American Heart Association. - Circulation
Significant mortality benefits have been documented in recipients of implantable cardioverter defibrillators (ICDs); however, the psychosocial distress created by the underlying arrhythmia and its potential treatments in patients and family members may be underappreciated by clinical care teams. The disentanglement of cardiac disease and device-related concerns is difficult. The majority of ICD patients and families successfully adjust to the ICD, but optimal care pathways may require additional psychosocial attention to all ICD patients and particularly those experiencing psychosocial distress. This state-of-the-science report was developed on the basis of an analysis and critique of existing science to (1) describe the psychological and quality-of-life outcomes after receipt of an ICD and describe related factors, such as patient characteristics; (2) describe the concerns and educational/informational needs of ICD patients and their family members; (3) outline the evidence that supports interventions for improving educational and psychological outcomes for ICD patients; (4) provide recommendations for clinical approaches for improving patient outcomes; and (5) identify priorities for future research in this area. The ultimate goal of this statement is to improve the precision of identification and care of psychosocial distress in ICD patients to maximize the derived benefit of the ICD.
A pilot trial to predict frailty syndrome: the Japanese Health Research Volunteer Study. - Experimental gerontology
Most definitions of frailty utilize US populations in their development. The concept of frailty has not been well studied in Japan, which has the largest percentage of older patients (per capita) in the world. We created a 5-year prospective cohort study of community-dwelling older Japanese adults. Participants were not frail at baseline, based on our definition adapted from the Canadian Study for Health and Aging Clinical Frailty Scale. Participants underwent a comprehensive geriatric assessment (CGA) at baseline, and final assessments were either in person or via mailed survey. We enrolled 407 individuals (184 men, mean age 78 Â± 4 years; 223 women, mean age 77 Â± 4 years). Sixty-five participants met criteria for frailty by the end of the study. In univariate analyses, eighteen separate parameters were associated with frailty, some of which included: age, gender, handgrip, timed walk, systolic blood pressure, pulse pressure, cognitive status, living alone, and hearing deficits. In multivariate analyses, the following elements remained associated with frailty: timed walk, pulse pressure, cognition deficits and hearing deficits. We established cut-off points for timed walk (5m/3s) and pulse pressure (60 mmHg). We then created a simple additive score for these four factors (present = 1; absent = 0). A score of 0 had a 93% negative predictive value for frailty while a score of 4 had a 70% positive predictive value. While further study is needed, this work creates an easy-to-administer tool that may be generalizable to other populations.Copyright Â© 2012 Elsevier Inc. All rights reserved.
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6810 Montague Dr Amarillo, TX 79109
2455 I-40 W