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Unroe M.,Duke University | Kahn J.M.,University of Pennsylvania | Carson S.S.,University of North Carolina at Chapel Hill | Govert J.A.,Duke University | And 7 more authors.
Annals of Internal Medicine | Year: 2010

Background: Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care facilities or about the associated resource utilization. Objective: To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation. Design: 1-year prospective cohort study. Setting: 5 intensive care units at Duke University Medical Center, Durham, North Carolina. Participants: 126 patients receiving prolonged mechanical ventilation (defined as ventilation for ≥4 days with tracheostomy placement or ventilation for ≥21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year. Measurements: Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. Physicians were interviewed in the hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and interfacility transportation. Medicare claims data were used to assign costs for postacute care. Results: 103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions [interquartile range, 3 to 5 transitions]), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 year, 11 patients (9%) had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency [4 patients; 21%] or dead [56 patients; 44%]). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was $306 135 (SD, $285 467), and total cohort cost was $38.1 million, for an estimated $3.5 million per independently functioning survivor at 1 year. Limitation: The results of this single-center study may not be applicable to other centers. Conclusion: Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support. Primary Funding Source: None. © 2010 American College of Physicians. Source

Russell B.J.,Center for Palliative Care | Rowett D.,Drug and Therapeutics Information Service | Currow D.C.,Flinders University
Journal of the American Geriatrics Society | Year: 2014

Objectives To document pro re nata (PRN) prescribing practices and to identify patterns with respect to clinical characteristics and the medications prescribed. Design Prospective consecutive case note review. Setting Two interrelated consultative hospice and palliative care services in regional Victoria, Australia. Participants Terminally ill inpatients and community-based individuals (N = 203) at the time of referral to a hospice or palliative care service. Measurements Number of medications that the referring physician prescribed on a PRN basis and on a regular basis for symptom control; comorbid disease, performance status, comorbidity burden, disease phase, and survival. Results Mean number of PRN medications prescribed was 3.0, with significantly higher rates in the last week of life (rate ratio (RR) = 1.30, 95% confidence interval (CI) = 1.07-1.59) and during the terminal phase of disease (RR = 1.36, 95% CI = 1.09-1.68). One-quarter of prescriptions were for medications that met the Beers consensus criteria for potentially inappropriate medication use in elderly persons. Conclusion These descriptive baseline data are new. A mean of three different medications allows responsiveness to a variety of fluctuating symptoms, but there was a large range within the sample, indicating that some individuals and their caregivers have a high burden of administration-related decision-making. © 2014, The American Geriatrics Society. Source

Hudson P.L.,University of Melbourne | Hudson P.L.,Queens University of Belfast | Hudson P.L.,Center for Palliative Care | Zordan R.,University of Melbourne | And 2 more authors.
Journal of Palliative Medicine | Year: 2011

Background and purpose: Reviews of the literature have consistently highlighted significant gaps with regard to research associated with family caregivers within the context of palliative care. We sought to determine a priority driven research agenda for this field of inquiry. Methods: A Web-based survey was sent to 80 people who had previously expressed interest in, or were members of The International Palliative Care Family Carer Research Collaboration (http://centreforpallcare.org/index.php/research/ipcfcrc/). Results: Fifty-five participants completed the survey (response rate, 70%) from 12 countries. Priority research areas included: intervention development and testing; underresearched caregiver groups; access to services; unmet needs; bereavement; experience and implications of the caregiver role; and development of assessment tools. Qualitative responses complemented these data and also acknowledged the importance of collaboration and development of a critical mass of researchers focusing in this area in order to progress knowledge. Conclusions: These results reinforce the findings of systematic reviews that have demonstrated a need for the evolution of intervention development focused on improving family caregiver support. However, there are other key areas that also warrant comprehensive attention, including marginalized family caregivers and strategies to assist health professionals to identify family caregivers who have significant psychosocial issues. © 2011, Mary Ann Liebert, Inc. Source

Stone J.,University of Melbourne | Willenberg L.,Center for Palliative Care | Apicella C.,University of Melbourne | Treloar S.,University of Queensland | Hopper J.,University of Melbourne
Breast Cancer Research and Treatment | Year: 2012

There is evidence that aspirin use reduces the risk of breast cancer. Increased mammographic density is known to be associated with increased breast cancer risk. Little is known about the association between mammographic density and aspirin or other non-steroidal anti-inflammatory drug (NSAID) use, but it is possible that the association between aspirin use and breast cancer risk might be due to the effect of aspirin on mammographic density. Multiple linear regression was used to investigate the association between measures of mammographic density and the use, frequency, and duration of aspirin and other NSAIDs such as paracetamol (acetaminophen), arthritis medication, and other over-the-counter or doctor-prescribed pain medications in 3286 women from the Australian Mammographic Density Twins and Sisters Study and the Genes Behind Endometriosis Study. We found no association between either dense area or percent dense area with any of the NSAIDs examined (all P > 0.06). If aspirin is reducing the breast cancer risk in women, it is likely doing so via a different pathway other than mammographic density measures that predict breast cancer risk. © 2011 Springer Science+Business Media, LLC. Source

Chapman M.D.,Center for Palliative Care | Le B.H.C.,Deaprtment of Palliative Care | Gorelik A.,Melbourne EpiCentre
BMJ Supportive and Palliative Care | Year: 2013

Objectives: Frailty denotes a vulnerability to poor outcomes and is a common risk factor for mortality in older persons. The Vulnerable Elders Survey (VES) is an easy to administer validated screening tool to detect a frail population. Assessment of frailty has the potential to aid in prognostication for the older community dwelling palliative population. This study seeks to evaluate the relationship of the VES to prognosis in this population. Methods: Prospective cohort study of patients over 65 years old admitted to a community palliative care service. The VES was performed in addition to the usual assessments of physical function. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Physical function and CCI were assessed to determine whether they improved the prognostic power of the VES. Patients were followed-up for 8 months with the primary endpoint of survival. Results: 197 patients completed the study with a high proportion of malignant diagnoses (87.5%); 98% of patients died during the study with a median survival of 61 days; 93.4% of patients were vulnerable on the VES and high risk scores predicted death within 100 days. Conclusions: In this study the VES demonstrated high rates of vulnerability and has the potential to improve the accuracy of prognosis in older palliative community dwelling patients. Improving prognostication has potential clinical benefits, including aiding clinical communication and determining the best use of community services. The limitations of this study and the evolving understanding of frailty suggest that further work in this area is required. Source

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