Hostname: page-component-cd9895bd7-7cvxr Total loading time: 0 Render date: 2024-12-25T21:04:08.867Z Has data issue: false hasContentIssue false
  • English
  • Français

Relationships among advance directives, principal diagnoses, and discharge outcomes in critically ill older adults

Published online by Cambridge University Press:  15 August 2012

Ji Won Yoo ,
Shunichi Nakagawa  and
Sulgi Kim
Ji Won Yoo*
Affiliation:
Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan Department of Internal Medicine, Korea University, Seoul, Republic of Korea
Shunichi Nakagawa
Affiliation:
Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York James J. Peters Veterans Affairs Medical Center, Geriatric Research, Education and Clinical Center, Bronx, New York
Sulgi Kim
Affiliation:
Department of Epidemiology, University of Washington, Seattle, Washington
*
Address correspondence and reprint requests to: Ji Won Yoo, University of Michigan Medical School – Internal Medicine, 300 North Ingalls Building, Room 932, Ann Arbor, MI 48109-2007. E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

The purpose of this study was to determine the relationships among advance directive status, principal diagnoses, and the discharge outcomes in community-dwelling, critically ill older adults.

Method:

Using administrative and clinical data (n = 1673), multinomial logit regressions were used to examine the relationships among advance directive status, principal diagnoses, and discharge outcomes (in-hospital deaths, hospice discharges, and transition to institutions).

Results:

In the overall sample, the adjusted probability of in-hospital deaths with advance directives (12%) was lower than that without advance directives (17%; odds ratio [OR] = 0.56; p = 0.007) and the adjusted probability of hospice discharges with advance directives (11%) was higher than that without advance directives (7%; OR = 1.96; p = 0.03). Subgroup analysis showed that the magnitude of the abovementioned changes was aggregated when their principal diagnoses were a group of diseases with more difficult prognostication (circulatory and respiratory diseases) and more potential for reversibility (infectious diseases). By contrast, the magnitude of the abovementioned findings was diminished with other principal diagnoses. On the other hand, the presence of advance directives did not make a contribution to transition from communities to institutions.

Significance of results:

Significantly fewer in-hospital deaths in addition to higher hospice discharges were observed with any advance directives in community-dwelling, critically ill older adults. The magnitude of these findings was aggregated when their principal diagnoses were a group of diseases with more difficult prognostication (circulatory and respiratory diseases) and more potential for reversibility (infectious diseases). By contrast, the magnitude of these findings was diminished with other principal diagnoses.

Keywords

Critical careHealth services for the agedAdvance directivesDiagnosis-related groups
Type
Original Articles
Information
Palliative & Supportive Care , Volume 11 , Issue 4 , August 2013 , pp. 315 - 322
Copyright
Copyright © Cambridge University Press 2012 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

American Hospital Association. (2010). Trendwatch chartbook: Trends in hospital financing. http://www.aha.org/aha/trendwatch/chartbook/2010/chapter4.pdf.Google Scholar
American Medical Association. (2010). Code of Medical Ethics of the American Medical Association 2010–2011: Council on Ethical and Judicial Affairs, Current Opinions with Annotations. Chicago: American Medical Association.Google Scholar
Angus, D.C., Linde-Zwirble, W.T., Lidicker, J., et al. (2001). Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical Care Medicine, 29, 1303–1310.Google Scholar
Auerbach, A.D., Katz, R., Pantilat, S.Z., et al. (2008). Factors associated with discussion of care plans and code status at the time of hospital admission: Results from the Multicenter Hospitalist Study. Journal of Hospital Medicine, 3, 437–445.CrossRefGoogle ScholarPubMed
Brody, A.A., Ciemins, E., Newman, J., et al. (2010). Effects of an inpatient palliative care team on discharge disposition. Journal of Palliative Medicine, 13, 541–548.Google Scholar
Cher, D.J. & Lenert, L.A. (1997). Method of Medicare reimbursement and the rate of potentially ineffective care of critically ill patients. Journal of the American Medical Association, 278, 1001–1007.CrossRefGoogle ScholarPubMed
Curtis, J.R. & Rubenfeld, G.D. (2001). Managing Death in the ICU: The Transition from Cure to Comfort. Oxford: Oxford University Press.Google Scholar
Digwood, G., Lustbader, D., Pekmezaris, R., et al. (2011). The impact of a palliative care unit on mortality rate and length of stay for medical intensive care unit patients. Palliative & Support Care, 9, 387–392.CrossRefGoogle ScholarPubMed
Fox, E., Landrum–McNiff, K., Zhong, Z., et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Journal of the American Medical Association, 282, 1638–1645.CrossRefGoogle ScholarPubMed
Halpern, N.A. & Pastores, S.M. (2010). Critical care medicine in the United States 2000–2005: An analysis of bed numbers, occupancy rates, payer mix, and costs. Critical Care Medicine, 38, 65–71.CrossRefGoogle ScholarPubMed
Hanks, G., Cherny, N.I., Christakis, N.A., et al. (2009). Oxford Textbook of Palliative Medicine, 4th ed.Oxford: Oxford University Press.Google Scholar
Hirschman, K.B., Abbott, K.M., Hanlon, A.L., et al. (2012). What factors are associated with having an advance directive among older adults who are new to long-term care services? Journal of American Medical Director Association, 13, 82.e7–11.CrossRefGoogle ScholarPubMed
Hosmer, D.W. & Lemeshow, S. (2001). Applied Logistic Regression, 2nd ed.New York: John Wiley and Sons.Google Scholar
Iwashyna, T.J., Ely, E.W., Smith, D.M., et al. (2010). Long-term cognitive impairment and functional disability among survivors of severe sepsis. Journal of the American Medical Association, 304, 1787–1794.CrossRefGoogle ScholarPubMed
Kaufmann, P.A., Smolle, K.H. & Krejs, G.J. (2009). Short- and long-term survival of nonsurgical intensive care patients and its relation to diagnosis, severity of disease, age and comorbidities. Current Aging Science, 2, 240–248.Google Scholar
Kelly, A.S., Ettner, S.L., Wenger, N.S., et al. (2011). Determinants of death in the hospital among older adults. Journal of American Geriatrics Society, 59, 2321–2325.CrossRefGoogle Scholar
Khouli, H., Astua, A., Dombrowski, W., et al. (2011). Changes in health-related quality of life and factors predicting long-term outcomes in older adults admitted to intensive care units. Critical Care Medicine, 39, 731–737.CrossRefGoogle ScholarPubMed
Kutner, J.S., Blake, M. & Meyer, S.A. (2002). Predictors of live hospice discharge: Data from the National Home and Hospice Care Survey (NHHCS). American Journal of Hospice & Palliative Care, 19, 331–337.Google Scholar
Kutner, J.S., Meyer, S.A., Beaty, B.L., et al. (2004). Outcomes and characteristics of patients discharged alive from hospice. Journal of American Geriatrics Society, 52, 1337–1342.Google Scholar
Lagman, R.L., Walsh, D., Davis, M.P., et al. (2007). All patient refined-diagnostic related group and case mix index in acute care palliative medicine. Journal of Supportive Oncology, 5, 145–149.Google Scholar
Lustbader, D., Pekmezaris, R., Frankenthaler, M., et al. (2011). Palliative medicine consultation impacts DNR designation and length of stay for terminal medical MICU patients. Palliative & Support Care, 9, 401–406.Google Scholar
Medicare Payment Advisory Commission. (2011). Hospital inpatient and outpatient services: Assessing payment adequacy and updating payments. http://www.medpac.gov/chapters/mar11_ch03.pdf.Google Scholar
Milbrandt, E.B., Kersten, A., Rahim, M.T., et al. (2008). Growth of intensive care unit resource use and its estimated cost in Medicare. Critical Care Medicine, 36, 2504–2510.Google Scholar
Morrell, E.D., Brown, B.P., Qi, R., et al. (2008). The do-not-resuscitate order: Associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act. Journal of Medical Ethics, 34, 642–647.CrossRefGoogle ScholarPubMed
Morrison, R.S., Penrod, J.D., Cassel, J.B., et al. (2008). Cost savings associated with US hospital palliative care consultation programs. Archives of Internal Medicine, 168, 1783–1790.Google Scholar
Nagappan, R. & Parkin, G. (2003). Geriatric critical care. Critical Care Clinics, 19, 253–270.CrossRefGoogle ScholarPubMed
Pisani, M.A. (2009). Considerations in caring for the critically ill older patient. Journal of Intensive Care Medicine, 24, 83–95.Google Scholar
Silveira, M.J., Kim, S.Y. & Langa, K.M. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, italic, 1211–1218.Google Scholar
Smith, T.J., Coyne, P., Cassel, B., et al. (2003). A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. Journal of Palliative Medicine, 6, 699–705.Google Scholar
Stokes, M.E., Davis, C.S. & Koch, G.G. (2009). Categorical Data Analysis Using the SAS System, 2nd ed.Cary, NC: SAS Institute.Google Scholar
SUPPORT Principal investigators. (1995). A controlled trial to improve care for seriously ill hospitalized patients: The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). Journal of the American Medical Association, 274, 1591–1598.CrossRefGoogle Scholar
Teno, J.M., Gruneir, A., Schwartz, Z., et al. (2007). Associations between advance directives and quality of end-of-life care: A national study. Journal of American Geriatrics Society, 55, 189–194.CrossRefGoogle ScholarPubMed
Teno, J.M., Licks, S., Lynn, J., et al. (1997). Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Journal of American Geriatrics Society, 45, 508–512.CrossRefGoogle ScholarPubMed
Teres, D., Rapoport, J., Lemeshow, S., et al. (2002). Effects of severity of illness on resource use by survivors and nonsurvivors of severe sepsis at intensive care unit admission. Critical Care Medicine, 30, 2413–2419.Google Scholar
Weissman, D.E. & Spragens, L.H. (2010). Disruptive innovation: Leveraging palliative care for the cost/quality sweet spot. 18th Annual Health Forum and the American Hospital Association leadership summit, San Diego, CA.Google Scholar
Wood, K.A. & Ely, E.W. (2003). What does it mean to be critically ill and elderly? Current Opinion in Critical Care, 9, 316–320.Google Scholar
Zier, L.S., Burack, J.H., Micco, G., et al. (2009). Surrogate decision makers' responses to physicians' predictions of medical futility. Chest, 136, 110–117.Google Scholar