Patterns of oral anticoagulant use for atrial fibrillation following transition to long-term care.
Patterns of oral anticoagulant use for atrial fibrillation following transition to long-term care.
Little is known regarding antithrombotic prescribing in U.S. hospice patients. We quantified the prevalence and predictors of receiving an antithrombotic prescription on hospice admission.
This was a cross-sectional study using electronic health record data from adult (age ≥ 18 years) decedents of a large, for-profit hospice chain who died between January 1, 2017, and December 31, 2019. Our primary outcome was having a prescription for antithrombotic (anticoagulant or antiplatelet) therapy on hospice admission. We used multivariable logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).
Among 54,643 hospice decedents, the mean age was 79.7 (standard deviation (SD) 13.2) years, 44.6% were male, and 57.0% were White. The median hospice length of stay was 9 (interquartile range 3–40) days, and 18,531 patients (33.9%) had a Palliative Performance Scale (PPS) score of 30%. Overall, 11,360 patients (20.8%) had at least one antithrombotic prescription on hospice admission. The most frequently prescribed antithrombotic classes were antiplatelets (15.7%) and direct oral anticoagulants (3.7%). Patients with PPS scores of 20%–30% (adjusted OR (aOR) 9.38, 95% CI 8.03–10.95), 40%–50% (aOR 15.69, 95% CI 13.38–18.40), and 60%–100% (aOR 15.67, 95% CI 12.41–19.79) were significantly more likely to receive an antithrombotic prescription compared to patients with a PPS score < 20%. Additionally, patients receiving care in an assisted living facility (aOR 4.34, 95% CI 3.86–4.87), nursing home (aOR 4.02, 95% CI 3.62–4.47), or at home (aOR 4.08, 95% CI 3.74–4.45) were more likely to receive an antithrombotic prescription compared to patients receiving care in an inpatient hospice setting.
Antithrombotic therapy was prevalent on hospice admission and most associated with better patient prognosis and non-inpatient hospice care locations. More research is needed to optimize antithrombotic prescribing in hospice care.
The Age-Friendly Health System movement has been building teams and systems to implement the assessment of the “4Ms” (What Matters, Medications, Mobility, and Mentation). Although each of the 4Ms is an evidence-based practice, the reporting of outcomes for people who receive the assessment of all 4Ms has been limited.
This retrospective matched cohort study included Veterans admitted to six VA medical centers implementing inpatient assessment of the 4Ms from January 2022 to December 2024. Using electronic health records, we identified a cohort of Veterans admitted to inpatient wards and with documented assessment of the 4Ms. Propensity score matching was used to select a matched cohort without complete 4M assessments. The matching algorithm required matching on facility, admission quarter, and year in addition to a propensity score based on covariates including demographics and comorbidities. We selected the AFHS outcomes of 30-day readmission, emergency department use, and mortality. We used Kaplan–Meier methods to estimate cumulative incidence of outcomes and Cox proportional hazard models to estimate hazard ratios.
The propensity matching analysis resulted in 2420 Veterans with 4Ms care and 4688 matched Veterans without (mean age 79 years, 97% male). The matched groups were well balanced. AFHS care with the 4Ms was associated with reduced hazard for readmission (HR 0.67, 95% CI 0.62–0.73) and statistically similar hazard for ED visits in 30 days (HR 0.95, 95% CI 0.82–1.13) and mortality (HR 1.02, 95% CI 0.86–1.21). Results were similar when restricting to those with dementia and excluding those with any of the 4Ms assessments in the control group.
In this retrospective cohort study, AFHS care including assessment of the 4Ms was associated with reduced readmission without changes in emergency department visits or mortality. The results support the effort of implementing AFHS evidence-based practices into inpatient care sites.
Social engagement is crucial for well-being, yet caregivers often face restrictions due to care responsibilities. The caregiver-specific consequences of these restrictions are underexplored.
We used cross-sectional data from the National Study of Caregiving (2021), a nationally representative study of 1619 unpaid caregivers of adults aged 65 years and older. Caregivers reported if care responsibilities kept them from participating in four social activities (visiting friends/family, attending religious services, going out for enjoyment, and attending group activities). Caregiver burden (emotional, physical, and/or financial) was self-reported. “Any” burden was defined as reporting at least one of the three types of burden. We performed survey-weighted, multivariable logistic regression to determine the adjusted probability of caregiver burden based on social activity participation.
Caregivers were on average 62.5 (SD 22) years old, 65% female, 53% children of the care recipient, and 73% White. 43% reported at least one form of caregiving burden: 35% emotional, 17% physical, and 9% financial. Caregivers had higher adjusted probabilities of “any” caregiving burden (p < 0.001) if they were kept from going out (88% vs. 62%), visiting family/friends (86% vs. 55%), or engaging in group activities (88% vs. 61%). For missed religious activities, caregivers primarily reported higher burden if they rated the missed activities as “important” versus “unimportant” (Any burden: 85% vs. 57%; Emotional burden: 74% vs. 45%; Physical burden: 65% vs. 29%, p < 0.05). Importance was not significant for other activities. There was a step-wise association between the number of missed activities and any reported burden (0 activities missed: 54%, 1 activity: 77%, 2+ activities: 91%, p < 0.01).
Restriction from social activities was associated with higher caregiver burden, with the impact of missing religious activities influenced by its importance to the caregiver. These findings emphasize the need for tailored interventions to help caregivers maintain social engagement despite care responsibilities.
For older adults with critical illness, decisions about life-sustaining therapies can be challenging. A time-limited trial (TLT) is a collaborative care plan endorsed by experts in palliative and critical care to help navigate these challenges. TLTs entail trying life-sustaining therapy for a defined duration. Response to treatment then informs whether to continue recovery-directed care or shift focus exclusively to comfort. TLTs require collaboration among clinicians, patients, and/or surrogate decision makers, yet there is little practical guidance on how to accomplish this. Thus, we sought to design a collaborative TLT planning tool and characterize its valued characteristics.
In this qualitative study framed by human-centered Design Thinking, we conducted a series of semi-structured interviews (n = 25) and focus groups (n = 5) with 28 participants who were (1) older adults (age ≥ 65) with serious illness, (2) adults of any age with surrogate decision-making experience for an older adult, and/or (3) intensive care unit (ICU) physicians. We purposively sampled across a Midwestern state to achieve diverse representation and used the Rigorous and Accelerated Data Reduction (RADaR) technique for qualitative analysis.
We used participants' input to design the ICU Care Plan, a paper-based tool consisting of a fillable template. The tool is designed to guide a collaborative TLT planning conversation among clinicians, patients, and surrogates and then serve as a visual summary of the care plan. Participants endorsed the tool as (1) creating a unified frame of reference for a complex process; (2) promoting transparency; and (3) setting and managing expectations. The tool exemplifies participants' design priorities of simplicity and flexibility.
We used a human-centered design process to develop a tool for in-the-moment TLT planning that is endorsed by older adults, surrogates, and ICU physicians. Low technology, intentionally simple interventions are a promising approach to promote patient- and family-centered collaboration.
Documentation of patient goals and preferences within medical records has the potential to align medication use with goals of care (GoC) and individualize medication appropriateness criteria. We characterized patient and surrogate-expressed GoC for older Veterans living with dementia and explored concordance with medication use during VA Community Living Center (CLC) (i.e., nursing home) stays.
We conducted a cross-sectional analysis using the VA Residential History File, Minimum Data Set, Corporate Data Warehouse, and Medicare claims for Veterans with dementia admitted to VA CLCs from 4/2021 to 12/2021 for > 7 days. We extracted free text responses for “Veteran goals in own words” from a standardized GoC note. Two coders classified GoC topics using iterative coding. We examined bar code medication administration data for aspirin, benzodiazepines, opioids and antidementia medications within the 7 days following admission. We determined a schema for potential goal-concordant medication use (e.g., opioids for GoC focused on comfort) and assessed concordance of medication use with GoC topics.
Among 1000 VA CLC residents with dementia and GoC documented, 46.4% of responses were reported by the Veteran versus a surrogate. Common topics included comfort (44.6%), life-sustaining treatments (31.8%), function (13.7%), care setting/transitions (12.9%), and life prolongation (11.2%). Medications were seldom discussed. Opioid and benzodiazepine use was classified as goal-concordant for 56.7% and 72.2% of patients who used them. Aspirin and antidementia medication use was more commonly classified as goal-discordant (54.7% and 38.7%, respectively).
Goals elicited via an open-ended question provided only indirect information relevant to medication use, but in many cases could be used to refine judgments of appropriateness. Integration of patient goals into formal criteria evaluating medication appropriateness is a logical next step for medication optimization research. Future research should explore the utility of questions specific to medications in GoC conversations for individuals with dementia.
The relationship between frailty and patient experiences of cancer care and treatment remains underexplored. This study evaluated this association using validated tools to assess frailty and various aspects of patient experience.
We conducted a prospective observational study of 584 patients with cancer who underwent comprehensive geriatric assessment (CGA) at a geriatric oncology service prior to treatment decision-making (August 2020–July 2022). Frailty was classified using a CGA-based frailty index as fit (< 0.2), pre-frail (0.2–0.35), or frail (> 0.35). Patient experience was assessed using the Control Preference Scale (CPS), Patient Assessment of Care for Chronic Conditions (PACIC) subscales (delivery system design/decision support and problem-solving/contextual counseling), and Decision Regret Scale (DRS). Logistic regression examined associations between frailty and outcomes, adjusting for relevant covariates.
The median age was 80 years (range, 51–97). Twenty percent of the patients were fit, 38% were pre-frail, and 42% were frail. Frailty was not associated with discordance between preferred and actual CPS roles (p = 0.14). However, frail patients were less likely than fit patients to report high-quality care based on PACIC scores at 3 and 6 months (p < 0.05). Moderate to strong regret (DRS score > 25) was expressed by 115 patients (28%) at 3 months and 109 patients (31%) at 6 months. Adjusted odds ratios for moderate to strong regret in frail versus fit patients were 2.61 (95% CI, 1.40–4.91; p = 0.003) at 3 months and 2.41 (95% CI, 1.30–4.50; p = 0.005) at 6 months.
Frailty was associated with lower perceived quality of care and higher decision regret following cancer treatment but not with differences in decision-making roles. Further research is warranted to understand the mechanisms underlying these associations to improve care experiences for older adults with cancer.
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