Adults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of ...function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care.
A national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors.
The cohort comprised 76,704 adults with median age 81 years (IQR 70-88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios aHRs. At 0-28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 95%CI 4.90-7.76), chronic obstructive pulmonary disease (aHR 5.01 95% CI 3.78-6.62), dementia (aHR 5.07 95% CI 3.80-6.77) and liver disease (aHR 9.75 95% CI 6.50-14.6) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 95%CI 1.04-1.39) compared with cancer 'other'. Risks increased with high multimorbidity for non-cancer (aHR 2.57 95% CI 2.36-2.79) and cancer (aHR 2.59 95% CI 2.13-3.15) (reference: lowest).
One in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE: Differences in utilization and costs of end-of-life care among developed countries are of considerable policy interest. OBJECTIVE: To compare site of death, health care utilization, and ...hospital expenditures in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using administrative and registry data from 2010. Participants were decedents older than 65 years who died with cancer. Secondary analyses included decedents of any age, decedents older than 65 years with lung cancer, and decedents older than 65 years in the United States and Germany from 2012. MAIN OUTCOMES AND MEASURES: Deaths in acute care hospitals, 3 inpatient measures (hospitalizations in acute care hospitals, admissions to intensive care units, and emergency department visits), 1 outpatient measure (chemotherapy episodes), and hospital expenditures paid by insurers (commercial or governmental) during the 180-day and 30-day periods before death. Expenditures were derived from country-specific methods for costing inpatient services. RESULTS: The United States (cohort of decedents aged >65 years, N = 211 816) and the Netherlands (N = 7216) had the lowest proportion of decedents die in acute care hospitals (22.2.% and 29.4%, respectively). A higher proportion of decedents died in acute care hospitals in Belgium (N = 21 054; 51.2%), Canada (N = 20 818; 52.1%), England (N = 97 099; 41.7%), Germany (N = 24 434; 38.3%), and Norway (N = 6636; 44.7%). In the last 180 days of life, 40.3% of US decedents had an intensive care unit admission compared with less than 18% in other reporting nations. In the last 180 days of life, mean per capita hospital expenditures were higher in Canada (US $21 840), Norway (US $19 783), and the United States (US $18 500), intermediate in Germany (US $16 221) and Belgium (US $15 699), and lower in the Netherlands (US $10 936) and England (US $9342). Secondary analyses showed similar results. CONCLUSIONS AND RELEVANCE: Among patients older than 65 years who died with cancer in 7 developed countries in 2010, end-of-life care was more hospital-centric in Belgium, Canada, England, Germany, and Norway than in the Netherlands or the United States. Hospital expenditures near the end of life were higher in the United States, Norway, and Canada, intermediate in Germany and Belgium, and lower in the Netherlands and England. However, intensive care unit admissions were more than twice as common in the United States as in other countries.
Liver disease mortality increased by 400% in the UK between 1970 and 2010, resulting in rising pressures on acute hospital services, and an increasing need for end-of-life care. We aimed to assess ...the effect of demographic, clinical, and health-care factors on costs, patterns of health-care use, and place of death in a national cohort of patients with cirrhosis and ascites in their last year of life.
We did a retrospective, nationwide analysis of all patients who died from cirrhosis in England between 2013 and 2015, who required large-volume paracentesis in their last year of life. The outcomes measured were health-care costs accrued in the last year of life, number of inpatient days in last year of life, 30-day readmission rate, and occurrence of unplanned hospital death (probability of dying in hospital after unplanned admission). Using generalised linear and logistic regression models, we examined the effect of 12 independent variables on each outcome: sex, ethnicity, age at death, index of multiple deprivation quintile, year of death, liver disease causing death, place of death, time from index presentation in last year of life to death, whether enrolled in a day-case paracentesis service (care group), paracentesis ratio (number of day-case large-volume paracentesis procedures as a proportion of the total number of procedures in the last year of life), number of hospital episodes in the last year of life (not involving large-volume paracentesis), and number of large-volume paracentesis procedures in the last year of life.
Between Jan 1, 2013, and Dec 31, 2015, 13 818 people in England died from liver disease and had large-volume paracentesis within their last year of life. For all patients, mean cost of the last year of life was £21 113 (SD 16 881), 17 888 (52·5%) of 34 068 readmissions occurred within 30 days of discharge, and 10 341 (74·8%) of 13 818 deaths occurred in hospital, of which 10 045 (97·1%) followed an emergency hospital admission. Patients who attended a day-case large-volume paracentesis service within their last year of life had significant reductions in cost (-£4240, 95% CI -4829 to -3651; p<0·0001), number of inpatient bed days (-16·98 days, -18·45 to -15·51; p<0·0001), probability of early readmission (odds ratio OR 0·35, 95% CI 0·31 to 0·40; p<0·0001), and probability of dying in hospital after unplanned admission (0·31, 0·27 to 0·34; p<0·0001), compared with patients who had unplanned care. For patients enrolled in day-case services, improvements in outcomes correlated with the proportion of large-volume paracentesis procedures done in a day-case (vs unplanned) setting.
The use of day-case large-volume paracentesis services in the last year of life was associated with lower costs, reduced pressure on acute hospital services, and a lower probability of dying in hospital, compared with patients who received exclusively unplanned care in their last year of life. Wider adoption of day-case models of care could reduce costs and improve outcomes in the last year of life.
David Telling Charitable Trust.
Moral concerns Pring, Andrew
Supply Management,
12/2013, Letnik:
18, Številka:
12
Trade Publication Article
The author has been particularly struck by two ongoing procurement initiatives: the heartfelt commitment to sustainability many companies display; and even more impressive, the profession's emerging ...support for Walk Free, the campaign to eradicate the appalling mediaeval-style slavery that nearly 30 million people still endure in these supposedly modern and enlightened times. It is the moral duty of every procurement professional to map and audit their supply chain and ensure it is "slavery proof". Slavery is not an evil that can be extirpated overnight. It will take years of endeavour to conquer and will be a true test of the profession's commitment to a higher role than enhancing shareholder value. Self-interest should play in favour of Walk Free's tenets.
Flying the Australian flag Pring, Andrew
Supply Management,
11/2013, Letnik:
18, Številka:
11
Trade Publication Article
One of the hallmarks of procurement professionals are they never lose their desire to keep learning. It is in that vein that the publication takes an in-depth look this month at Australia's approach ...to securing best value in purchasing, combined with a revealing profile of the new CIPS President, Craig Lardner, the first Australian to take up the chains of office. The pace of change is equally evident in a new potentially epoch-making initiative unveiled by CIPS group chief executive David Noble recently for licensing the profession.
CIPS Australasia team persuaded government officials to change one of the myriad job titles in the occupation box that respondents must tick from "supply manager" to "procurement manager". The job ...semantics wasn't mere sleight of hand but proper recognition that procurement in Australia as a profession has advanced considerably in the past decade -- both in terms of numbers but also through procurement's contribution to the business world beyond its traditional cost-cutting role. The new CIPS president Craig Lardner benchmarks 'Procurement Australia' against four KPIs: maturity; public sector progress; member loyalty; and peer respect. On all four counts, Lardner says, the profession is in relatively good health, particularly on loyalty levels. Lardner says procurement's role across industry hinges on whether the CEO has had what he calls "a Damascus moment" and realises procurement has more to offer. Procurement's growing societal role may be about to take a big step forward following the move by one of Australia's richest men to campaign against economic slavery.
Telling it like it is Pring, Andrew
Supply Management,
10/2013, Letnik:
18, Številka:
10
Trade Publication Article
If you just see yourself as working in procurement, CIPS President Paula Gildert said, you're standing in a lesser role than you deserve. The Novartis global head of development strategic sourcing is ...not interested in lesser roles for her profession. Procurement has so much more to offer than delivering savings. You can support the objectives of the chief executive in so many ways. It's not the whole answer, but, fellow speaker Jonas Olsson, VP group purchasing at Trelleborg, the Swedish industrial group, shared a clever way to highlight procurement's importance to colleagues. His team all sport a specially designed logo on their shirts to identify themselves instantly, and every email they send bears it too.
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