From palliative care to GEDI WISE:

Transcription

1 From palliative care to GEDI WISE: Evolution of a new emergency care model for older adults with serious illness and association with intensive care use Carine Davila Icahn School of Medicine at Mount Sinai, New York American Geriatrics Society Annual Conference, Care Transitions, Orlando, FL May 17 th, 2014 #AGS14 Department of Emergency Medicine

2 Disclosures I received research funding from the Medical Student Training in Aging Research (MSTAR) Program, administered by AFAR, the American Federation on Aging Research and NIA, the National Institute on Aging. The GEDI WISE program described in the following presentation is supported by Award 1C1CMS , the Department of Health and Human Services, Centers for Medicare & Medicaid Services. This presentation s contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

3 Why study this? Half of older Americans are seen in the ED in the last month of life, and three-quarters visit the ED in the last 6 months of life Early palliative care consultation may have various benefits - Improved quality of life - Decreased cost of care Recent study of older adults with serious illness highlighted that over 75% thought about end-of-life care but only 12% preferred life-prolonging care ED is a key decision point where providers set the subsequent care trajectory of a hospitalization

4 GEDI WISE: Palliative Care Interventions Workforce Informatics Triage nurse screens all ED patients 65+ with ISAR (Identification of Seniors at Risk) to identify high-risk patients Midlevel providers (nurse practitioners and physician assistants) then approach high-risk patients for advance care planning, and palliative care and hospice referrals as appropriate Routine EMR-integration of ISAR screening, health care proxy forms, and advanced care planning templates Patients flagged for advanced care planning show up on electronic trackboard

5 GEDI WISE: Palliative Care Interventions Structural Education and training May 2011: 8-bed Palliative Care Unit opened Feb 2012: 14-bed Geriatric ED incorporates skid-proof floors, handrails, and diurnal lighting with indoor skylight and noise Education in Palliative and End of Life Care for Emergency Medicine GeriTalk, a communication skills training program Respecting Choices, an advance care planning facilitator course New screening tools (ISAR), new resources (hospice referral), and new clinical protocols introduced

6 Research Aim & Hypothesis Aim: to evaluate how introducing palliative care measures for older adults in the emergency department can impact intensive care unit admission rate and palliative care unit admission rate from the ED Hypothesis: GEDI WISE palliative care interventions may have an affect on the intensive care unit and palliative care unit admission rates

7 Methods Study Design Time series analysis of administrative data to examine continuous quality improvement

8 Methods: Time Series Analysis Time series vs. traditional regression Regression Analysis Time Series Analysis Controls: Patients 65+ who did not receive pall care interventions Cases: Patients 65+ who did receive palliative care interventions Patients 65+ did not receive pall care Patients 65+ did receive pall care *Requires data to determine whether or not a patient received palliative care interventions *Uses time to approximate the likelihood that a patient received palliative care interventions

9 Methods & Dataset Study Design Time series analysis of administrative data to examine continuous quality improvement Study Period January 2011 to May 2013 Setting Dataset The Mount Sinai Hospital, ED Urban, Academic Tertiary Care ED Compiled from electronic medical records and 6 administrative datasets 38,240 unique patient encounters

10 Variables Outcomes Covariates Intensive Care Unit (ICU) admission rate Palliative Care Unit (PCU) admission rate Age (Continuous) Gender (Female) Race / Ethnicity (White, Black, Hispanic, Other) Insurance status (Medicare & Medicaid dual eligibles, Medicare only, other private/self-pay) Comorbidity (Charlson-Manitoba score) Emergency Severity Index (1-5, assigned at triage)

11 Preliminary results: ICU admission rate decreased over time Significant decrease p-value: <0.001 beta: Significant decrease (adjusted) p-value: <0.001 beta: Palliative Care Geriatric Unit opens ED opens Note: Beta reflects how much the admission rate changes each day. Adjusted indicates regression adjusted for age, gender, race/ethnicity, insurance status, ESI, and comorbidity

12 Preliminary results: PCU admission rate increased over time No significant change p-value: 0.80 beta: Significant increase (adjusted) p-value: beta: Geriatric ED opens Note: Beta reflects how much the admission rate changes each day. Adjusted indicates regression adjusted for age, gender, race/ethnicity, insurance status, ESI, and comorbidity

13 Limitations Time is an imperfect measure of intervention(s) received There are potentially global confounders that could not be accounted for in the analysis (e.g. introduction of electronic medical record system) that may have impacted the results Study was conducted in a large urban, tertiary care academic teaching hospital, so its results may not be generalizable to other settings

14 Implications ICU admission rate for older adults from the ED declined from January 2011 to May 2013 Results are different than recently reported national ICU admission rates based on National Hospital Ambulatory Care Survey data (Mullins 2013) PCU admission rate for older adults from the ED increased from June 2011 to May 2013 Impact of effect of specific interventions requires further analysis

15 Future Research Track interventions on a patient-encounter level ISAR screening NP/PA intervention for advanced care planning Geriatric ED use Determine corresponding changes in younger adult population to understand if these trends are unique to the older adult population Explicitly determine patients or surrogates goals of care, to more closely assess congruence with the setting to which patients are admitted Assess potential cost-savings based on these preliminary trends in decreased ICU use

16 Acknowledgements Mentors: Ula Hwang, MD, MPH Corita Grudzen, MD, MSHS GEDI-WISE team Gary Winkel, PhD Lynne Richardson, MD Enver Holder-Hayes, MPH All team members MSTAR (Medical Student Training in Aging Research) Program Rainier Soriano, MD Melissa Aldridge, PhD Celicia Montgomery Mount Sinai Emergency Medicine Research Training Program Laura Rivera

17 Questions? Carine Davila MD Candidate, Class of 2016 Icahn School of Medicine at Mount Sinai

18 Backup

19 References 1. Smith AK, McCarthy E, Weber E, Cenzer IS, Boscardin J, Fisher J, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff (Millwood). 2012;31(6): Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early Palliative Care for Patients with Metastatic Non Small-Cell Lung Cancer. N Engl J Med. 2010;363: Morrison RS, Penrod JD, Cassel JB, Caust-Ellenbogen M, Litke A, Spragens L, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16): Penrod JD, Deb P, Dellenbaugh C, Burgess JF, Jr., Zhu CW, Christiansen CL, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8): Penrod JD, Deb P, Luhrs C, Dellenbaugh C, Zhu CW, Hochman T, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006;9(4): Heyland DK, Barwich D, Pichora D, Dodek P, Lamontagne F, You JJ, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9): Mullins PM, Goyal M, Pines JM. National growth in intensive care unit admissions from emergency departments in the United States from 2002 to Acad Emerg Med. 2013;20(5):

20 Palliative Care ED Interventions, timing Year External factors Integrated EMR Inpatient PCU opens GEDI WISE-specific Geriatric ED opens Education begins Workforce hiring Informatics

21 Comorbidity Measures Elixhauser ICD-9 secondary diagnosis codes and DRG inpatient billing codes analyzed Inclusion into one of 31 comorbidity groups is determined Can be used with inpatient data only (Elixhauser A, Steiner C, Harris R,et al. Comorbidity Measures for Use with Administrative Data. Medical Care, Vol 36, No.1. Lippencott-Raven Publishers, 1988) Charlson-Manitoba ICD-9 secondary diagnosis codes are analyzed Inclusion into one of 17 comorbidity groups is determined Inclusion flags are weighted appropriately and summed to generate a comorbidity score Can be used with inpatient or outpatient data, for a single encounter or across multiple encounters (Quan H, Li B, Couris CM,et al. Updating and Validating the Charlson Comorbidity Index and score for Risk Adjustment in Hospital Discharge Abstracts Using Data From 6 Countries. American Journal of Epidemiology, Vol 173, No.6. Baltimore, MD: Oxford University Press, 2011)