State Variation in Mechanical Ventilation of Hospitalized Patients - - PowerPoint PPT Presentation

State Variation in Mechanical Ventilation of Hospitalized Patients with Advanced Dementia

Joan M Teno, M.D., M.S. Susan Mitchell, MD, MPH Pedro Gozalo, Ph.D. Susan Tolle, MD Christine Ritchie, MD, MSPH Jen Bunker, MPH Jessica Orgarek, MS Vincent Mor, Ph.D. OHSU, Brown University, UCFS, and Harvard University

Pneumonia

– In 1898, Osler note that pneumonia was a “friend of the aged.” – For persons with advanced dementia, 1 year mortality from pneumonia is 74.3%. – Our goal is to characterize state variation in temporal trends of mechanical ventilation

Methods (1)

• Sample of Medicare Beneficiaries

– Nursing home (NH) residents in a NH at 120 days prior to hospital admission – Age 66 and older – Years studied 2000 and 2014 – MDS closest to hospital admission that had Cognitive Performance Score of >= 5 indicating advanced cognitive impairment and 4 or more ADLs – Fee-for-service Medicare

Methods (2)

• Minimum Data Set (MDS) merged with

Medicare Claims Data

• Multivariable regression model

estimated adjusted probability of mechanical ventilation for these subjects adjusting for age, race, function, level of cognitive impairment, and comorbidities. Rates of mechanical ventilation are reported over time and by state.

Results – Sample Description

Characteristic NH Residents n= 343,813

• Avg. Age

83.3 Gender (% Female) 62.5% Race (% Black) 19.5% One year mortality 74.4% 2000 rate of mechanical ventilation 4.2/100 2014 rate of mechanical ventilation 15.0 /100

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10 20 30

mean rate of mechanical ventilation per 1000 admissions

2000 2005 2010 2015 year States with Less 50 admissions Other states New York California

CA and NY

• Two states (NY and CA) accounted for

19.5% of hospital admissions but 37.8% of admissions with pneumonia that were mechanically ventilated.

• In CA, the probability of mechanical

ventilation for hospitalized patients increased from 6.9% to 22.4% while NY increased from 9.4% to 27.4%.

• In the rest of the US, the probability

increased from 3.0% to 10.6%.

• In states >50 admissions in 2014,

probability increased from 3.2% to 11.8%

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Limitations

• Secondary analyses of administrative data – we do

not have information on patient preferences. Over time, substantial growth of hospice.

• Observational study – possible other attributes of

the region may play a role in the observed increase rate of mechanical ventilation

• Growth of Assisted Living Facilities – which

potentially changed the number of persons in a NH with advanced dementia

Conclusion

• Substantial state variation in the use of

mechanical ventilation in persons with advanced dementia exists and raises quality concerns given that. mechanical ventilation is a potentially burdensome intervention with high one year mortality in this population.

Implication

• Efforts are needed to address the

striking increase in mechanical ventilation in persons with advanced dementia as well as to examine state variation to insure that mechanical ventilation is used based on informed preferences based on knowledge of the likely outcome of care.

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Thank you…………