VA Hospice and Palliative Consideration: Distinguishing Veterans at High Danger of Mortality.


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VA Hospice and Palliative Care: Identifying Veterans at High Risk of Mortality ... Extent of Inpatients Who Died who had Palliative Care Consults, ...
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VA Hospice and Palliative Care: Identifying Veterans at High Risk of Mortality Ann Hendricks PhD, Lynn Wolfsfeld MPP Health Care Financing & Economics (HCFE) Boston VA Healthcare System, HSR&D April 23, 2008 Email: Ann.Hendricks@va.gov Lynn.Wolfsfeld@va.gov

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Topics Background on VA Hospice and Palliative Care Overview of RRP Analysis of Inpatients (Methods, Results, Conclusions) Next Steps

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VA HPC Initiatives Establishment of National VA Office of Hospice and Palliative Care (2004) Fellowship programs Hospice-veteran organization programs Directive to build up palliative consideration counsel groups at all VAMCs (2003)

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Number of Palliative Care Consults Vary Across VISNs, FY2006-2007 There was a 11% national increment in the quantity of palliative consideration counsels reported in FY07 (23,240) when contrasted with FY06 (20,943) for the 127 and 126 offices reporting individually. From: Hospice and Palliative Care Fiscal Year 2007 Status Report

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Proportion of Inpatients Who Died who had Palliative Care Consults, FY2006-2007 For VA generally speaking, the rate of inpatient passings with a related palliative consideration counsel expanded from 42 to 47 percent for FY07. The normal number of days between palliative consideration counsel and passing additionally expanded from 45 to 47 days (with the middle expanding from 34 to 37) from FY06 to FY07. The development in these ranges demonstrates more noteworthy and prior association of palliative consideration groups with veterans drawing nearer passing while the variability among VISNs mirrors the changing degrees of palliative consideration incorporation. From: Hospice and Palliative Care Fiscal Year 2007 Status Report

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FY05 Strategic Initiative* Improving access to hospice and palliative consideration in inpatient and outpatient settings Exploration of robotized case-discovering procedures 81% of offices had no computerized case discovering strategy to distinguish veterans suitable for HPC *From HPC FY 2005 Status Report

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Project Objectives To work with a specialist board to recognize analyze and/or occasions in inpatient, outpatient and long haul care settings that could showed a referral to the hospice and palliative consideration group To make PC calculations for the markers utilizing information components accessible as a part of the different national VA databases To decide the predominance of the pointers To test the last pointers concurred on by the master board by consolidating patients related to the markers with mortality information to perceive how prescient the pointers are

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Expert Panel National Director – Hospice and Palliative Care Hospital Administrators (2) Hospice and Palliative Care Specialists (2 VA – 1 non-VA) National Chief – Hematology/Oncology ICU Intensivist (1)

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Mission Statement "To build up a commonsense device which recognizes veterans at generous danger for requiring particular end-of-life consideration, frequently including palliative consideration and/or hospice administrations."

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Criteria for Inclusion in Case Finding Metric Low-hanging organic product Predicted likelihood of half or a greater amount of passing on inside a year Cancers with poor anticipations Multifaceted methodology Across settings and conditions (Inpatient, outpatient, nursing homes) Patients near death (days, months+) ICU Events and Conditions Chronic conditions

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top to bottom examination of conditions meeting first criteria for incorporation Low-hanging natural product Predicted likelihood of half or a greater amount of kicking the bucket inside a year Cancers with poor visualizations

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Methods VA NPCD Data FY 2001-2005 VA Vital Statistics File (Mortality through March 2006) Population – inpatients with tumor analyze Index Date – first appearance of conclusion (in VA) following 12 months with no nurture that determination (in VA)

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Specifications (Populations) CANCERS ICD-9 CODES Head/neck 141-148 Trachea/bronchus/lung 162 Prostate 185 Colon 183 Liver 155 Pancreatic 157 Esophageal 150 Lymphomas 200-202 Leukemias (acute) 204.0, 205.0, 206.0, 207.2, 207.7, 208.0 Melanoma 172 CNS 191 All other cancers All remaining ICD-9 codes140-239

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Regression (SAS – LifeReg) Parametric Accelerated Failure Time Model Allows for right controlling Dependent Variable Number of months survived Independent Variables Age Gender Advanced Disease Separate model for every condition

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Indications of Advanced Disease ICD-9 196 = Secondary and unspecified harmful neoplasm of lymph hubs ICD-9 197 = Secondary dangerous neoplasm of respiratory and digestive frameworks ICD-9 198 = Secondary threatening neoplasm of other determined locales for instance (kidney, cerebrum, skin, bone...)

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ILLUSTRATIVE SURVIVAL CURVES AND MEDIANS

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ILLUSTRATIVE SURVIVAL CURVES AND MEDIANS

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THRESHOLD FOR INCLUSION IN CASE FINDING METRIC Predicted likelihood of half or a greater amount of biting the dust inside 12 months Equivalent to middle anticipated months survived <= 12

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MEDIAN PREDICTED MONTHS OF SURVIVAL (FROM INDEX DATE), HOSPITAL INPATIENTS * ICD-9 196 = Secondary and unspecified dangerous neoplasm of lymph hubs; ICD-9 197 = Secondary dangerous neoplasm of respiratory and digestive frameworks; ICD-9 198 = Secondary threatening neoplasm of other indicated destinations for instance (kidney, mind, skin, bone...)

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MEDIAN PREDICTED MONTHS OF SURVIVAL (FROM INDEX DATE), WITHOUT INDICATION OF ADVANCED DISEASE, HOSPITAL INPATIENTS, BY AGE

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MEDIAN PREDICTED MONTHS OF SURVIVAL (FROM INDEX DATE), WITH INDICATION OF ADVANCED DISEASE, HOSPITAL INPATIENTS, BY AGE

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PRELIMINARY RECOMMENDATIONS FOR CONDITIONS TO INCLUDE IN A CASE FINDING METRIC FOR CANCER INPATIENTS – ACUTE SETTING

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Next Steps Assess V66.7 and TS96 codes Refine ebb and flow investigation - extra take a gander at malignancies – outpatients, co-morbidities, LOS Additional examinations – unending conditions, nursing home patients, outpatients, ICU patients, practical status Implementation