Critical care use during the course of serious illness.

Despite its expense and importance, it is unknown how common critical care use is. We describe longitudinal patterns of critical care use among a nationally representative cohort of elderly patients monitored from the onset of common serious illnesses. A retrospective population-based cohort study of elderly patients in fee-for-service Medicare is used, with 1,108,060 Medicare beneficiaries at least 68 years of age and newly diagnosed with serious illnesses: 1 of 9 malignancies, stroke, congestive heart failure, hip fracture, or myocardial infarction. Medicare inpatient hospital claims from diagnosis until death (65.1%) or fixed-right censoring (more than 4 years) were reviewed. Distinct hospitalizations involving critical care use (intensive care unit or critical care unit) were counted and associated reimbursements were assessed; repeated use was defined as five or more such hospitalizations. Of the cohort, 54.9% used critical care at some time after diagnosis. Older patients were much less likely to ever use critical care (odds ratio, 0.31; comparing patients more than 90 years old with those 68-70 years old), even after adjustment. A total of 31,348 patients (2.8%) were repeated users of critical care; they accounted for 3.6 billion dollars in hospital charges and 1.4 billion dollars in Medicare reimbursement. We conclude that critical care use is common in serious chronic illness and is not associated solely with preterminal hospitalizations. Use is uneven, and a minority of patients who repeatedly use critical care account for disproportionate costs.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61412/2/04.AJRCCM.supp.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61412/1/04.AJRCCM.pd

Child Injury Risks are Close to Home: Parent Psychosocial Factors Associated with Child Safety

Objective: In several populations, maternal depression has been associated with reduced child safety. In an urban pediatric Emergency Department, we examined the relationship between parental depression, social support, and domestic conflict and child safety behaviors. Methods: We studied consecutive patients in an Emergency Department. Trained interviewers used a structured instrument to assess patient, primary caregiver, and household demographics, socio-economic status, psychosocial factors, child safety behaviors (whether a gun was in the home, poisons were locked, a functioning smoke detector was present, and use of carseats or seatbelts), and whether the home was smoke-free. 1,116 patients provided adequate data. Results: Depression was associated with a modest and not statistically significant reduction in child safety behaviors in this population. Lack of social support and the presence of domestic conflict were robustly, independently, and statistically significantly associated with less safe homes. Domestic conflict was associated with more smoking in the home. Conclusion: In our population, child safety was associated less with depression and more with parental lack of social support and domestic conflict. These can be assessed in a Emergency Department and may be amenable to intervention

In Sickness and In Health: Understanding the Effects of Marriage on Health

My DissertationDespite substantial research, how marriage reduces mortality remains unclear. Using a novel data set of over 150,000 elderly couples developed from the Medicare claims and examining the impact of widowhood vs. marriage on mortality, this dissertation seeks to adjudicate among the many plausible mechanisms. First, I exploit the variation between diseases in how responsive those diseases are to putative intervening processes to test which hypotheses can explain patterns of relative mortality. I find that in general the less healthy a person is, the less responsive they are to the death of a spouse – the most enduring mortality effects of spousal death are found among the healthiest elderly. Thus, support is found for models in which marriage provides immediate instrumental help; marriage does not appear to improve health by improving habits or by increasing some other stock of health capital that inheres in patients after the death of their spouse. The major mortality benefits of marriage also are not mediated via direct emotional or physiological effects, nor are they an artifact of selection or shared environment. Second, I show that the married appear to choose better inpatient hospital care, as measured in a number of different ways. They then have longer lengths of stay than the widowed, but do not appear to receive differential quality of care given the provider chosen. In a final chapter, I argue that relationships improve health by serving as a form of general capital, most useful when individuals face a wide variety of choices about their health.National Research Service Award Grant 5 T32 GM07281 Population Research Center has also provided me with support as a predoctoral fellow, through National Research Service Award Grant T32-AG00243http://deepblue.lib.umich.edu/bitstream/2027.42/61424/27/Chapter_1_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/26/Chapter_2_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/25/Chapter_3_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/24/Chapter_4_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/23/Chapter_5_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/22/Appendix_A_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/21/Original_Appendices_B_and_C.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/10/Bibliography.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/28/Front_Matter.pd

Survivorship Will Be the Defining Challenge of Critical Care in the 21st Century

In an invited editorial, I argue that critical care is facing a cross-roads. We can now save many patients lives. But we need to broaden our sense of our mission to include understanding, caring for, and improving, the lives of those many patients who survive critical illnessGrant Support: By the National Institutes of Health (grant K08HL091249).http://deepblue.lib.umich.edu/bitstream/2027.42/77540/1/10.Annals.Survivorship.Editorial.pd

The network structure of critical care transfers, 1993

Poster presented at Annual MeetingBackground: In light of wide variations between hospitals in their quality of critical care, some have proposed moving patients to better quality. A system of critical care transfers already exists, but it is little studied. Methods: All 1993 Medicare claims were examined for the 576 acute care hospitals in the Mid-Atlantic region. Results: Critical care transfers are common. There is a single continuous transfer network linking hospitals in the Mid-Atlantic region. There are signs that congestion may be a problem in this network. Conclusion: The existing transfer network may be a useful policy tool to improve the outcomes of critically ill patients, but more study is needed.NIH grant HL07891-09http://deepblue.lib.umich.edu/bitstream/2027.42/61403/1/SCCM_poster_comp.pd

Seduction and Insight from Cross-National Comparisons

Editorial discussing the stregnths and limitations of crossnational comparisons of critical care, with particular reference to Use of Intensive Care Services during Terminal Hospitalizations in England and the United States Hannah Wunsch, Walter T. Linde-Zwirble, David A. Harrison, Amber E. Barnato, Kathryn M. Rowan, and Derek C. Angus AJRCCM 2009 180: 875-880.Supported in part by 1K08HL091249-01 from the NIH/NHLBIhttp://deepblue.lib.umich.edu/bitstream/2027.42/64267/1/09.AJRCCM.editorial.seduction.insight.pd

Guided transfer of critically ill patients: where patients are transferred can be an informed choice

Purpose of Review: Given increasingly scarce health care resources and highly differentiated hospitals, with growing demand for critical care, interhospital transfer is an essential part of the care of many patients. The purpose of this review is to examine the extent to which hospital quality is considered when transferring critically ill patients, and to examine the potential benefits to patients of a strategy that incorporates such objective quality data into referral patterns. Recent Findings: Interhospital transfer of critically ill patients is now common and safe. While extensive research has focused on which patients should be transferred and when they should be transferred, recent study has focused on where patients should be transferred. Yet, the choice of destination hospital is rarely recognized as a therapeutic choice with implications for patient outcomes. The recent public release of high-quality, risk- and reliability-adjusted outcome data for most hospitals now offers physicians an informed basis on which to choose to which destination hospital a patient should be transferred. A strategy of “guided transfer” that integrates public quality information into critical care transfer decisions is now feasible. Summary: Although hospitals often transfer patients, there may be substantial room for improvement in transfer patterns. Guiding transfers on the basis of objective quality information may offer substantial benefits to patients, and could be incorporated into quality improvement initiatives.This work was supported by K08 HL091249 from the National Institutes of Healthhttp://deepblue.lib.umich.edu/bitstream/2027.42/86792/1/11.I.Courey.CurrOpCritCare.Guided.Transfers.pd

Male Perpetrators of Intimate Partner Violence: Support for Health Care Interventions Targeted at Level of Risk

The mental health correlates of male aggression or violence against an intimate partner (IPV) are examined using exploratory cluster analysis for 81 men who self-reported risk factors for IPV perpetration on a computer-based health risk assessment. Men disclosing IPV perpetration could be meaningfully subdivided into two different clusters: a high pathology/high violence cluster, and lower pathology/low violence cluster. These groups appear to perpetrate intimate partner violence in differing psychoemotional contexts and could be robustly identified using multiple distinct analytic methods. If men who self-disclose IPV in a health care setting can be meaningfully subdivided based on mental health symptoms and level of violence, it lends support for potential new targeted approaches to preventing partner violence perpetration by both women and men.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65004/1/10.Rhodes.I.Behaviour.Change.pd

Marriage, widowhood, and health-care use

Despite suggestive evidence, there has been no adequately powered systematic study of the ways in which marital status influences health care consumption. Using a novel data set of 609016 newly diagnosed, seriously ill elderly individuals in the USA, and employing hierarchical linear models, we look at differences in the experience of hospitalization as a function of marital status. We find that the married consistently use higher quality hospitals and have shorter lengths of stay. On the other hand, the married and the widowed appear to receive similar quality care once they are in the hospital. Marital status thus has a substantial impact on the health care obtained by the elderly. We suggest that these patterns are most consistent with spouses exerting their benefits by functioning as higher-order decision-makers than as home health assistants.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61411/1/03.I.Christakis.SSM.pd

Attitude and Self-reported Practice Regarding Prognostication in a National Sample of Internists

Background Since prognostication appears increasingly important in clinical practice, especially in end-of-life care, we examined physicians' experiences and attitudes regarding it. Methods We mailed a survey to a national sample of 1311 internists, yielding 697 responses that were analyzed with multivariate models and other means. Findings were supplemented by qualitative comments from 162 physicians and by interviews with 20. Results On an annual basis, the typical internist addressed the question "How long do I have to live?" 10 times, withdrew or withheld life support 5 times, and referred 5 patients to hospice. Nevertheless, physicians disdain prognostication: 60.4% find it "stressful" to make predictions; 58.7% find it "difficult"; 43.7% wait to be asked by a patient before offering predictions; 80.2% believe patients expect too much certainty; 50.2% believe that if they were to make an error, patients might lose confidence; 89.9% believe they should avoid being too specific; and 56.8% report inadequate training in prognostication. With respect to the key concept of "terminal" illness, physicians on average believe that such patients should have 13.5±11.8 weeks to live, but responses varied substantially from 1 to 75 weeks. Conclusions Physicians (1) commonly encounter situations that require prognostication, (2) feel poorly prepared for prognostication, (3) find it stressful and difficult to make predictions, (4) believe that patients expect too much certainty and might judge them adversely for prognostic errors, and (5) vary in how they regard the key concept of being "terminally ill." These observations may have significant consequences for patient care.This study was supported in part by the Soros Foundation Project on Death in America Faculty Scholars Program, New York, NY; by a National Research Service Award dissertation award from the Agency for Health Care Policy and Research, Washington, DC; and by the University of Pennsylvania Center for Bioethics, Philadelphia.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61404/1/98.Christakis.I.ArchIntMed.pd