Abstract
Background/Objectives:
Hospitalists are increasingly the attending physician for hospitalized patients, and the scheduling of their shifts can affect patient continuity. For dementia patients, the impact is unknown.
Design:
Longitudinal study using physician billing claims between 2000 and 2014 to examine the association of continuity of care with feeding tubes (FT) insertion.
Setting:
US Hospitals.
Participants:
Between 2000 and 2014,166,056 hospitalizations of persons with a prior nursing home stay, advanced cognitive impairment, and four or more ADL (mean age 84.2, 30.4% male, 81.0% white).
Measurements:
Continuity of care measured at the hospital level with the Sequential Continuity Index (SECON; ranging from 0–100, higher score indicating higher continuity).
Results:
Rates of a hospitalist acting as the attending physician increased from 9.6% in 2000 to 22.6% in 2010, while a primary care physician with a predominant outpatient focus acting as the attending physician decreased from 50.3% in 2000 to 12.6% in 2014. Post-2010, a mixture of physician specialties increased from 55.5% to 66.4% with a reduction in hospitalists 22.6% (2010) to 14.1% (2013). Continuity of care decreased over time with SECON dropping from 63.0 to 43.5. Adjusting for patient baseline risk factors, a non-linear association was observed between SECON and FT insertion. Using cubic splines in the multivariate logistics regression model, the risk of FT insertion in a hospital where the SECON score dropped from 82 to 23 had an adjusted risk ratio (ARR) of FT insertion of 1.48 (95% 1.34–1.63) while hospitals in which SECON dropped from 51 to 23 had a FT insertion ARR of 1.38 (95% CI 1.27–1.50).
Conclusion:
Hospitalized dementia patients in hospitals in which continuity of care was lower had higher rates of FT insertions. Newer models of care are needed to enhance care continuity to ensure treatment consistent with likely outcomes of care and goals of care.
Keywords: Continuity of care, Feeding tubes, Hospitalist, Secular trends
Introduction
Physicians have increasingly focused their practice in one setting of care, with a rapid growth in physicians who specialize in the hospital setting 1,2 or the nursing home setting.3 Hospitalists focus their practice in the acute care hospital and increasingly work in shifts, which results in frequent handoffs that decrease continuity of care during a patient’s hospitalization. Additionally, many intensive care units (ICU) are “closed”, thus resulting in another handoff when patients are transferred from an ICU to a regular hospital floor. Each transfer of care responsibility from one physician to another may result in loss of clinical information which can lead to fragmented, poorly coordinated care and, potentially, medical errors. Fragmentation of care in certain populations has been associated with decreased survival 4,5, increased hospital admissions 6,7 and hospital readmissions 8, increased rates of emergency department visits 6,9 and lower probability of discharge.8,10 In particular, for vulnerable populations like dementia patients, these handoffs may be especially detrimental.6 Frequent handoffs could impact the trust of the proxy decision-maker in the health care team and could result in request for treatments with limited effectiveness at the close of life.
The use of feeding tubes in persons with advanced dementia is one potential unintended consequence of increasing fragmentation of care of these hospitalized persons. We hypothesized that hospitals with increased fragmentation over time could result in the use of feeding tubes, a treatment with evidence of limited effectiveness in persons with advanced dementia. The Choosing Wisely Program11 and the American Geriatric Society’s position statement12 provide evidence that feeding tubes are not recommended for persons with advanced dementia. A growing body of evidence questions the use of feeding tubes in persons with advanced dementia,11 finding no improvement in survival,13 weight gain,14 prevention of aspiration pneumonia,15 or healing of pressure ulcers.16 On the contrary, feeding tube insertion during a hospitalization was associated with increased risk of new pressure ulcers secondary to increased incontinence from diarrhea and use of restraints.16 While there have been national trends in the reduction of feeding tube use, this trend has varied by geographic region of the country.17 In this paper, we examine whether hospital changes in care fragmentation (i.e., the number of handoffs between physicians) is associated with differential use of feeding tubes in hospitalized persons with advanced dementia.
Methods
Sample
In this research, the 2000–2014 Minimum Data Set (MDS) was linked to Medicare Part A claims and 20% of Part B claims to define a cohort of hospitalized persons with advanced dementia. Information on cognitive and functional impairment was derived from an MDS assessment completed between 1 and 120 days prior to the index hospitalization. The majority (82.9%) of persons were in a nursing home just prior to admission. Advanced dementia was defined based on a Cognitive Performance Scale (CPS) of five or six in addition to four or more activities of daily living (ADL) impairments. Cases where the MDS indicated that the person already had a feeding tube were excluded. Starting in October 2010, the MDS transitioned from version 2.0 to 3.0, resulting in changes to the measurement of cognition and elimination of the documentation on orders to forgo life-sustaining treatment. Based on our previous analyses, orders to forgo life-sustaining treatment such as do-not-resuscitate (DNR) or orders to forgo artificial hydration and nutrition are important predictors of feeding tube insertion during a hospitalization. Thus, we conducted two analyses. The first used data from 2000 to 2014, and the second used only data from 2000–2010, a time when the MDS contained information on orders to forgo life-sustaining treatment.
Study Variable
The main study outcome is the insertion of percutaneous endoscopic gastronomy (PEG) feeding tubes based on ICD-9 procedure codes identified in previous research.18 The main independent variable is measuring short-term continuity of care or fragmentation of care during a hospitalization. The Sequential Continuity Index (SECON)19 in this study measures the number of physician visits that were performed by the same physician as recorded in the previous evaluation and management bill. The index varies between zero and one, with one indicating that the same physician saw the patient on every day of that hospitalization. For this analysis, we multiplied SECON by 100 to get a score that varied between 0–100. The mean SECON index was measured at the hospital level for our cohort of hospitalized advanced dementia patients. SECON was examined at the hospital level because for an individual patient, a low SECON index may reflect the patient’s disease severity, and correlation of the patient-level SECON with patient confounders may lead to selection bias of our coefficient estimates. Using physician specialty on the Medicare evaluation and management physician claims, we classified physicians as either hospitalist who focused their care in the hospital setting, primary care physicians focused mostly on the outpatient setting, or as hospital-based specialists. A hospitalist was defined as a general internist, family practitioner, or geriatrician whose total evaluation and management Medicare billing comprised of 90% or greater in the acute care hospital setting.1 A physician was classified as the attending physician based on billing for hospital level of care beyond the admission history and physical exam and/or the completion of discharge billing code. The attending physician was classified as primary care physician, hospitalist, hospital-based specialist, or mixture of two or more of these physician types.
Statistical Analysis
Analyses were done at the level of a patient’s hospitalization, using a multivariable fixed effects logistic regression model to examine the within-hospital association over time between the mean hospital SECON index and whether or not the patient had a PEG tube inserted while hospitalized. SECON was modeled using a cubic spline to account for its non-linear relationship with FT insertion observed in descriptive analyses. The model adjusted for patient characteristics including socio-demographics (age, gender, race), medical diagnoses, difficulty chewing or swallowing, the timing of the MDS assessment from hospital admission, ADL impairments based count of the number ADL impairments (for the analysis of 2000–2014) or the 0–28 point scale (for the analysis of 2000–2010), and the Cognitive Performance Scale.20 To examine the association of change in mean hospital-level SECON score and FT insertions, we used the model estimates based on the calculated cubic splines to calculate the adjusted risk ratios (ARR) of FT insertion relative to the low-fragmentation level. Confidence intervals of these ARRs were calculated using bootstrap methods. Analyses was done with hospitals that had at least two hospital admissions of persons with advanced dementia per year. As a sensitivity analyses, the analyses were repeated with only those hospitalizations for pneumonia and/or septicemia to ensure a uniform cohort and a second sensitivity analysis used 2000–2010 data that included presence of a DNR order and/or order to forgo artificial hydration and nutrition from MDS 2.0.
Results
Between 2000 and 2014, there were 166,056 hospitalizations of persons with advanced dementia, with 2010 reporting only part of the year secondary to the change in the federally required MDS assessment tool for nursing homes. Table 1 characterizes these patients shortly before those hospitalizations between 2000, 2005, 2010, and 2014. Overall, the majority of persons were female (69.9%) and white (81.0%). Over time, there was a decrease in weight loss, dropping from 15.7% in 2000 to 10.6% in 2014 (p<0.001). In-hospital FT insertion during this time decreased from 9.2% to 6.2%.
Table 1:
Sample Description by Year
| Variable | 2000 | 2005 | 2010 | 2014 |
|---|---|---|---|---|
| Sociodemographic, % or mean (95% CI) | ||||
| Male | 30.1 (29.3, 30.9) |
31.3 (30.6, 32.2) |
32.5 (31.0, 34.0) |
33.0 (31.4, 34.6) |
| Age | 83.5 (83.4–83.6) |
83.1 (83.0–83.2) |
83.0 (82.8–83.2) |
84.6 (84.4–84.9) |
| Whitea | 82.9 (82.3, 83.6) |
79.0 (78.2, 79.7) |
76.4 (75.0–77.7) |
71.8 (70.3–73.4) |
| Black | 13.7 (13.1, 14.3) |
16.6 (15.9, 17.3) |
17.5 (16.3, 18.7) |
21.0 (19.7,22.4) |
| Asian | 0.6 (0.5, 0.8) |
0.9 (0.8, 1.1) |
1.7 (1.3, 2.2) |
1.8 (1.3, 2.2) |
| Hispanic | 1.5 (1.3, 1.7) |
2.4 (2.2, 2.7) |
3.1 (2.6, 3.7) |
3.7 (3.2–4.3) |
| Other | 0.6 (0.5, 0.8) |
0.5 (0.4, 0.7) |
0.8 (0.6, 1.2) |
0.7 (0.4,1.0) |
| MDS & Utilization, % or mean (95% CI) | ||||
| DNRb order prior to hospitalizations | 46.2 (45.2, 47.0) |
50.3 (49.4, 51.2) |
46.2 (44.7, 47.8) |
N/A |
| Hospital Length of stay | 8.9 (8.8–9.0) |
8.7 (8.6–8.8) |
8.2 (8.1–8.4) |
6.5 (6.3–6.6) |
| Patient died in hospital | 11.0 (10.5, 11.6) |
10.4 (9.9, 10.9) |
7.7 (6.9, 8.6) |
8.3 (7.4, 9.2) |
| Patient discharged to hospice | 3.4 (3.1, 3.7) |
7.6 (7.2, 8.1) |
12.2 (11.2, 13.3) |
18.1 (16.9,19.5) |
| Weight loss | 15.7 (15.1, 16.4) |
14.4 (13.9, 15.1) |
12.5 (11.5, 13.6) |
10.6 (9.6, 11.7) |
| ICU use | 16.5 (15.9, 17.0) |
22.7 (22.0, 23.4) |
30.8 (29.7, 32.0) |
37.5 (36.4, 38.7) |
| Feeding tube insertion during hospitalization | 9.2 (8.7, 9.6) |
8.1 (7.6, 8.5) |
6.8 (6.1, 7.4) |
6.2 (5.7,6.8) |
race categories do not include “unknown”, or “native American” due to small cells.
DNR= Do not resuscitate
Between 2000 and 2014, advanced dementia patients were less likely to be cared for by a primary care physician as the attending physician (decreasing from 50.3% to 12.0%, p<.001 see Figure 1) and were more likely to be cared for by a hospitalist as the attending physician (increasing from 9.6% to 14.1%) or a mixture of physicians (increasing from 31.8% to 66.4%). A primary care physician billing for care during hospitalization decreased from 70.3% in 2000 to 30.0% in 2014 while hospitalists billing for hospital level care increased from 15.1% to 36.1%. Despite a reduction in hospital length of stay, the number of unique health care providers billing during hospitalizations increased from a mean of 2.32 to 3.54 (p<.001). Hospitals’ mean SECON decreased from 2000 to 2014 from 63.0 to 43.5 (p <.001).
Figure 1.
presents the temporal trend on whether a hospitalist, primary care physician, or mixture of physicians including specialist acted as the attending physician between 2000 and 2014. Additionally, the Sequential Continuity Index (labelled SECON) is measure of fragmentation which varies from 0 (indicating higher fragmentation) to 100.
Table 2 reports advanced dementia patients’ risk of PEG insertion in hospitals going from a SECON of 82 to 23 (indicating increasing fragmentation) was ARR 1.48 (95% CI 1.34– 1.63), while hospitals decreasing from 51 to 23 had an ARR of 1.38 (95% CI 1.27–1.50). Among the hospitalizations with pneumonia and/or septicemia, similar trends were noted with the risk of PEG insertion at ARR (1.42, 95% CI 1.20–1.64 comparing SECON of 84 to 24) and a decrease in SECON for 52 to 24 with an ARR of 1.38 (95% CI 1.10–1.44). A similar trend was seen when the analysis was restricted to the 2000–2010 to allow the inclusion of orders for life sustaining treatment.
Table 2.
Multivariate Association of Hospital Change in Fragmentation with PEG Feeding Tube Insertion
| Cohort | SECON* | ARR (95% CI) |
|---|---|---|
| All admissions from 2000–2014 | 82 to 23 | 1.48 (1.34– 1.63) |
| All admissions from 2000–2014 | 51 to 23 | 1.38 (1.27–1.50) |
| Pneumonia/ septicemia admissions 2000–2014 | 84 to 24 | 1.42 (1.20–1.64) |
| Pneumonia/ septicemia admissions 2000–2014 | 52 to 24 | 1.38 (1.10–1.44) |
| All admissions from 2000–2010 | 82 to 24 | 1.40 (1.26–1.54) |
| Pneumonia/ septicemia admissions 2000–2010 | 85 to 24 | 1.42 (1.18–1.66) |
SECON = Sequential Continuity Index
Discussion
Our health care system has increasingly staffed the role of the attending physician with hospitalists 21 and staffed intensive care units with intensive care physicians, resulting in more frequent handoffs between physicians that reduces continuity of care. At a time where the use of hospitalists and intensivists is increasing, our analyses found that the number of physicians that billed during a hospitalization increased from 2.32 to 3.54 between 2000 and 2014. SECON, a measure of fragmentation at the hospital level, decreased 63.0 to 43.5. Persons admitted to a hospital that increased care fragmentation over time had increased odds of PEG feeding tube insertion, a procedure that the ABIM Choosing Wisely Program11 questioned the value of in persons with advanced dementia. One response to increasing fragmentation is to increase efforts that improve the handoff of critical information to ensure care coordination. However, emerging research on the importance of the therapeutic alliance between physicians, dying persons, and their family may suggest a different intervention, where continuity of the same trusted provider may be critical to decision-making at the close of life.22,23
Despite our use of a hospital fixed-effects model, a uniform cohort of advanced cognitive impairment, severely functionally impaired patients, and potential confounders derived from the comprehensive MDS assessment, there are limitations that need to be acknowledged. The rate of hospital admissions for persons with an advanced cognitive impairment declined slightly over time, raising the possibility that “sicker” persons or persons with different preference patterns were admitted in the latter years. A sensitivity analyses of persons admitted with pneumonia and/or septicemia yielded similar findings. A further sensitivity analyses focused on data from 2000–2010, where the MDS-recorded information on the presence of orders to forgo life-sustaining treatment, including DNR orders, provides potential information on the goals of care. The designation of attending physician was based on health care provider billing beyond the admission history and physical exam and completion of the discharge billing code. It should be noted that decisions to insert a feeding tube may involve a subspecialist or consultations with a speech therapist. Finally, these results may be prone to ecological fallacy in that continuity was measured at the hospital level. Despite these limitations, results from national data raise important concerns over hospitals with increased care fragmentation during the hospitalization of persons with advanced dementia, which may result in care that is not consistent with a patient’s goals of care and with the evidence that questions the effectiveness of feeding tubes in this population.
Despite the declining use of feeding tubes17 nationally, advanced dementia patients admitted to hospitals that increased their care fragmentation were more likely to have a FT inserted, even among patients admitted with pneumonia and/or septicemia. The best evidence shows that the use of feeding tubes in persons with advanced dementia does not improve survival, prevent aspiration pneumonia, or heal pressure ulcers. Future research is needed to understand the role of how fragmentation of care impacts the decision to insert a FT in persons with advanced dementia.
Acknowledgements
Financial Disclosure: Research reported in this publication was supported by the National Institute On Aging of the National Institutes of Health under Award Number P01AG027296. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.”
Footnotes
Conflict of Interest The authors report no conflict of interest.
Contributor Information
Joan M Teno, OHSU, Portland, OR.
Susan Mitchell, Harvard Medical School, Boston, MA.
Jennifer Bunker, OHSU, Portland, OR.
David Meltzer, University of Chicago, Chicago, IL.
Pedro Gozalo, Policy, and Practice, Brown University School of Public Health, Providence, RI.
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