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 4.2/100 mechanical ventilation 2014 rate of 15.0 /100 mechanical ventilation
mean rate of mechanical ventilation per 1000 admissions 30 20 10 0 2000 2005 2010 2015 year States with Less 50 admissions Other states New York California 6
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% 7
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 . 10
Thank you…………
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