Life In The Slower Lane

Here is the structured PICO analysis for the twenty-sixth article you uploaded:

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Full Title (verbatim and exact):

“Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents?”

Harrison JM, Agarwal M, Stone PW, Gracner T, Sorbero M, Dick AW

Journal of Palliative Medicine (2021); 24(9):1334–1341

DOI: https://doi.org/10.1089/jpm.2020.0577

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Type of Article:

Cross-sectional observational study

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PICO Analysis:

Population:

• 143,223 U.S. nursing home (NH) residents, including:
  • 42,761 residents with advanced illness (defined cohorts: advanced dementia, congestive heart failure [CHF], and chronic obstructive pulmonary disease [COPD])
• Residents were drawn from 838 nursing homes included in a 2017–2018 national survey linked to MDS 3.0 and Medicare inpatient records 

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Intervention:

• Integration of palliative care and infection management, measured via a validated 9-item index covering:
  • Patient/caregiver involvement in advance care planning
  • Formalised advance care documentation (e.g. medical orders, POLST)
  • Routine practices integrating palliative and infection management
• Composite scores ranged from 0 to 100, with higher scores indicating greater alignment with best practice 

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Comparator:

• Lower levels of integration intensity served as the comparator in the regression analysis
• Analyses evaluated outcomes by quartile or one standard deviation differences in integration scores

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Outcome:

1. Person-centred outcomes:

• Not directly assessed, but proxies included:
  • Hospital transfer avoidance (associated with reduced distress and better quality of death)
  • Alignment with goals of care through advance care planning (e.g. avoiding aggressive infection treatment at end of life)

2. Process outcomes:

• All-cause hospital transfers:
  • Integration intensity significantly associated with lower odds among all NH residents (OR 0.93) and especially those with advanced dementia (OR 0.85)
• Hospital transfers due to infection:
  • A one-SD increase in integration was associated with a 12.84% reduction in infection-related hospital transfers among residents with advanced dementia (p < 0.001)
  • No significant impact for CHF or COPD cohorts 

3. Health system outcomes:

• Integration intensity may reduce:
  • Unnecessary hospital admissions
  • Healthcare costs and Medicare burden
  • Use of antibiotics inconsistent with palliative goals
• Standard palliative care or outbreak control policies alone were not significantly associated with reductions in hospital transfers 

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Summary Conclusion:

This study demonstrates that higher levels of integration between palliative care and infection management in nursing homes are associated with significant reductions in hospital transfers, particularly for residents with advanced dementia. The impact was less pronounced for those with CHF or COPD. Integration was measured through practices like advance care planning, documentation of treatment preferences, and merging of infection protocols with palliative care goals. These findings support the adoption of integrated care models to reduce burdensome, potentially non-beneficial hospitalisation at the end of life for cognitively impaired nursing home residents.

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