A national study of organizational features of inpatient medicine and the association with aggressiveness of care near the end of life
Larue, Nicole M.
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Background: Patients with advanced cancer are receiving increasingly aggressive care near the end of life, but it is not known to what degree acute care organizational characteristics may influence the intensity of care provided. Objective: To characterize the organizational features of acute care VA Medical Centers (VAMCs) which predict the delivery of aggressive end-of-life care in a cohort of patients with advanced malignancy. Research Design: Two forms of study design were used in our data collection. A cross-sectional descriptive study was performed to assess the current state of inpatient medicine services across the VHA nationally. Surveys were administered to chiefs of medicine and medicaiiCU directors at all of the 124 currently existing acute care VAMCs. A retrospective administrative data analysis was performed on a specified cohort of 9700 patients with advanced malignancies, who were admitted to one of the VAMCs in the last year of life. Based on the survey completion rate, our final analytic sample included 7105 patients across 74 different facilities. The final analysis employed generalized linear mixed-effect models to account for the clustering of patients at the facility level. Measures: Independent organizational variables of interest included the presence and number of academic teaching teams, use of hospitalists, ICU structure and staffing and integration of non-physician providers. Primary outcome measures were previously defined administrative data indicators of aggressiveness of care near the end of life, including: 1) ICU admission within the last 30 days of life, 2) >1 ER visit in the last 30 days of life and 3) chemotherapy administration within the last 2 weeks of life. The patient characteristics of age, gender, marital status, percent service connected, cancer diagnosis, and number of hospital days in the last six months and year of life were controlled for in all of the analyses. [TRUNCATED]
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