Browsing by Author "Sachs, Greg"
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Item Characterizing Avoidability of Nursing Home Residents: Comparing the Claims-Based Algorithm and Nurse Assessment(Oxford University Press, 2022-12-20) Blackburn, Justin; Carnahan, Jennifer; Hickman, Susan; Sachs, Greg; Unroe, Kathleen; Health Policy and Management, School of Public HealthThe elevated risks associated with transferring nursing home residents to the hospital are problematic, but identifying which transfers can be avoided is complex. Using billing claims to determine “avoidability” based on hospital discharge diagnostic codes ignores resource constraints, clinical comorbidities, and asymmetrical information between nursing home staff making the transfer decision at the onset of clinical changes and hospital billing departments following treatment and diagnostic procedures. Conversely, relying on clinical staff assessments at the time of transfer may be an impractical and resource-intensive strategy to drive payment reform and improve quality. Using Medicare claims data representing emergency department and hospitalization transfers from 38 nursing facilities in Indiana from 2016-2020, we compared classification of transfers using a claims-based algorithm and trained nurse assessments of avoidability. Among 960 transfers, nurses judged 48.4% were potentially avoidable while 30.8% were classified as such using claims data. Of concordant assessments, 15.3% were avoidable and 36.0% as not avoidable. Of discordant assessments, 33.1% were judged avoidable by nurses only and 15.5% via the claims-based algorithm (Kappa=0.0153). Discordance was most frequent among transfers with heart failure (64%, n=42), psychosis (74.5%, n=34), acute renal disease (50%, n=28); and lowest among urinary tract infections (31.3%, n=64). No resident demographic or clinical characteristics were associated with discordance (age, race, sex, cognitive function scale, activities of daily living, or CHESS scale). High discordance in determining avoidability may be driven by presentation of symptoms or other condition-specific factors. Policies to reduce avoidable hospitalizations must not rely on overly simplistic approaches for identification.Item Development Of A Brief Measure Of Communication Quality: The 5- And 10-Item Family Inpatient Communication Surveys(Oxford University Press, 2022) Burke, Emily; Slaven, James; Taylor, Tracy; Monahan, Patrick; Sachs, Greg; Torke, Alexia; Biostatistics and Health Data Science, Richard M. Fairbanks School of Public HealthCommunication quality between clinical care teams and families impacts important outcomes like satisfaction, depression, and anxiety. Assessment tools must be efficient and reliable to be useful in the clinical environment. We report the development of 5 and 10-item versions of the validated 30-item Family Inpatient Communication Survey (FICS). Data were from 364 surrogate decision makers (SDMs) for incapacitated older adults in the ICU. Most SDMs were adult children (66.8%). SDMs were 70.9% female, 68.9% white, with a mean age of 58.3. Exploratory factor analysis revealed high internal reliability for the single-factor FICS5 (α= .88) and two-factor FICS10 (α= .93). The FICS10 reliably measures two subscales: information (α= .91) and emotional support (α=.81). Good discriminant and predictive validity were demonstrated when comparing total scores to outcomes at 6-8 weeks after hospital discharge, including anxiety (correlation coefficient (ρ)= -.13; p=.0234 ), depression (ρ =-.15; p=.0076), decision regret (ρ =--.15; p=.0066), and satisfaction (ρ =-..48; p<.0001). Repeating analysis with a new sample (n=188) revealed similar results with Cronbach’s alpha ranging from .81 to .93. The FICS5 revealed significant associations (p<.05) at 6-8 weeks after discharge with distress (-.22), while the FICS10 demonstrated significant associations with distress (-.28), anxiety (-.20), depression (-.19) and decision regret (-.27). Confirmatory factor analysis indicated adequate fit (CFI: FICS5= .994, FICS10= .994; RMSEA: FICS5= .093, FICS10= .103). The FICS provides clinicians and interventionists with a reliable, low burden tool to evaluate communication quality and respond quickly, which could impact satisfaction and other important outcomes for patients and families.Item Improving Nursing Facility Care Through an Innovative Payment Demonstration Project: Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care Phase 2(Wiley, 2018-08) Unroe, Kathleen T.; Fowler, Nicole R.; Carnahan, Jennifer L.; Holtz, Laura R.; Hickman, Susan E.; Effler, Shannon; Evans, Russell; Frank, Kathryn I.; Ott, Monica L.; Sachs, Greg; Medicine, School of MedicineOptimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) is a 2‐phase Center for Medicare and Medicaid Innovations demonstration project now testing a novel Medicare Part B payment model for nursing facilities and practitioners in 40 Indiana nursing facilities. The new payment codes are intended to promote high‐quality care in place for acutely ill long‐stay residents. The focus of the initiative is to reduce hospitalizations through the diagnosis and on‐site management of 6 common acute clinical conditions (linked to a majority of potentially avoidable hospitalizations of nursing facility residents1): pneumonia, urinary tract infection, skin infection, heart failure, chronic obstructive pulmonary disease or asthma, and dehydration. This article describes the OPTIMISTIC Phase 2 model design, nursing facility and practitioner recruitment and training, and early experiences implementing new Medicare payment codes for nursing facilities and practitioners. Lessons learned from the OPTIMISTIC experience may be useful to others engaged in multicomponent quality improvement initiatives.Item Investigating the Avoidability of Hospitalizations of Long Stay Nursing Home Residents: Opportunities for Improvement(Oxford University Press, 2018-07-05) Unroe, Kathleen T.; Hickman, Susan E.; Carnahan, Jennifer L.; Hass, Zach; Sachs, Greg; Arling, Greg; Medicine, School of MedicineBackground and Objectives: To examine the relationship between hospital diagnoses associated with hospital transfers of long stay nursing home residents, ratings of avoidability of transfer, and RN-identified quality improvement opportunities. Research Design and Methods: Prospective clinical demonstration project, named OPTIMISTIC, with trained RNs embedded in nursing homes that performed root cause analyses for 1,931 transfers to the hospital between November 2014 and July 2016. OPTIMISTIC RNs also rated whether transfers were avoidable, identified quality improvement opportunities, and recorded hospital diagnoses. Resident characteristics were obtained from Minimum Data Set assessments. Relationships between six hospital diagnoses commonly considered "potentially avoidable" and OPTIMISTIC RN root cause analysis findings were examined. Facilities were participating in the OPTIMISTIC demonstration project designed to reduce hospital transfers during the study period. Results: Twenty-five percent of acute transfers associated with six common diagnoses were considered definitely or probably avoidable by project RNs versus 22% of transfers associated with other diagnoses. The most common quality improvement opportunity identified for transfers rated as avoidable was that the condition could have been managed safely if appropriate resources were available, a factor cited in 45% of transfers associated with any of the six diagnoses. Problems with communication among stakeholders were the most commonly noted area for improvement (48%) for transfers associated with other diagnoses. Many other areas for quality improvement were noted, including earlier detection of change in status and the need for understanding patient preferences or a palliative care plan. Discussion and Implications: Although some nursing home transfers may later be deemed potentially avoidable based on post-transfer hospital diagnosis from Medicare claims data, OPTIMISTIC nurses caring for these residents at time of transfer categorized the majority of these transfers as unavoidable irrespective of the hospital diagnosis. Multiple quality improvement opportunities were identified associated with these hospital transfers, whether the transfer was considered potentially avoidable or unavoidable.Item Palliative Care for People With Moderate-Severe Dementia in the Community: Results of the In-Peace Trial(Oxford University Press, 2024-12-31) Sachs, Greg; Johnson, Nina; Gao, Sujuan; Pan, Minmin; Torke, Alexia; Hickman, Susan; Kroenke, Kurt; Medicine, School of MedicineDementia care management programs in the community demonstrate some benefits. Study limitations include limited numbers of people living with dementia (PLWD) with advanced disease or from minoritized populations; lack of palliative care components; and limited success reducing health care utilization. IN-PEACE tested dementia care management integrated with palliative care for PLWD with moderate-severe disease in the community and their caregivers. 201 PLWD-caregiver dyads were randomized to either a dementia care coordinator (99) or usual care (102) and followed for 24 months. Outcomes were neuropsychiatric symptoms (NPI-Q severity) and symptom management (SM-EOLD) in PLWD; distress (NPI-Q distress) and depression symptoms (PHQ-8) in caregivers; and the combined measure of ED visits/hospitalizations. Outcomes were assessed quarterly. Separate mixed effects models were run for each symptom/distress measure and a zero-inflated Poisson model compared the mean number of ED/hospitalization events. Subgroup analyses were conducted based on baseline NPI-Q severity, sex, race, income, and health system. There were no statistically significant differences between groups in any symptoms or distress measures in PLWD or caregivers. PLWD receiving the intervention, however, had substantially fewer ED/hospitalization events (means 1.06 events versus 2.37, p < 0.007). The intervention reduced the proportion of PLWD who had one or more ED/hospitalization events (78.4% of controls vs. 50.5% of intervention, p < 0.001). The relative risk reduction was 35.6% for an event, absolute risk reduction 27.9%, and number needed to treat (NNT) of 3.6. PLWD with higher NPI-Q at baseline and Black PLWD experienced greater reductions in ED visit hospitalization events.Item Patients' attitudes of dementia screening across the Atlantic(Wiley, 2009-06) Justiss, Michael D.; Boustani, Malaz; Fox, Chris; Katona, Cornelius; Perkins, Anthony J.; Healey, Patrick J.; Sachs, Greg; Hui, Siu; Callahan, Christopher M.; Hendrie, Hugh C.; Scott, Emma; Department of Medicine, IU School of MedicineBACKGROUND: Dementia is a common and growing global public health problem. It leads to a high burden of suffering for society with an annual cost of $100 billion in the US and $10 billion in the UK. New strategies for both treatment and prevention of dementia are currently being developed. Implementation of these strategies will depend on the presence of a viable community or primary care based dementia screening and diagnosis program and patient acceptance of such a program. OBJECTIVE: To compare the acceptance, perceived harms and perceived benefits of dementia screening among older adults receiving their care in two different primary health care systems in two countries. DESIGN: A Cross-sectional study. SETTING: Primary care clinics in Indianapolis, USA and Kent, UK. PARTICIPANTS: A convenience sample of 245 older adults (Indianapolis, n = 125; Kent, n = 120). OUTCOMES: Acceptance of dementia screening and its perceived harms and benefits as determined by a 52-item questionnaire (PRISM-PC questionnaire). RESULTS: Four of the five domains were significantly different across the two samples. The UK sample had significantly higher dementia screening acceptance scores (p < 0.05); higher perceived stigma scores (p < 0.05); higher perceived loss of independence scores (p < 0.01); and higher perceived suffering scores (p < 0.01) than the US sample. Both groups perceived dementia screening as beneficial (p = 0.218). After controlling for prior experience with dementia, acceptance and stigma were marginalized. CONCLUSIONS: Older adults attending primary care clinics across the Atlantic value dementia screening but have significant concerns about dementia screening although these concerns differed between the two countries. Low acceptance rates and high rates of perceived harms might be a significant barrier for the introduction of treatment or preventive methods for dementia in the future.Item The Relationship Between Dementia Severity & Caregiver Preferences for Decision Making Role Regarding Mammography(Oxford University Press, 2021-12-17) Frank, Molly; Park, Seho; Lane, Kathleen; Torke, Alexia; Schonberg, Mara; Sachs, Greg; Schwartz, Peter; Fowler, Nicole; Biostatistics, School of Public HealthThe incidence of Alzheimer’s disease and related dementias (ADRD) and breast cancer increases with age. Despite being one of the most effective ways to diagnose breast cancer early, mammography in ADRD patients comes with an increased risk of treatment complications and false-positive results. Family caregivers are often involved in the decision-making process, and this study evaluates the relationship between dementia severity and caregiver preferences when making decisions about mammography with the patient alone, and with the patient and doctor. We included 181 caregivers from the Decisions about Cancer screening in Alzheimer’s Disease trial, which uses the Dementia Severity Rating Scale (DSRS) to assess dementia severity and a modified Control Preferences Scale (CPS) to assess each caregiver’s preferred decision-making approach. Multinomial logistic regression models evaluated the relationship between DSRS and CPS categories (active, passive, and collaborative), while controlling for the caregivers’ age, sex, race, education, and relationship to patient. Model 1 examined the caregivers’ preferred role with the patient, and it found a significant association between increased dementia severity and preference for a collaborative approach (p<0.001) or passive approach (p<0.05) compared to an active approach. Model 2 did not find a significant association between dementia severity and the caregivers’ preferred role when making decisions with the patient and doctor; however, those with increased age and education were more likely to prefer an active role. The association between dementia severity, caregiver characteristics, and decision-making preferences supports the need for approaches to support ADRD caregivers with medical decision making.Item Research in Palliative and End-of-Life Communication and Training (RESPECT) Center: Year 2(Office of the Vice Chancellor for Research, 2012-04-13) Hickman, Susan E.; Haase, Joan E.; Sachs, GregThe mission of the Research in Palliative and End-of-Life Communication and Training (RESPECT) Center is to build a collaborative, interdisciplinary scientific community of researchers and clinicians to work together to advance the science of communication in palliative and end-of-life care across the lifespan. Center Goals: • Accelerate the development of innovative descriptive and intervention research trials relevant to communication and decision-making in children, adolescents, adults, and elders with serious and/or life-threatening illness • Develop new community partnerships for translational science to enhance palliative and end-of-life care research and practice • Create mentorship opportunities for developing scholars who will become the next generation of productive, passionate palliative and end-of-life care researchers The RESPECT Center is comprised of 18 faculty, 3 post-doctorial trainees and 3 staff members. The RESPECT Center meets twice monthly to review and discuss members’ projects, content, design, draft proposals, and brainstorming sessions. In the first year, 9 grants were submitted, 12 publications were accepted and $6,534,611 dollars awarded. In Year 1, the RESPECT center sponsored 2 visiting scholars. Finally, the RESPECT Center is funding 4 pilot projects and will continue to mentor developing scholars.Item Research in Palliative and End-of-Life Communication and Training (RESPECT) Center: Year 3 2012-2013(Office of the Vice Chancellor for Research, 2013-04-05) Hickman, Susan E.; Haase, Joan E.; Sachs, GregThe mission of the Research in Palliative and End-of-Life Communication and Training (RESPECT) Center is to build a collaborative, interdisciplinary scientific community of researchers and clinicians to work together to advance the science of communication in palliative and end-of-life care across the lifespan. Center Goals: • Accelerate the development of innovative descriptive and intervention research trials relevant to communication and decision-making in children, adolescents, adults, and elders with serious and/or life-threatening illness • Develop new community partnerships for translational science to enhance palliative and end-of-life care research and practice • Create mentorship opportunities for developing scholars who will become the next generation of productive, passionate palliative and end-of-life care researchers The RESPECT Center is comprised of 19 faculty, 3 post-doctoral trainees and 3 staff members. Faculty meet twice a month to review and provide feedback to support the development of ideas and submission of research grants. In the 2011-2012 funding year, RESPECT Center faculty submitted 11 grants and received over $7.9 million dollars in funding, representing an increase of 21 % from the previous year. Additionally, faculty collaborated on the dissemination of findings and published XX articles on palliative and end-of-life care. The Center’s Visiting Scholar Series has hosted visits by 7 nationally recognized experts to consult with faculty and share their expertise with the community. On March 1, 2013, the RESPECT Center hosted a one-day statewide conference to bring together researchers and clinicians in Carmel, Indiana. The conference entitled, Translating Research into Best Practice: Improving Palliative and End-of-life Care, was attended by approximately 150 participants from 45 organizations. Finally, the RESPECT Center awarded 5 pilot study grants to help researchers develop critically important pilot data and continues to mentor developing scholars interested in the science of communication in palliative and end-of-life care.