Bartley, Mairead M.

Context: Early palliative care can improve end-of-life outcomes, but referrals to palliative care specialists can be delayed in the primary care setting. Objective: This pilot study assessed the effect of a machine-learning algorithm on time to palliative care in a primary care population. Methods: Patients (aged ≥18 years) were eligible if they were empaneled with a primary care provider (PCP) from July 20, 2020, through May 30, 2021. The algorithm evaluated their health records and presented patients who were predicted to have the greatest need for palliative care. Records were then reviewed by palliative care specialists, and patients were randomized in a stepped-wedge fashion to have a referral notification sent to their PCPs if unmet palliative care needs were verified. Time-to-event outcomes were evaluated with Poisson regression models. Results: Of the 127,080 patients evaluated, 934 had their health records presented for review. Some patients were repeatedly presented by the algorithm (total presentations: 1592). In the intervention arm, PCPs were prompted to order a palliative care consultation for 142 patients. The time to 0.1% of the population receiving a palliative care consultation was 60.9 days for the intervention arm versus 71.8 days for the control arm (probability of a shorter time with the intervention, 0.88). Conclusion: A machine-learning algorithm to identify palliative care needs was successfully integrated into a primary care practice. More work is needed to improve the workflow.

Introduction People most likely to be affected by Alzheimer’s disease and related dementias (ADRD) are underrepresented in clinical research. Identifying and addressing factors which may influence their research participation is important to advance science and promote diversity. We examined the influence of social determinants of health (SDOH) on research participation among people living with ADRD. Methods We included those age 55 years and older living with ADRD, followed in our community practice in Rochester, Minnesota, who completed a questionnaire assessing SDOH and had at least one clinic visit between June 1, 2019 and June 1, 2020. Demographic and SDOH factors were examined by research participation. Results Among 3273 people included, research participation was low overall (265/3273; 8.1%). People participating in research were more likely to be socially integrated and of higher educational attainment (p < 0.05). Conclusion Promoting social interaction is a potential area for focus to increase research participation in at risk populations.

People living with dementia have high rates of hospitalizations. Identifying factors that influence hospitalization is important. This study examines the influence of physical activity levels on risk of hospitalization and emergency department (ED) use among older people living with mild cognitive impairment (MCI) or dementia followed in our primary care practice in Rochester, Minnesota, United States. We included those age 55 years and older, who had a clinic visit between June 1, 2019 and June 30, 2021 and completed a social determinants of health questionnaire about physical activity levels ( n = 3090). Physical activity was classified as sufficiently active, insufficiently active, or physically inactive. Risk of hospitalization and ED visits by physical activity levels were examined. People who were physically inactive were at higher risk of hospitalization and ED visits ( p < .001) compared with those who were sufficiently active. This highlights an area for health promotion in people living with MCI and dementia.

Objective People living with dementia often have high care needs at the end-of-life. We compared care delivery in the last year of life for people living with dementia in the community (home or assisted living facilities [ALFs]) versus those in skilled nursing facilities (SNFs). Methods A retrospective study was performed of older adults with a dementia diagnosis who died in the community or SNFs from 2013 through 2018. Primary outcomes were numbers of hospitalizations and emergency department visits in the last year of life. Secondary outcomes were completed advance care plans, hospice enrollment, time in hospice, practitioner visits, and intensive care unit admissions. Results Of 1203 older adults with dementia, 622 (51.7%) lived at home/ALFs; 581 (48.3%) lived in SNFs. At least 1 hospitalization was recorded for 70.7% living at home/ALFs versus 50.8% in SNFs ( P < .001), similar to percentages of emergency department visits (80.2% vs 58.0% of the home/ALF and SNF groups, P < .001). SNF residents had more practitioner visits than home/ALF residents: median (IQR), 9.0 (6.0-12.0) versus 5.0 (3.0-9.0; P < .001). No advance care plan was documented for 12.2% (n = 76) of the home/ALF group versus 4.6% (n = 27) of the SNF group ( P < .001). Nearly 57% of SNF residents were enrolled in hospice versus 68.3% at home/ALFs ( P < .001). The median time in hospice was 26.5 days in SNFs versus 30.0 days at home/ALFs ( P = .67). Conclusions Older adults with dementia frequently receive acute care in their last year of life. Hospice care was more common for home/ALF residents. Time in hospice was short.