Whalen, Francis X.

Abstract Background At hospice enrollment, patients are asked preferences regarding antibiotic use. Limited evidence on how these medications impact survival makes it difficult for clinicians to offer clear guidance. To support decision-making and antimicrobial stewardship, we assessed the association between antibiotic use and survival in outpatient hospice patients. Methods The association between antibiotic use and survival was evaluated using a time-dependent Cox proportional hazards model, adjusted for age, sex, Charlson Comorbidity Index, and hospice-qualifying conditions (HQCs). The cohort included patients enrolled in a large health system’s outpatient hospice program between June 20, 2017, and January 1, 2023. Results Among 6169 patients with an HQC, 1233 received at least one antimicrobial prescription during the study period. The median time from hospice enrollment to first prescription was 16 days (IQR 3-83). Antimicrobial prescribing patterns varied by HQC category. In time-dependent Cox models, antibiotic use was associated with increased hazard of death (aHR 1.47; 95% confidence interval [CI], 1.37–1.57).Stratified analyses showed the strongest association with increased mortality in patients with cancer HQCs (aHR 1.67; 95% CI, 1.50–1.87) and a survival benefit in those with infectious HQCs (aHR 0.60; 95% CI, 0.40–0.89). Discussion Physicians, patients, and families often overestimate the benefits of antibiotics near the end of life. The observed increase in mortality shortly after antibiotic initiation suggests that symptoms prompting antibiotic use may reflect the dying process rather than treatable infection. Knowledge of the limited role of antibiotics in prolonging life in hospice settings may improve decision-making and enhance the quality of end-of-life care.

Background Patients are enrolled into hospice for a variety of conditions. There are few recent data on the differences of survival duration after hospice enrollment, particularly regarding age, sex, and reason for hospice admission. Methods Using previously obtained data, we calculated age at enrollment, reported sex, and classified patients into nine classes of hospice-qualifying conditions (HQC). We then applied Wilcoxon rank-sum analysis comparing median survival and the percent of patients surviving at least 6 months. Findings 53.38% of patients were female. The median age was 83.03 years. The median survival duration overall was 17.36 days (Inter-quartile range 5.35-62.08). Median survival was lowest for “Infectious” HQC (4.69d) and highest for “Other” (28.53d). Women survived longer than men (19.34 vs 15.37 days). Those older than median survived longer (20.51 days vs 15.03). Overall, 9.47% of enrollees survived at least 6 months. This was more common for women (10.99%), those older than 83 (12.44%), and those enrolled for dementia (16.46%). Discussion Relevant information of what can be expected after hospice enrollment is crucial for families and patients. These differences also indicate potential bias in assessment of hospice applicability, enrolling women, older patients, and patients with specific diagnoses earlier in their disease course.

Background Patients enrolling in hospice care are asked their preferences for antibiotic treatment. There is little information regarding which patients are more likely to receive antibiotics. To better inform discussions, we sought to characterize the use of antibiotics in the outpatient hospice setting. Methods We performed a retrospective review of patients enrolled in outpatient hospice within the Mayo Clinic Health System from 1/1/2017 through 1/1/2023. We calculated what percent of patients received antibiotics based on Hospice Qualifying Condition (HQC), age at enrollment, sex, survival time, and Charlson Comorbidity Index and calculated adjusted odds ratios (aOR). We documented which antibiotics were prescribed based on HQC. Results Of 6452 patients identified, 1259 (19.5%) received antibiotic prescriptions. Cephalosporins were the most common class of antibiotics prescribed (22.8% of antibiotics prescribed), followed by fluoroquinolones (20.3%) and penicillin derivatives (14.9%). Patients with Pulmonary HQCs were most likely to receive antibiotics (28.6% aOR 1.85 [1.51-2.25]), those with neurologic HQCs were least likely (14.9% aOR 0.66 [0.53-0.83]). There was no difference of age for those receiving antibiotics (80.7 yr) vs those not receiving (80.3 yr [ P = 0.25]), or for sex (male vs female aOR 1.10 [0.96-1.26). 4.6% of those surviving <7d received antibiotics (aOR .22 [0.17-0.29]), compared to 47.7% of those surviving >6mo (aOR 4.46 [3.50-5.69]). Discussion 19.5% of patients will receive antibiotics during their hospice course, with more frequent prescriptions in those surviving longer periods and those enrolled for pulmonary conditions. It is important to clarify patient preferences regarding antimicrobial utilization at the time of hospice enrollment.

Background Antibiotics are frequently prescribed at the end of life, though the benefits and harms are not well understood. Methods We abstracted relevant findings from articles published in English in the past 25 years to answer questions generated by discussion among the authors and with stakeholders in Palliative Care and Infectious Diseases. Findings Prescribing practices vary based on individual situation and geographic location. Patients with cancer and those hospitalized receive more antibiotics than those enrolled in outpatient hospice. Urinary tract infections and pulmonary infections are the most common conditions treated with antibiotics at the end of life -most often with penicillin derivatives and vancomycin in the hospital, fluoroquinolones in outpatient, and cephalosporins in both settings. When asked, patients most often prefer limiting antibiotics to symptom management at the end of life. Physicians’ over-estimation of patient preference for antibiotics and the increased probability of misdiagnosis increases antibiotic prescription rates. Antibiotics can improve symptoms when used for specific diseases at the cost of drug reactions, resistant organisms, and delayed discharge. Antibiotic use has variable results on survival duration. Antimicrobial stewardship exists in hospital and long-term care facilities, but not outpatient hospice groups. Stewardship interventions could increase proper use of antibiotics, but more information is needed to apply these interventions to hospice groups. Conclusions Antibiotics at the end of life are impactful and efforts to educate patients and providers will be invaluable in optimizing care.

AbstractRationale, aims and objectivesChecklists have been adopted by various institutions to improve patient outcomes. In particular, readmission prevention checklists may be of potential value to improve patient care and reduce medical costs. As a result, a prior quality improvement study was conducted to create an intensive care unit readmission prevention checklist. The previous pilot demonstrated zero readmissions when the readmission prevention checklist was utilized but yielded low compliance (30%). Thus, a subsequent quality initiative was undertaken to refine the readmission prevention checklist with the primary aim of improved compliance while maintaining a reduced readmission rate that was observed with the original quality improvement study.MethodA single‐centre, cross‐sectional study for assessing baseline data and a prospective observational study to assess the effectiveness of a refined readmission prevention checklist tool in a 20‐bed tertiary medical‐surgical intensive care unit at an academic medical centre in Rochester, MN was conducted. Medical patients admitted through the emergency department, upon direct transfer from outside facility, and post‐operative surgical patients at our institution were included. A refined readmission prevention checklist tool was administered during an 8‐week pilot period for medical and post‐operative surgical patients.ResultsThe refined readmission prevention checklist resulted in an even lower compliance (10.5%) from the initial phase likely resulting from utilization of a paper readmission prevention checklist in an electronic medical environment. Moreover, the refined readmission prevention checklist demonstrated a 22% unplanned readmission rate for patients in which the tool was utilized.ConclusionsIn conclusion, the findings of the current quality improvement study may serve to rethink the process of health care delivery that applies paper tools in an electronic medical environment.