Publications by Year: 2023

RATIONALE AND OBJECTIVES: The COVID-19 pandemic has caused much uncertainty and disruption in healthcare resulting in many challenges for strategic planning. Scenario planning is a tool that allows healthcare leaders to plan healthcare delivery strategies by incorporating the uncertainties into the analysis and planning process.

MATERIALS AND METHODS: Variables were identified which will have major impact on the future, but whose future direction is uncertain. The extremes of these drivers were used to generate multiple scenarios. A subset of scenarios was used to evaluate potential tactics to determine which may be high yield in the face of uncertainty.

RESULTS: Unlike traditional strategic planning, scenario planning does not develop a single future with a path to that future. Scenario planning evaluates tactics to determine which would be helpful in specific scenarios, multiple different futures or under specific conditions.

CONCLUSION: We present a scenario planning model which can be used to determine specific tactics to accommodate the uncertainty due to variable healthcare delivery needs in the COVID-19 era.

BACKGROUND: Prior studies have shown variation in the intensity of end-of-life care in intensive care units (ICUs) among patients of different races.

OBJECTIVE: We sought to identify variation in the levels of care at the end of life in the ICU and to assess for any association with race and ethnicity.

DESIGN: An observational, retrospective cohort study.

SETTINGS: A tertiary care center in Boston, MA.

PARTICIPANTS: All critically ill patients admitted to medical and surgical ICUs between June 2019 and December 2020.

EXPOSURE: Self-identified race and ethnicity.

MAIN OUTCOME AND MEASURE: The primary outcome was death. Secondary outcomes included "code status," markers of intensity of care, consultation by the Palliative care service, and consultation by the Ethics service.

RESULTS: A total of 9083 ICU patient encounters were analyzed. One thousand two hundred fifty-nine patients (14%) died in the ICU; the mean age of patients was 64 years (standard deviation 16.8), and 44% of patients were women. A large number of decedents (22.7%) did not have their race identified. These patients had a high rate of interventions at death. Code status varied by race, with more White patients designated as "Comfort Measures Only" (CMO) (74%) whereas more Black patients were designated as "Do Not Resuscitate/Do Not Intubate (DNR/DNI) and DNR/ok to intubate" (12.1% and 15.7%) at the end of life; after adjustment for age and severity of illness, there were no statistical differences by race for the use of the CMO code status. Use of dialysis at the end of life varied by self-identified race. Specifically, Black and Unknown patients were more likely to receive renal replacement therapy, even after adjustment for age and severity of illness (24% and 20%, p = 0.003).

CONCLUSIONS: Our data describe a gap in identification of race and ethnicity, as well as differences at the end of life in the ICU, especially with respect to code status and certain markers of intensity.

IMPORTANCE: Long-term acute care hospitals (LTCHs) are common sites of postacute care for patients recovering from severe respiratory failure requiring mechanical ventilation (MV). However, federal payment reform led to the closure of many LTCHs in the US, and it is unclear how closure of LTCHs may have affected upstream care patterns at short-stay hospitals and overall patient outcomes.

OBJECTIVE: To estimate the association between LTCH closures and short-stay hospital care patterns and patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective, national, matched cohort study used difference-in-differences analysis to compare outcomes at short-stay hospitals reliant on LTCHs that closed during 2012 to 2018 with outcomes at control hospitals. Data were obtained from the Medicare Provider Analysis and Review File, 2011 to 2019. Participants included Medicare fee-for-service beneficiaries aged 66 years and older receiving MV for at least 96 hours in an intensive care unit (ie, patients at-risk for prolonged MV) and the subgroup also receiving a tracheostomy (ie, receiving prolonged MV). Data were analyzed from October 2022 to June 2023.

EXPOSURE: Admission to closure-affected hospitals, defined as those discharging at least 60% of patients receiving a tracheostomy to LTCHs that subsequently closed, vs control hospitals.

MAIN OUTCOMES AND MEASURES: Upstream hospital care pattern outcomes were short-stay hospital do-not-resuscitate orders, palliative care delivery, tracheostomy placement, and discharge disposition. Patient outcomes included hospital length of stay, days alive and institution free within 90 days, spending per days alive within 90 days, and 90-day mortality.

RESULTS: Between 2011 and 2019, 99 454 patients receiving MV for at least 96 hours at 1261 hospitals were discharged to 459 LTCHs; 84 LTCHs closed. Difference-in-differences analysis included 8404 patients (mean age, 76.2 [7.2] years; 4419 [52.6%] men) admitted to 45 closure-affected hospitals and 45 matched-control hospitals. LTCH closure was associated with decreased LTCH transfer rates (difference, -5.1 [95% CI -8.2 to -2.0] percentage points) and decreased spending-per-days-alive (difference, -$8701.58 [95% CI, -$13 323.56 to -$4079.60]). In the subgroup of patients receiving a tracheostomy, there was additionally an increase in do-not-resuscitate rates (difference, 10.3 [95% CI, 4.2 to 16.3] percentage points) and transfer to skilled nursing facilities (difference, 10.0 [95% CI, 4.2 to 15.8] percentage points). There was no significant association of closure with 90-day mortality.

CONCLUSIONS AND RELEVANCE: In this cohort study, LTCH closure was associated with changes in discharge patterns in patients receiving mechanical ventilation for at least 96 hours and advanced directive decisions in the subgroup receiving a tracheostomy, without change in mortality. Further studies are needed to understand how LTCH availability may be associated with other important outcomes, including functional outcomes and patient and family satisfaction.

OBJECTIVES: Pregnancy provides a critical opportunity to engage individuals with opioid use disorder in care. However, before the COVID-19 pandemic, there were multiple barriers to accessing buprenorphine/naloxone during pregnancy. Care disruptions during the pandemic may have further exacerbated these existing barriers. To quantify these changes, we examined trends in the number of individuals filling buprenorphine/naloxone prescriptions during the COVID-19 pandemic.

METHODS: We estimated an interrupted time series model using linked national pharmacy claims and medical claims data from prepandemic (May 2019 to February 2020) to the pandemic period (April 2020 to December 2020). We estimated changes in the growth rate in the monthly number of individuals filling buprenorphine/naloxone prescriptions in the 6 months preceding a delivery claim, per 100,000 pregnancies, during the COVID-19 pandemic.

RESULTS: We identified 2947 pregnant individuals filling buprenorphine/naloxone prescriptions. Before the pandemic, there was positive growth in the monthly number of individuals filling buprenorphine/naloxone prescriptions (4.83%; 95% confidence interval [CI], 3.82-5.84%). During the pandemic, this monthly growth rate declined for both individuals on commercial insurance and individuals on Medicaid (all payers: -5.53% [95% CI, -6.65% to -4.41%]; Medicaid: -7.66% [95% CI, -10.14% to -5.18%]; Commercial: -3.59% [95% CI, -5.32% to -1.87%]).

CONCLUSION: The number of pregnant individuals filling buprenorphine/naloxone prescriptions was increasing, but this growth has been lost during the pandemic.