E. J. Lilley1,2, J. W. Scott1, A. Krasnova1, E. Schneider1, A. H. Haider1, Z. Cooper1 1Brigham And Women’s Hospital,The Center For Surgery And Public Health,Boston, MA, USA 2Robert Wood Johnson – Rutgers,Department Of Surgery,New Brunswick, NJ, USA
Introduction: Severe traumatic brain injury (TBI) in older patients is associated with poor prognosis, with rates of mortality or functional dependence exceeding 80%. For non-survivors, aggressive, rescue-directed care may include burdensome treatments at the end of life and impede appropriate provision of hospice, an established quality marker for end-of-life (EOL) care. It is not known whether hospitals with low in-hospital mortality also deliver high-quality EOL care to non-survivors. Therefore, we sought to compare EOL care of older non-survivors with severe TBI treated at low-mortality hospitals against all others.
Methods: Using 2001-2011 Medicare data, we identified patients > 65 years with severe TBI (head AIS > 3) who survived > 1 day in-hospital. Patients at low case-volume hospitals (< 5 eligible patients per year) were excluded. Two categories of non-survivors were analyzed: those who died in-hospital and those who died < 30-days post-discharge. The primary independent variable was in-hospital mortality ranking of the treating hospital: Hospitals were divided into quartiles based on in-hospital mortality and those in the lowest quartile were considered high-performing. EOL care outcomes included intensity of treatment (gastrostomy and tracheostomy) and hospice enrollment. Outcomes of patients treated at high-performing hospitals were compared with others using multivariate Cox regression (30-day post-discharge mortality) and multivariate logistic regression models (EOL care outcomes) adjusting for age, sex, race, and comorbidity.
Results:Among 35,057 older patients hospitalized with severe TBI, 57% died in-hospital or 30-days post-discharge. By definition, in-hospital mortality was lower at high-performing hospitals than at others (36% vs. 49%), yet 30-day post-discharge mortality was the reverse: 26% in high-performing hospitals vs. 19% at others (HR 1.41 [CI 1.32-1.50], p < 0.01). Compared with patients treated at other hospitals, in-hospital non-survivors at high-performing hospitals had similar rates of gastrostomy (3.9% vs. 4.1%, OR 0.94 [CI 0.77-1.15], p = 0.57), tracheostomy (6.9% vs. 6.4%, OR 1.08 [CI 0.92-1.26], p = 0.34), and no clinically significant difference in hospice enrollment (2.2% vs. 1.6%, OR 1.38 [CI 1.05-1.83], p = 0.02). In contrast, 30-day post-discharge non-survivors at high-performing hospitals had fewer high-intensity treatments and a greater proportion were enrolled in hospice (Figure).
Conclusion:These findings suggest that high-performing hospitals are better able to identify patients with poor prognosis and provide appropriate EOL care.
