Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure.

RATIONALE: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care.

OBJECTIVE: To identify risk factors, in particular whether an early goals of care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure.

METHODS: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ≥48 hours mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (>=$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization.

RESULTS: Patients in the sample had a median age of 71 (IQR 62-79) years. About half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. Over half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had 50% lower risk of a high-cost hospitalization (RR 0.50, 95% CI 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU as compared to a medical ICU were associated with higher likelihood of high-cost hospitalization.

CONCLUSIONS: Early GOCD for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.