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Article ; Online: Why is end-of-life inpatient cost high among cancer patients? A prospective cohort study.

Balasubramanian, Ishwarya / Malhotra, Chetna

2024 Volume 13, Issue 4, Page(s) e7057

Abstract: Background: Inpatient cost for cancer patients is high during the last year of life, but reasons for this are not understood. We aim to understand the type of hospital admissions and inpatient services associated with an increase in inpatient cost in ... ...

Abstract	Background: Inpatient cost for cancer patients is high during the last year of life, but reasons for this are not understood. We aim to understand the type of hospital admissions and inpatient services associated with an increase in inpatient cost in last year of life. Methods: We used survey and billing records of 439 deceased patients with a solid metastatic cancer, enrolled in a prospective cohort study. Based on cost per day of inpatient admissions, we classified admissions as low- or high-intensity. We decomposed the inpatient cost into cost for different inpatient services. We examined the inpatient cost in the last year of life. We also assessed patient characteristics associated with higher inpatient cost in the next 3 months. Results: Towards death, proportion of inpatient cost for "maintenance care" increased while that for intensive care unit (ICU) and surgeries decreased. Low-intensity, compared to high-intensity admissions had a higher proportion of cost for "maintenance care" and a lower proportion for surgeries and ICU. Number of low-intensity admissions increased more steeply towards death than high-intensity admissions. Both admission types contributed equally to the share of inpatient cost. Older patients were less likely to have a high-intensity admission (β:-0.01, CI: -0.02, 0.00). Greater preference for life extension (β: 0.06, CI: 0.01, 0.11) and inaccurate prognostic belief were associated with higher cost of high-intensity admissions (β: 0.32, CI: 0.03, 0.62). Conclusions: Findings suggest that inpatient costs in last year of life may be reduced if maintenance care is availed in low-cost settings such as hospice/palliative care alongside steps to reduce non-beneficial surgeries and ICU admissions.
MeSH term(s)	Humans ; Inpatients ; Prospective Studies ; Neoplasms/epidemiology ; Neoplasms/therapy ; Palliative Care ; Hospitalization ; Intensive Care Units ; Death ; Terminal Care ; Retrospective Studies
Language	English
Publishing date	2024-03-08
Publishing country	United States
Document type	Journal Article
ZDB-ID	2659751-2
ISSN	2045-7634 ; 2045-7634
ISSN (online)	2045-7634
ISSN	2045-7634
DOI	10.1002/cam4.7057
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Online: Can Timely Outpatient Visits Reduce Readmissions and Mortality Among Heart Failure Patients?

Balasubramanian, Ishwarya / Malhotra, Chetna

Journal of general internal medicine

2024

Abstract: Background: Outpatient follow-up after a hospital discharge may reduce the risk of readmissions, but existing evidence has methodological limitations.: Objectives: To assess effect of outpatient follow-up within 7, 14, 21 and 30 days of a hospital ... ...

Abstract	Background: Outpatient follow-up after a hospital discharge may reduce the risk of readmissions, but existing evidence has methodological limitations. Objectives: To assess effect of outpatient follow-up within 7, 14, 21 and 30 days of a hospital discharge on 30-day unplanned readmissions or mortality among heart failure (HF) patients; and whether this varies for patients with different clinical complexities. Design: We analyzed medical records between January 2016 and December 2021 from a prospective cohort study. Using time varying mixed effects parametric survival models, we examined the association between not having an outpatient follow-up and risk of adverse events. We used interaction models to assess if the effect of outpatient follow-up visit on outcomes varies with patients' clinical complexity (comorbidities, grip strength, cognitive impairment and length of inpatient stay). Participants: Two hundred and forty-one patients with advanced HF. Main measures: 30-day all-cause (or cardiac) adverse event defined as all cause (or cardiac) unplanned readmissions or death within 30 days of an unplanned all-cause (or cardiac) admission or emergency department visit. Key results: We analyzed 1595 all-cause admissions, inclusive of 1266 cardiac admissions. Not having an outpatient follow-up (vs having an outpatient follow-up) significantly increased the risk of 30-day all-cause adverse event. (risk [95% CI] - 14 days: 35.1 [84.5,-1.1]; 21 days: 43.9 [48.2,6.7]; 30 days: 31.1 [48.5, 7.9]) The risk (at 21 days) was higher for those with one co-morbidity (0.25 [0.11,0.58]), mild (0.67 [0.45, 1.00]) and moderate cognitive impairment (0.38 [0.17, 0.84]), normal grip strength (0.57 [0.34, 0.96]) and length of inpatient stay 7-13 days (0.45 [0.23, 0.89]). Conclusion: Outpatient follow-up within 30 days after a hospital discharge reduced risk of 30-day adverse events among HF patients, the benefit varying according to clinical complexity. Results suggest the need to prioritize patients who benefit from outpatient follow-up for these visits.
Language	English
Publishing date	2024-04-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	639008-0
ISSN	1525-1497 ; 0884-8734
ISSN (online)	1525-1497
ISSN	0884-8734
DOI	10.1007/s11606-024-08755-1
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Article ; Online: Instability in Caregivers' Perception of Dementia as a Terminal Disease.

Malhotra, Chetna / Balasubramanian, Ishwarya

Journal of the American Medical Directors Association

2023 Volume 24, Issue 9, Page(s) 1427–1432

Abstract: Objectives: Family caregivers' perception that dementia is a terminal disease influence end-of-life (EoL) care of persons with severe dementia (PwSDs). Yet, this perception and the extent to which it changes over time is underexplored. We assessed PwSD ... ...

Abstract	Objectives: Family caregivers' perception that dementia is a terminal disease influence end-of-life (EoL) care of persons with severe dementia (PwSDs). Yet, this perception and the extent to which it changes over time is underexplored. We assessed PwSD caregivers' perception of dementia as a terminal disease and changes in this perception over time. Design: Prospective cohort. Setting and participants: Two hundred fifteen primary informal caregivers of community-dwelling PWSDs in Singapore were surveyed every 4 months over a period of 16 months. Methods: We assessed the proportion of caregivers who perceived that dementia is a terminal disease and the extent to which it changed between the previous time points. Using mixed effects multinomial regression models, we assessed factors associated with caregivers' perception and changes in perception between consecutive time points. Results: At baseline, only 26% of the caregivers reported correctly that dementia is a terminal disease. This changed over time, not necessarily toward a correct perception. Caregivers of PwSDs with an acute medical condition in the last 4 months (risk ratio [RR] 2.19, 95% CI 1.21, 3.97) and those with higher functional dependence (RR 1.11, 95% CI 1.01,1.22) were more likely and those of older PwSDs were less likely (RR 0.87, 95% CI 0.81, 0.93) to perceive dementia as a terminal disease. Caregivers of PwSDs who had experienced an acute medical problem in the last 4 months (RR 1.58, 95% CI 1.00, 2.49) were also more likely to shift their perception toward being correct. Caregivers of PwSDs who had more agitation behaviors were more likely to shift their perception toward being incorrect (RR 1.04, 95% CI 1.00,1.07) CONCLUSIONS AND IMPLICATIONS: Few caregivers perceived dementia as terminal, and this perception changed over time and differed according to age and the health status of PwSD. Results have implications regarding the frequency of prognostic discussions.
MeSH term(s)	Humans ; Caregivers ; Prospective Studies ; Health Status ; Dementia ; Perception
Language	English
Publishing date	2023-08-08
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2171030-2
ISSN	1538-9375 ; 1525-8610
ISSN (online)	1538-9375
ISSN	1525-8610
DOI	10.1016/j.jamda.2023.07.001
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Zs.A 5971: Show issues

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Article ; Online: Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time.

Malhotra, Chetna / Balasubramanian, Ishwarya

Journal of Alzheimer's disease : JAD

2023 Volume 93, Issue 3, Page(s) 967–975

Abstract: Background: Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time.: Objective: Assess caregivers' EOL care goal for PWSDs and change in these ...

Abstract	Background: Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time. Objective: Assess caregivers' EOL care goal for PWSDs and change in these goals over time. Methods: Using a prospective cohort of 215 caregivers of PWSDs, we assessed the proportion of caregivers whose EOL care goal for PWSDs changed between two consecutive time points. Mixed effects multinomial regression models assessed factors associated with caregivers' EOL care goals for PWSD (maximal, moderate, minimal life extension); and change in EOL care goal from previous time point. Results: At baseline, 20% of the caregivers had a goal of maximal life extension for their PWSD, and 59% changed their EOL care goal at least once over a period of 16 months. Caregivers of PWSDs with lower quality of life (RR: 1.15, CI: 1.06, 1.24), who expected shorter life expectancy for PWSDs (RR: 10.34, CI: 2.14, 49.99) and who had an advance care planning discussion (RR: 3.52, CI: 1.11, 11.18) were more likely to have a goal of minimal life extension for PWSD. Caregivers with higher anticipatory grief (RR: 0.96, CI: 0.93,1) were more likely to have a goal of maximal life extension. Change in PWSDs' quality of life and change in caregivers' anticipatory grief were associated with change in caregivers' EOL care goals. Conclusion: Caregivers' EOL care goals for PWSDs change over time with change in PWSD and caregiver related factors. Findings have implications regarding how health care providers can engage with caregivers.
MeSH term(s)	Humans ; Caregivers ; Goals ; Quality of Life ; Prospective Studies ; Terminal Care ; Dementia/therapy
Language	English
Publishing date	2023-04-30
Publishing country	Netherlands
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1440127-7
ISSN	1875-8908 ; 1387-2877
ISSN (online)	1875-8908
ISSN	1387-2877
DOI	10.3233/JAD-221161
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Zs.A 6084: Show issues

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Article ; Online: Repeated dosing with oral racemic ketamine as a successful rescue intervention for coping with life events in recurrent major depressive disorder.

Menon, Vikas / Kale, Akshayee / Balasubramanian, Ilambaridhi / Andrade, Chittaranjan

Asian journal of psychiatry

2024 Volume 94, Page(s) 103973

MeSH term(s)	Humans ; Ketamine/therapeutic use ; Depressive Disorder, Major/drug therapy ; Antidepressive Agents/therapeutic use ; Recurrence ; Adaptation, Psychological ; Depressive Disorder, Treatment-Resistant/drug therapy ; Depression
Chemical Substances	Ketamine (690G0D6V8H) ; Antidepressive Agents
Language	English
Publishing date	2024-02-21
Publishing country	Netherlands
Document type	Letter
ZDB-ID	2456678-0
ISSN	1876-2026 ; 1876-2018
ISSN (online)	1876-2026
ISSN	1876-2018
DOI	10.1016/j.ajp.2024.103973
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Article ; Online: Caregiver-reported use of physical restraints among community-dwelling older adults with severe dementia in Singapore.

Andres, Ellie Bostwick / Chaudhry, Isha / Balasubramanian, Ishwarya / Poco, Louisa / Malhotra, Chetna

Journal of the American Geriatrics Society

2024

Abstract: Background: Older adults with severe dementia are at increased risk of being physically restrained in nursing homes and acute care settings, but little is known about restraint use among those cared for at home. This study explores caregiver-reported ... ...

Abstract	Background: Older adults with severe dementia are at increased risk of being physically restrained in nursing homes and acute care settings, but little is known about restraint use among those cared for at home. This study explores caregiver-reported use of restraints among community-dwelling older adults with severe dementia. Methods: Using cross-sectional data from 215 family caregivers, we describe restraint use among older adults with severe dementia living at home. We then use multivariable logistic regression to identify factors associated with restraint use. Results: Nearly half (47%) of caregivers reported on older adults who had been subject to restraints. Most caregivers reporting restraint use suggested safety reasons, such as prevention of falls (68%), wandering (30%), and removal of catheters or feeding tubes (29%); and 44% indicated doctors or other health care providers were involved in the decision to restrain. Feeding tubes (OR = 4.16, 95% CI: 1.27-13.59) and physically aggressive agitation behaviors (OR = 1.93, 95% CI: 1.09-3.40) were associated with higher odds of restraint use among older adults with severe dementia. Caregivers who received strong emotional support from friends (OR = 0.45, 95% CI: 0.21-0.95) were less likely to report restraint use while serving as a caregiver to others (OR = 2.77, 95% CI: 1.36-5.63) increased the odds of restraint use. Conclusions: The pervasiveness of restraint use is concerning and suggests a lack of evidence-based guidance and support for both caregivers and healthcare providers to prevent restraint use among older adults with severe dementia cared for at home.
Language	English
Publishing date	2024-02-29
Publishing country	United States
Document type	Journal Article
ZDB-ID	80363-7
ISSN	1532-5415 ; 0002-8614
ISSN (online)	1532-5415
ISSN	0002-8614
DOI	10.1111/jgs.18797
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Article ; Online: Healthcare Cost Trajectories in the Last 2 Years of Life Among Patients With a Solid Metastatic Cancer: A Prospective Cohort Study.

Balasubramanian, Ishwarya / Finkelstein, Eric / Malhotra, Rahul / Ozdemir, Semra / Malhotra, Chetna

Journal of the National Comprehensive Cancer Network : JNCCN

2022 Volume 20, Issue 9, Page(s) 997–1004.e3

Abstract: Background: Most studies describe the "average healthcare cost trend" among patients with cancer. We aimed to delineate heterogeneous trajectories of healthcare cost during the last 2 years of life of patients with a metastatic cancer and to assess the ... ...

Abstract	Background: Most studies describe the "average healthcare cost trend" among patients with cancer. We aimed to delineate heterogeneous trajectories of healthcare cost during the last 2 years of life of patients with a metastatic cancer and to assess the associated sociodemographic and clinical characteristics and healthcare use. Patients and methods: We analyzed a sample of 353 deceased patients from a cohort of 600 with a solid metastatic cancer in Singapore, and we used group-based trajectory modeling to identify trajectories of total healthcare cost during the last 2 years of life. Results: The average cost trend showed that mean monthly healthcare cost increased from SGD $3,997 during the last 2 years of life to SGD $7,516 during the last month of life (USD $1 = SGD $1.35). Group-based trajectory modeling identified 4 distinct trajectories: (1) low and steadily decreasing cost (13%); (2) steeply increasing cost in the last year of life (14%); (3) high and steadily increasing cost (57%); and (4) steeply increasing cost before the last year of life (16%). Compared with the low and steadily decreasing cost trajectory, patients with private health insurance (β [SE], 0.75 [0.37]; P=.04) and a greater preference for life extension (β [SE], -0.14 [0.07]; P=.06) were more likely to follow the high and steadily increasing cost trajectory. Patients in the low and steadily decreasing cost trajectory were most likely to have used palliative care (62%) and to die in a hospice (27%), whereas those in the steeply increasing cost before the last year of life trajectory were least likely to have used palliative care (14%) and most likely to die in a hospital (75%). Conclusions: The study quantifies healthcare cost and shows the variability in healthcare cost trajectories during the last 2 years of life. Policymakers, clinicians, patients, and families can use this information to better anticipate, budget, and manage healthcare costs.
MeSH term(s)	Cohort Studies ; Health Care Costs ; Humans ; Neoplasms/epidemiology ; Neoplasms/therapy ; Neoplasms, Second Primary ; Palliative Care ; Prospective Studies
Language	English
Publishing date	2022-09-22
Publishing country	United States
Document type	Journal Article
ZDB-ID	2250759-0
ISSN	1540-1413 ; 1540-1405
ISSN (online)	1540-1413
ISSN	1540-1405
DOI	10.6004/jnccn.2022.7038
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Article ; Online: Psychiatric adverse reactions to COVID-19 vaccines: A rapid review of published case reports.

Balasubramanian, Ilambaridhi / Faheem, Abdul / Padhy, Susanta Kumar / Menon, Vikas

Asian journal of psychiatry

2022 Volume 71, Page(s) 103129

Abstract: We aimed to review the available reports of psychiatric adverse reactions to COVID vaccines. Electronic databases such as PubMed and Google scholar were combed to identify relevant reports. We found a total of 11 reports describing 14 cases of ... ...

Abstract	We aimed to review the available reports of psychiatric adverse reactions to COVID vaccines. Electronic databases such as PubMed and Google scholar were combed to identify relevant reports. We found a total of 11 reports describing 14 cases of psychiatric reactions; these were mostly altered mental states, psychosis, mania, depression, and functional neurological disorder. The index case was commonly a young or middle-aged adult. All reports pertained to the use of either mRNA or vector-based vaccines. Symptom onset was within 10 days of vaccination in all cases; as such, this seems to be a high-risk period warranting vigilance.
MeSH term(s)	Adult ; COVID-19/prevention & control ; COVID-19 Vaccines/adverse effects ; Humans ; Middle Aged ; Psychotic Disorders/etiology ; SARS-CoV-2 ; Vaccination/adverse effects
Chemical Substances	COVID-19 Vaccines
Language	English
Publishing date	2022-04-13
Publishing country	Netherlands
Document type	Case Reports ; Journal Article ; Review
ZDB-ID	2456678-0
ISSN	1876-2026 ; 1876-2018
ISSN (online)	1876-2026
ISSN	1876-2018
DOI	10.1016/j.ajp.2022.103129
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Article: Metaplastic Paneth Cells in Extra-Intestinal Mucosal Niche Indicate a Link to Microbiome and Inflammation.

Singh, Rajbir / Balasubramanian, Iyshwarya / Zhang, Lanjing / Gao, Nan

Frontiers in physiology

2020 Volume 11, Page(s) 280

Abstract: Paneth cells are residents of the intestinal epithelium. Abnormal appearance of Paneth cells has been widely documented in non-intestinal tissues within the digestive tract and even observed in non-gastrointestinal organs. Although metaplastic Paneth ... ...

Abstract	Paneth cells are residents of the intestinal epithelium. Abnormal appearance of Paneth cells has been widely documented in non-intestinal tissues within the digestive tract and even observed in non-gastrointestinal organs. Although metaplastic Paneth cells are part of the overarching pathology of intestinal metaplasia (IM), only a fraction of intestinal metaplastic lesions contain Paneth cells. We survey literature documenting metaplastic Paneth cells to gain insights into mechanism underlying their etiologic development as well as their potential relevance to human health. A synthesized view from this study suggests that the emergence of metaplastic Paneth cells at extra-intestinal mucosal sites likely represents a protective, anti-bacterial, and inflammatory response evoked by an altered microbial activity.
Language	English
Publishing date	2020-03-31
Publishing country	Switzerland
Document type	Journal Article ; Review
ZDB-ID	2564217-0
ISSN	1664-042X
ISSN	1664-042X
DOI	10.3389/fphys.2020.00280
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Article ; Online: From sensing to shaping microbiota: insights into the role of NOD2 in intestinal homeostasis and progression of Crohn's disease.

Balasubramanian, Iyshwarya / Gao, Nan

American journal of physiology. Gastrointestinal and liver physiology

2017 Volume 313, Issue 1, Page(s) G7–G13

Abstract: ... ...

Abstract	NOD2
MeSH term(s)	Crohn Disease/metabolism ; Crohn Disease/pathology ; Disease Progression ; Gene Expression Regulation/physiology ; Homeostasis ; Humans ; Intestinal Mucosa/metabolism ; Intestines/microbiology ; Intestines/pathology ; Microbiota/physiology ; Nod2 Signaling Adaptor Protein/genetics ; Nod2 Signaling Adaptor Protein/metabolism
Chemical Substances	NOD2 protein, human ; Nod2 Signaling Adaptor Protein
Language	English
Publishing date	2017-04-27
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	603840-2
ISSN	1522-1547 ; 0193-1857
ISSN (online)	1522-1547
ISSN	0193-1857
DOI	10.1152/ajpgi.00330.2016
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