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  1. Article ; Online: Advance care planning: It is time to rethink our goals.

    Malhotra, Chetna

    Journal of the American Geriatrics Society

    2023  Volume 71, Issue 12, Page(s) 3963–3966

    MeSH term(s) Humans ; Goals ; Advance Care Planning ; Communication
    Language English
    Publishing date 2023-07-31
    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.18511
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  2. Article ; Online: Why is end-of-life inpatient cost high among cancer patients? A prospective cohort study.

    Balasubramanian, Ishwarya / Malhotra, Chetna

    Cancer medicine

    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
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  3. 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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  4. Article ; Online: Barriers to advance care planning among patients with advanced serious illnesses: A national survey of health-care professionals in Singapore.

    Malhotra, Chetna / Chaudhry, Isha

    Palliative & supportive care

    2023  , Page(s) 1–8

    Abstract: Objectives: To assess the barriers that health-care professionals (HCPs) face in having advance care planning (ACP) conversations with patients suffering from advanced serious illnesses and to provide care consistent with patients' documented ... ...

    Abstract Objectives: To assess the barriers that health-care professionals (HCPs) face in having advance care planning (ACP) conversations with patients suffering from advanced serious illnesses and to provide care consistent with patients' documented preferences.
    Methods: We conducted a national survey of HCPs trained in facilitating ACP conversations in Singapore between June and July 2021. HCPs responded to hypothetical vignettes about a patient with an advanced serious illness and rated the importance of barriers (HCP-, patient-, and caregiver-related) in (i) conducting and documenting ACP conversations and (ii) providing care consistent with documented preferences.
    Results: Nine hundred eleven HCPs trained in facilitating ACP conversations responded to the survey; 57% of them had not facilitated any in the last 1 year. HCP factors were reported as the topmost barriers to facilitating ACP. These included lack of allocated time to have ACP conversations and ACP facilitation being time-consuming. Patient's refusal to engage in ACP conversations and family experiencing difficulty in accepting patient's poor prognosis were the topmost patient- and caregiver-related factors. Non-physician HCPs were more likely than physicians to report being fearful of upsetting the patient/family and lack of confidence in facilitating ACP conversations. About 70% of the physicians perceived caregiver factors (surrogate wanting a different course of treatment and family caregivers being conflicted about patients' care) as barriers to providing care consistent with preferences.
    Significance of results: Study findings suggest that ACP conversations be simplified, ACP training framework be improved, awareness regarding ACP among patients, caregivers, and general public be increased, and ACP be made widely accessible.
    Language English
    Publishing date 2023-04-03
    Publishing country England
    Document type Journal Article
    ZDB-ID 2454009-2
    ISSN 1478-9523 ; 1478-9515
    ISSN (online) 1478-9523
    ISSN 1478-9515
    DOI 10.1017/S1478951523000214
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  5. 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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  6. 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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  7. Article ; Online: Caregivers' Burden and Anticipatory Grief Increases Acute Health Care Use in Older Adults with Severe Dementia.

    Malhotra, Chetna / Chaudhry, Isha / Shah, Shimoni Urvish

    Journal of the American Medical Directors Association

    2024  Volume 25, Issue 7, Page(s) 104981

    Abstract: Objectives: To assess the bidirectional association of caregivers' burden and anticipatory grief with acute health care use (inpatient or emergency admission) among older adults with severe dementia.: Design: Prospective cohort.: Setting and ... ...

    Abstract Objectives: To assess the bidirectional association of caregivers' burden and anticipatory grief with acute health care use (inpatient or emergency admission) among older adults with severe dementia.
    Design: Prospective cohort.
    Setting and participants: A total of 215 family caregivers of older adults with severe dementia in Singapore were surveyed every 4 months for 3 years (up to 10 surveys). We measured caregiver burden using the Caregiver Reaction Assessment scale and anticipatory grief using the Marwit Meuser Caregiver Grief Inventory-Short Form.
    Methods: Using separate multivariable mixed-effects logistic regressions, controlling for relevant confounders, we assessed the association of caregiver burden and anticipatory grief (independent variables measured at time t) with older adults' acute health care use in the next 4 months (outcome measured at time t + 1). We also performed separate multivariable mixed-effects linear regressions to assess the association of older adults' acute health care use in the past 4 months (independent variable measured at time t) with caregiver burden and anticipatory grief (outcomes measured at time t).
    Results: At baseline, 33% of the older adults had an inpatient or emergency admission in the past 4 months. Regression results showed that higher caregiver burden [odds ratio (OR), 1.58; 95% CI, 1.15-2.16] and anticipatory grief (OR, 1.02; 95% CI, 1.00-1.04) significantly increased the likelihood of older adults experiencing acute health care use in the next 4 months. However, older adults' acute health care use in the past 4 months did not significantly change their caregivers' burden or anticipatory grief.
    Conclusions and implications: Higher caregiver burden and anticipatory grief increase the likelihood of older adults having acute health care use. Addressing caregivers' well-being has implications for reducing acute health care use in older adults and the economic burden of severe dementia.
    Language English
    Publishing date 2024-04-07
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2171030-2
    ISSN 1538-9375 ; 1525-8610
    ISSN (online) 1538-9375
    ISSN 1525-8610
    DOI 10.1016/j.jamda.2024.03.001
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  8. Article ; Online: Complexity of implementing a nationwide advance care planning program: results from a qualitative evaluation.

    Malhotra, Chetna / Ramakrishnan, Chandrika

    Age and ageing

    2022  Volume 51, Issue 10

    Abstract: Background: We evaluated Singapore's national advance care planning (ACP) program to understand challenges to its implementation within multiple clinical settings.: Methods: We conducted focus group discussions (FGDs) with a purposive sample of ... ...

    Abstract Background: We evaluated Singapore's national advance care planning (ACP) program to understand challenges to its implementation within multiple clinical settings.
    Methods: We conducted focus group discussions (FGDs) with a purposive sample of health care professionals (HCPs) involved in ACP program delivery within acute care hospitals, primary care clinics and nursing homes. FGDs were stratified into three categories based on HCPs' role within the ACP framework-leaders versus facilitators and advocates versus nursing home heads. Using NVivo 11, we analysed data using thematic analysis and Conceptual Framework for Implementation Research.
    Results: A total of 107 HCPs from 25 organisations participated in 22 FGDs. Findings revealed wide variation in ACP implementation among organisations and identified 12 themes organized within four domains-outer setting (lack of public awareness, shortcomings in inter-organisational partnerships, performance driven policies), inner setting (lack of commitment from organisational leadership, paucity of dedicated resources, absence of an institution-wide ACP culture, lack of physician engagement), characteristics of HCPs (language barriers) and process (inadequate training, complexity of conversations and documentations, challenges to retrieving ACP documents, absence of comprehensive monitoring and evaluation).
    Conclusion: ACP program implementation is complex and faces multiple health care system challenges. To integrate ACP within routine clinical care, ACP processes should be simplified, training framework be strengthened, physicians be engaged and an ACP supportive culture be created within and outside organisations. Findings will be used to guide ACP implementation within the country and globally.
    MeSH term(s) Humans ; Advance Care Planning ; Nursing Homes ; Health Personnel ; Focus Groups ; Communication ; Qualitative Research
    Language English
    Publishing date 2022-10-21
    Publishing country England
    Document type Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 186788-x
    ISSN 1468-2834 ; 0002-0729
    ISSN (online) 1468-2834
    ISSN 0002-0729
    DOI 10.1093/ageing/afac224
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  9. Article ; Online: The cost of caring: How advanced cancer patients affect Caregiver's employment in Singapore.

    Su, Jasmine / Malhotra, Chetna

    Psycho-oncology

    2022  Volume 31, Issue 7, Page(s) 1152–1160

    Abstract: Background: With ageing populations and rising cancer incidence, more people are becoming informal caregivers. Informal caregivers are less likely to work than non-caregivers, yet little is known about how their employment changes over time. This study ... ...

    Abstract Background: With ageing populations and rising cancer incidence, more people are becoming informal caregivers. Informal caregivers are less likely to work than non-caregivers, yet little is known about how their employment changes over time. This study aimed to examine the association between decline in cancer patient's health (termed health shock) and caregiver's employment. A secondary aim was to assess characteristics of caregivers who stayed employed despite the health shock and the burden of caring for advanced stage cancer patients.
    Method: This study used data from 270 dyads of advanced cancer patients and their caregivers who participated in the Cost of Medical Care of Patients with Advanced Serious Illness in Singapore study. The dyads were interviewed every 3 months for 2 years. Fixed-effects regression was used to analyse the association between patient health shock and two caregiver employment outcomes (i.e., employment status and work disruptions).
    Results: Ninety-seven% of caregivers whose patient experienced a health shock reported work disruptions. About 13% of caregivers whose patient experienced at least one health shock left employment, compared to 5% of those whose patient did not experience any health shock. Following a patient health shock, caregivers were significantly less likely to be employed (β: -0.03; 95% CI, -0.05 to -0.001) and more likely to experience work disruptions (β: 0.06; 95% confidence interval [CI], -0.01 to 0.12). Caregivers who were young, educated, unmarried, not spousal caregivers, and not living with their patients were more likely to stay employed despite patient health shock (p < 0.01 for all).
    Conclusion: Findings show that caregivers' employment is affected by their patients' health through the caregiving trajectory. Continuous support for caregivers catered to specific vulnerable subgroups may be important to keeping caregivers in the workforce.
    MeSH term(s) Caregivers ; Cost of Illness ; Employment ; Humans ; Neoplasms ; Singapore
    Language English
    Publishing date 2022-02-21
    Publishing country England
    Document type Journal Article
    ZDB-ID 1118536-3
    ISSN 1099-1611 ; 1057-9249
    ISSN (online) 1099-1611
    ISSN 1057-9249
    DOI 10.1002/pon.5903
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  10. Article ; Online: Quality of life and its predictors among patients with metastatic cancer in Bangladesh: the APPROACH survey.

    Rahman, Rubayat / Mariam, Lubna / Su, Rebecca / Malhotra, Chetna / Ozdemir, Semra

    BMC palliative care

    2024  Volume 23, Issue 1, Page(s) 2

    Abstract: Background: This study aimed to assess the health-related quality of life (HRQOL) (physical, functional, emotional, social, spiritual) and psychological (anxiety and depression) well-being and their associations with patient characteristics among ... ...

    Abstract Background: This study aimed to assess the health-related quality of life (HRQOL) (physical, functional, emotional, social, spiritual) and psychological (anxiety and depression) well-being and their associations with patient characteristics among patients with metastatic cancer in Bangladesh.
    Methods: A convenience sample of 386 Bangladeshi patients with stage IV solid cancers was recruited from a palliative care outpatient department and an inpatient palliative center. Dependent variables included the physical, functional, emotional, social, and overall scores of the Functional Assessment of Cancer Therapy-General (FACT-G) scale, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being (FACIT-SP) scale, the anxiety, depression, and overall scores of the Hospital Anxiety and Depression (HADS) scale. Linear regressions examined the association between dependent variables and patient characteristics.
    Results: A substantial proportion of Bangladeshi patients reported anxiety (59% of outpatients and 55% of inpatients) and depression (60% of outpatients and 73% of inpatients) symptoms. Generally, greater financial difficulty and symptom burden scores were associated with worse health outcomes. Older patients reported poorer functional and spiritual well-being but better anxiety scores. Females reported worse anxiety and depressive symptoms and physical well-being but better spiritual outcomes.
    Conclusions: Additional efforts must be directed at improving the HRQOL of patients with metastatic cancer in Bangladesh. Furthermore, assistance should be made more accessible to vulnerable groups, including women, the elderly, and those with financial difficulty.
    MeSH term(s) Humans ; Female ; Aged ; Quality of Life/psychology ; Bangladesh/epidemiology ; Neoplasms/complications ; Neoplasms/psychology ; Emotions ; Anxiety/epidemiology ; Anxiety/psychology ; Depression/psychology
    Language English
    Publishing date 2024-01-03
    Publishing country England
    Document type Journal Article
    ZDB-ID 2091556-1
    ISSN 1472-684X ; 1472-684X
    ISSN (online) 1472-684X
    ISSN 1472-684X
    DOI 10.1186/s12904-023-01301-6
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