Factors associated with costly and potentially burdensome hospital care among patients with dementia and respiratory failure

Understanding contributors to costly and potentially burdensome hospital care for critically ill patients with dementia is of interest to healthcare systems and may facilitate efforts to ensure care is concordant with patients’ goals. We conducted an electronic health record (EHR)-based retrospective cohort study of 298 adults with dementia identified using International Classification of Diseases codes. Patients were hospitalized with respiratory failure (receiving ≥2 days mechanical ventilation) at one of two teaching hospitals in Seattle, Washington between 2011 and 2017. We collected patient demographic and clinical characteristics from the EHR, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, or mobility limitations) and clinical service (medical, surgical, neurologic). We measured multimorbidity using the Deyo-Charlson Comorbidity Index. We ascertained whether a goals-of- care discussion (GOCD) was documented in the EHR within 48 hours of intensive care unit (ICU) admission using a validated natural language processing algorithm. Logistic regression was used to identify characteristics associated with high hospitalization costs measured using the hospital system’s accounting database and defined as total cost in the top third of the sample (>=$145,000). We found that only a minority of patients (31%) had a GOCD documented within 48 hours of ICU admission. Adjusting for other measured characteristics, patients for whom a GOCD was documented within 48 hours of ICU admission had a 50% lower risk of a high-cost hospitalization (RR 0.50, 95% CI 0.2-0.9). Older age, limited English proficiency, and residing in a nursing home were also 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 a higher likelihood of high-cost hospitalization. In conclusion, in this cohort study having an early GOCD in the ICU for patients with dementia and respiratory failure was associated with lower total hospitalization costs. However, understanding the nature of the association, causal or non-causal, likely will require the conduct of a randomized trial.