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Associations between the Veteran Health Administration's Life-Sustaining Treatment Decisions Initiative and Quality of Care at the End of Life

Batten, Adam; Cohen, Jennifer H; Foglia, Mary Beth; Alfandre, David
PMID: 35020477
ISSN: 1557-7740
CID: 5118792

Challenging the Myths of the Against Medical Advice Discharge

Alfandre, David
PMID: 35286829
ISSN: 1539-3704
CID: 5190502

Discharges against medical advice and 30-day healthcare costs: an analysis of commercially insured adults

Onukwugha, Eberechukwu; Gandhi, Aakash Bipin; Alfandre, David
PMID: 34783251
ISSN: 2042-6313
CID: 5049052

Adverse Discharge Outcomes Associated With the Medicare Hospital Readmissions Reduction Program Among Commercially Insured Adults

Alfandre, David; Bipin Gandhi, Aakash; Onukwugha, Eberechukwu
ABSTRACT/UNASSIGNED:It is unknown if changes in the rate of discharges against medical advice (DAMA) are related to the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP). We performed an interrupted time series analysis of monthly DAMA rates per 1,000 discharges of all enrolled individuals 18-64 years old with a hospitalization between January 1, 2006, and December 31, 2015, in a commercially insured population. We performed a segmented linear regression with two interruptions: (1) April 2010 to coincide with the passage of the HRRP and (2) October 2012 to coincide with the implementation of HRRP penalties. There were 1,087,812 discharges representing 668,823 individuals over 120 months. The downward trend in monthly DAMA rates was reversed significantly after April 2010 with a sustained 0.1 increase in the monthly rate that continued after the implementation of penalties in October 2012. Allowing for the two interruptions, there was a statistically significant positive trend (0.10; 0.06-0.13, p < .01) in April 2010. Relative to the first interruption, there was no statistically significant change in the slope in October 2012; the estimated slope was -0.04 (-0.08 to 0.002). Monthly DAMA rates increased in anticipation of and after HRRP implementation, suggesting a potential relationship between the HRRP and DAMA.
PMID: 33724963
ISSN: 1945-1474
CID: 5146972

A Duty to Plan: Proactive Goals of Care Conversations with Seriously Ill Veterans Who Test Positive for COVID-19 [Letter]

Cohen, Jennifer; Foglia, Mary Beth; Batten, Adam; Alfandre, David
PMID: 33950344
ISSN: 1525-1497
CID: 4874022

Annals for Hospitalists Inpatient Notes - Challenging the Myths of the Against Medical Advice Discharge

Alfandre, David
PMID: 34662167
ISSN: 1539-3704
CID: 5043132

A Shot at Inclusion: Reconsidering Categorical Exclusion of Hospice Patients from COVID Vaccine Allocation

Weaver, Meaghann S; Geppert, Cynthia M A; Alfandre, David J
PMID: 33762164
ISSN: 1873-6513
CID: 4855542

Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures

Alfandre, David; Sharpe, Virginia Ashby; Geppert, Cynthia; Foglia, Mary Beth; Berkowitz, Kenneth; Chanko, Barbara; Schonfeld, Toby
Much of the sustained attention on pandemic preparedness has focused on the ethical justification for plans for the "crisis" phase of a surge when, despite augmentation efforts, the demand for life-saving resources outstrips supply. The ethical frameworks that should guide planning and implementation of the "contingency" phase of a public health emergency are less well described. The contingency phase is when strategies to augment staff, space, and supplies are systematically deployed to forestall critical resource scarcity, reduce disproportionate harm to patients and health care providers, and provide patient care that remains functionally equivalent to conventional practice. We describe an ethical framework to inform planning and implementation for COVID-19 contingency surge responses and apply this framework to 3 use cases. Examining the unique ethical challenges of this mediating phase will facilitate proactive ethics conversations about healthcare operations during the contingency phase and ideally lead to ethically stronger health care practices.
PMID: 33998972
ISSN: 1536-0075
CID: 5387002

"Thanks Doc, But I Prefer to Stay" ̶ Finding Our Way Out of Contentious Hospital Discharge Planning [Comment]

Alfandre, David
PMID: 34152920
ISSN: 1536-0075
CID: 4933922

An Exploratory Study of Goals of Care Conversations Initiated with Seriously Ill Veterans in the Emergency Room

Foglia, Mary Beth; Cohen, Jennifer H; Batten, Adam; Alfandre, David
PMID: 33170071
ISSN: 1557-7740
CID: 4675912