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Wachterman MW, Sinha A, Leveille T, Waikar SS, Widera E, Romero K, Bokhour B. Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease. J Am Geriatr Soc 2024; 72:2060-2069. [PMID: 38777614 PMCID: PMC11226377 DOI: 10.1111/jgs.18936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD. METHODS Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice. RESULTS With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD. CONCLUSIONS Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Sushrut S Waikar
- Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Eric Widera
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Palliative Care, University of California San Francisco, San Francisco, California, USA
| | - Kai Romero
- Division of Palliative Care, University of California San Francisco, San Francisco, California, USA
- By the Bay Health, San Francisco, California, USA
| | - Barbara Bokhour
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- Center for Healthcare Organization and Implementation of Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts, USA
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Ernecoff NC, Robinson MT, Motter EM, Bursic AE, Lagnese K, Taylor R, Lupu D, Schell JO. Concurrent Hospice and Dialysis Care: Considerations for Implementation. J Gen Intern Med 2024; 39:798-807. [PMID: 37962726 PMCID: PMC11043284 DOI: 10.1007/s11606-023-08504-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023]
Abstract
IMPORTANCE Hospice positively impacts care at the end of life for patients and their families. However, compared to the general Medicare population, patients on dialysis are half as likely to receive hospice. Concurrent hospice and dialysis care offers an opportunity to improve care for people living with end-stage kidney disease (ESKD). OBJECTIVE We sought to (1) develop a conceptual model of the Program and (2) identify key components, resources, and considerations for further implementation. DESIGN We conducted a template analysis of qualitative interviews and convened a community advisory panel (CAP) to get feedback on current concurrent care design and considerations for dissemination and implementation. PARTICIPANTS Thirty-nine patients with late-stage chronic kidney disease (CKD), family caregivers, bereaved family caregivers, hospice clinicians, nephrology clinicians, administrators, and policy experts participated in interviews. A purposive subset of 19 interviewees composed the CAP. MAIN MEASURES Qualitative feedback on concurrent care design refinements, implementation, and resources. KEY RESULTS Participants identified four themes that define an effective model of concurrent hospice and dialysis: it requires (1) timely goals-of-care conversations and (2) an interdisciplinary approach; (3) clear guidelines ensure smooth transitions for patients and families; and (4) hospice payment policy must support concurrent care. CAP participants provided feedback on the phases of an effective model of concurrent hospice and dialysis, and resources, including written and interactive educational materials, communication tools, workflow processes, and order sets. CONCLUSIONS We developed a conceptual model for concurrent hospice and dialysis care and a corresponding resource list. In addition to policy changes, clinical implementation and educational resources can facilitate scalable and equitable dissemination of concurrent care. Concurrent hospice and dialysis care must be systematically evaluated via a hybrid implementation-effectiveness trial that includes the resources outlined herein, based on our conceptual model of concurrent care delivery.
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Affiliation(s)
| | - Mayumi T Robinson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Erica M Motter
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexandra E Bursic
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Keith Lagnese
- Optum Home & Community Care, Landmark Health, Huntington Beach, CA, USA
| | | | - Dale Lupu
- School of Nursing, George Washington University, Washington, DC, USA
| | - Jane O Schell
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Dialysis Clinic, Inc, Nashville, TN, USA
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Chu WM, Tsai HB, Chen YC, Hung KY, Cheng SY, Lin CP. Palliative Care for Adult Patients Undergoing Hemodialysis in Asia: Challenges and Opportunities. JOURNAL OF HOSPICE AND PALLIATIVE CARE 2024; 27:1-10. [PMID: 38449832 PMCID: PMC10911979 DOI: 10.14475/jhpc.2024.27.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/03/2024] [Accepted: 02/03/2024] [Indexed: 03/08/2024]
Abstract
This article underscores the importance of integrating comprehensive palliative care for noncancer patients who are undergoing hemodialysis, with an emphasis on the aging populations in Asian nations such as Taiwan, Japan, the Republic of Korea, and China. As the global demographic landscape shifts towards an aging society and healthcare continues to advance, a marked increase has been observed in patients undergoing hemodialysis who require palliative care. This necessitates an immediate paradigm shift to incorporate this care, addressing the intricate physical, psychosocial, and spiritual challenges faced by these individuals and their families. Numerous challenges impede the provision of effective palliative care, including difficulties in prognosis, delayed referrals, cultural misconceptions, lack of clinician confidence, and insufficient collaboration among healthcare professionals. The article proposes potential solutions, such as targeted training for clinicians, the use of telemedicine to facilitate shared decision-making, and the introduction of time-limited trials for dialysis to overcome these obstacles. The integration of palliative care into routine renal treatment and the promotion of transparent communication among healthcare professionals represent key strategies to enhance the quality of life and end-of-life care for people on hemodialysis. By embracing innovative strategies and fostering collaboration, healthcare providers can deliver more patient-centered, holistic care that meets the complex needs of seriously ill patients within an aging population undergoing hemodialysis.
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Affiliation(s)
- Wei-Min Chu
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Post‐Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Epidemiology of Aging, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan
| | - Hung-Bin Tsai
- Division of Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Chi Chen
- Institute of Clinical Nursing, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuan-Yu Hung
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Cheng-Pei Lin
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
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4
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Moss AH, Harbert G, Aldous A, Anderson E, Nicklas A, Lupu DE. Pathways Project Pragmatic Lessons Learned: Integrating Supportive Care Best Practices into Real-World Kidney Care. KIDNEY360 2023; 4:1738-1751. [PMID: 37889550 PMCID: PMC10758509 DOI: 10.34067/kid.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023]
Abstract
Key Points A multisite quality improvement project using the Institute for Healthcare Improvement learning collaborative structure helped kidney care teams identify seriously ill patients and implement supportive care best practices. Helpful approaches included needs assessment, Quality Assurance and Performance Improvement tools, peer exchange, clinician role modeling, data feedback, and technical assistance. Dialysis center teams tailored implementation of best practices into routine dialysis workflows with nephrologist prerogative to delegate goals of care conversations to nurse practitioners and social workers. Background Despite two decades of national and international guidelines urging greater availability of kidney supportive care (KSC), uptake in the United States has been slow. We conducted a multisite quality improvement project with ten US dialysis centers to foster implementation of three KSC best practices. This article shares pragmatic lessons learned by the project organizers. Methods The project team engaged in reflection to distill key lessons about what did or did not work in implementing KSC. Results The seven key lessons are (1 ) systematically assess KSC needs; (2 ) prioritize both the initial practices to be implemented and the patients who have the most urgent needs; (3 ) use a multifaceted approach to bolster communication skills, including in-person role modeling and mentoring; (4 ) empower nurse practitioners and social workers to conduct advance care planning through teamwork and warm handoffs; (5 ) provide tailored technical assistance to help sites improve documentation and electronic health record processes for storing advance care planning information; (6 ) coach dialysis centers in how to use required Quality Assurance and Performance Improvement processes to improve KSC; and (7 ) implement systematic approaches to support patients who choose active medical management without dialysis. Conclusions Treatment of patients with kidney disease is provided in a complex system, especially when considered across the continuum, from CKD to kidney failure on dialysis, and at the end of life. Even among enthusiastic early adopters of KSC, 18 months was insufficient time to implement the three prioritized KSC best practices. Concentrating on a few key practices helped teams focus and see progress in targeted areas. However, effect for patients was attenuated because federal policy and financial incentives are not aligned with KSC best practices and goals. Clinical Trial registry name and registration number Pathways Project: KSC, NCT04125537 .
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Affiliation(s)
- Alvin H. Moss
- Sections of Nephrology and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | | | - Annette Aldous
- Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Elizabeth Anderson
- Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, DC
| | - Dale E. Lupu
- School of Nursing, George Washington University, Washington, DC
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Feder SL, Zhan Y, Abel EA, Smith D, Ersek M, Fried T, Redeker NS, Akgün KM. Validation of Electronic Health Record-Based Algorithms to Identify Specialist Palliative Care Within the Department of Veterans Affairs. J Pain Symptom Manage 2023; 66:e475-e483. [PMID: 37364737 PMCID: PMC10527602 DOI: 10.1016/j.jpainsymman.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND The measurement of specialist palliative care (SPC) across Department of Veterans Affairs (VA) facilities relies on algorithms applied to administrative databases. However, the validity of these algorithms has not been systematically assessed. MEASURES In a cohort of people with heart failure identified by ICD 9/10 codes, we validated the performance of algorithms to identify SPC consultation in administrative data and differentiate outpatient from inpatient encounters. INTERVENTION We derived separate samples of people by receipt of SPC using combinations of stop codes signifying specific clinics, current procedural terminology (CPT), a variable representing encounter location, and ICD-9/ICD-10 codes for SPC. We calculated sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for each algorithm using chart review as the reference standard. OUTCOMES Among 200 people who did and did not receive SPC (mean age = 73.9 years (standard deviation [SD] = 11.5), 98% male, 73% White), the validity of the stop code plus CPT algorithm to identify any SPC consultation was: Sensitivity = 0.89 (95% Confidence Interval [CI] 0.82-0.94), Specificity = 1.0 [0.96-1.0], PPV = 1.0 [0.96-1.0], NPV = 0.93 [0.86-0.97]. The addition of ICD codes increased sensitivity but decreased specificity. Among 200 people who received SPC (mean age = 74.2 years [SD = 11.8], 99% male, 71% White), algorithm performance in differentiating outpatient from inpatient encounters was: Sensitivity = 0.95 (0.88-0.99), Specificity = 0.81 (0.72-0.87), PPV = 0.38 (0.29-0.49), and NPV = 0.99 (0.95-1.0). Adding encounter location improved the sensitivity and specificity of this algorithm. CONCLUSIONS VA algorithms are highly sensitive and specific in identifying SPC and in differentiating outpatient from inpatient encounters. These algorithms can be used with confidence to measure SPC in quality improvement and research across the VA.
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Affiliation(s)
- Shelli L Feder
- Yale School of Nursing (S.L.F., Y.Z.), Orange, Connecticut, USA; VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA.
| | - Yan Zhan
- Yale School of Nursing (S.L.F., Y.Z.), Orange, Connecticut, USA
| | - Erica A Abel
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA
| | - Dawn Smith
- Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center (D.S., M.E.), Philadelphia, Pennsylvania, USA
| | - Mary Ersek
- Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center (D.S., M.E.), Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing (M.E.), Philadelphia, Pennsylvania, USA
| | - Terri Fried
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA; Yale Program on Aging (T.F.), New Haven, Connecticut, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing (N.S.R.), Storrs, Connecticut, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System (S.L.F., E.A.A., T.F., K.M.A.), West Haven, Connecticut, USA; Yale School of Medicine (E.A.C., T.F., K.M.A.), Orange, Connecticut, USA
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Ernecoff NC, Motter EM, Robinson MT, Lagnese K, Taylor R, Schell JO. Perspectives of Caregivers and Clinicians on a Concurrent Hospice and Dialysis Program: A Qualitative Analysis. Am J Kidney Dis 2023; 82:373-376. [PMID: 36965826 DOI: 10.1053/j.ajkd.2023.01.450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/17/2023] [Indexed: 03/27/2023]
Affiliation(s)
| | - Erica M Motter
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mayumi T Robinson
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Jane O Schell
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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Soipe AI, Leggat JE, Abioye AI, Devkota K, Oke F, Bhuta K, Omotayo MO. Current trends in hospice care usage for dialysis patients in the USA. J Nephrol 2023; 36:2081-2090. [PMID: 37556052 DOI: 10.1007/s40620-023-01721-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/30/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The predictors and latest trends in hospice utilization, adequate duration of hospice care, and dialysis discontinuation without hospice enrollment among patients with end stage kidney disease are not fully known; the aim of this study was to assess them, analysing data from the United States Renal Data System. METHODS Data from the United States Renal Data System for patients with kidney failure who died between January 1, 2012, and December 31, 2019, were analyzed. Chi-square and logistic regression were used to evaluate associations between outcomes of interest and predictors, while Joinpoint regression was used to examine trends. RESULTS Among 803,049 patients, the median (IQR) age was 71 (17) years, 57% were male, 27% enrolled in hospice, 8% discontinued dialysis before death without hospice enrollment, and 7% remained in hospice for ≥ 15 days. Patients 65 years and older (adjusted odds ratio [aOR]: 2.75, 95% CI 2.71-2.79) and White race (aOR: 1.79, 95% CI 1.77-1.81) were more likely to enroll in hospice. White patients (aOR: 0.75, 95% CI 0.73-0.76) and those who never received a kidney transplant (aOR: 0.75, 95% CI 0.73-0.78) were less likely to have adequate duration of hospice care. Hospice enrollment and standardized duration of hospice care increased over time, with an average annual percentage change of 1.1% (95% CI 0.6-1.6) and 5% (95% CI 2.6-7.4), respectively. CONCLUSIONS Approximately one in every four patients with kidney failure who died between 2012 and 2019 had a history of hospice enrollment, while one in every 12 discontinued dialysis before death without hospice enrollment. There was an upward trend in the duration of hospice care.
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Affiliation(s)
- Ayorinde I Soipe
- Division of Nephrology, Department of Medicine, Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA.
- Department of Medicine, Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA.
| | - John E Leggat
- Division of Nephrology, Department of Medicine, Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
| | - Ajibola I Abioye
- Department of Global Health and Population, Harvard TH Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Kriti Devkota
- Division of Nephrology, Department of Medicine, Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
| | - Fausat Oke
- Hospice and Palliative Care Buffalo, 225 Como Park Blvd, Buffalo, NY, 14227, USA
| | - Kunal Bhuta
- Division of Nephrology, Department of Medicine, Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
- Department of Medicine, Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
| | - Moshood O Omotayo
- Hospice and Palliative Care Buffalo, 225 Como Park Blvd, Buffalo, NY, 14227, USA
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Ernecoff NC, Anhang Price R. Concurrent Care as the Next Frontier in End-of-Life Care. JAMA HEALTH FORUM 2023; 4:e232603. [PMID: 37594744 DOI: 10.1001/jamahealthforum.2023.2603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Importance Hospice care is a unique type of medical care for people near the end of life and their families, with an emphasis on providing physical and psychological symptom management, spiritual care, and family caregiver support to promote quality of life. However, many people in the US who could benefit from hospice have very short stays or do not enroll at all due to current hospice policy. Changing policy to allow for concurrent availability of disease-directed therapy and hospice care-known as concurrent care-offers an opportunity to increase hospice use and lengths of stay. Observations Under Medicare payment policy, hospices are responsible for covering all costs related to patients' terminal conditions under a per diem rate. This payment structure has led to a de facto requirement that patients forgo costly therapies (including life-prolonging treatments or those with palliative intent) on enrollment in hospice because they are prohibitively expensive. In other countries, in Medicaid for children, and in the Veterans Health Administration in the US, there is greater flexibility in providing hospice services alongside life-prolonging care. Often paired with innovative payment models, concurrent care smooths practical, psychological, and physical care transitions when patient goals prioritize comfort. For example, allowing simultaneous receipt of hospice care and dialysis for people living with end-stage kidney disease-a group with relatively low hospice enrollment-can act as a bridge to hospice and potentially promote longer lengths of stay. Conclusions and Relevance Medicare and health care delivery systems are increasingly testing payment and care delivery models to improve hospice use via concurrent care, offering an important opportunity for innovation to better meet the needs of people living with serious illness and their families.
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Abstract
Meeting the needs of people at the end of life (EOL) is a public health (PH) concern, yet a PH approach has not been widely applied to EOL care. The design of hospice in the United States, with its focus on cost containment, has resulted in disparities in EOL care use and quality. Individuals with non-cancer diagnoses, minoritized individuals, individuals of lower socioeconomic status, and those who do not yet qualify for hospice are particularly disadvantaged by the existing hospice policy. New models of palliative care (both hospice and non-hospice) are needed to equitably address the burden of suffering from a serious illness.
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Affiliation(s)
- Sarah H Cross
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA
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Mullins MA, Ruterbusch J, Cote ML, Uppal S, Wallner LP. Trends in hospice referral timing and location among individuals dying of ovarian cancer: persistence of missed opportunities. Int J Gynecol Cancer 2023; 33:1099-1105. [PMID: 37208020 PMCID: PMC10577799 DOI: 10.1136/ijgc-2023-004405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE To evaluate trends, racial disparities, and opportunities to improve the timing and location of hospice referral for women dying of ovarian cancer. METHODS This retrospective claims analysis included 4258 Medicare beneficiaries over age 66 diagnosed with ovarian cancer who survived at least 6 months after diagnosis, died between 2007 and 2016, and enrolled in a hospice. We examined trends in timing and clinical location (outpatient, inpatient hospital, nursing/long-term care, other) of hospice referrals and associations with patient race and ethnicity using multivariable multinomial logistic regression. RESULTS In this sample, 56% of hospice enrollees were referred to a hospice within a month of death, and referral timing did not vary by patient race. Referrals were most commonly inpatient hospital (1731 (41%) inpatient, 703 (17%) outpatient, 299 (7%) nursing/long-term care, 1525 (36%) other), with a median of 6 inpatient days prior to hospice enrollment. Only 17% of hospice referrals were made in an outpatient clinic, but participants had a median of 1.7 outpatient visits per month in the 6 months prior to hospice referral. Referral location varied by patient race, with non-Hispanic black people experiencing the most inpatient referrals (60%). Hospice referral timing and location trends did not change between 2007 and 2016. Compared with individuals referred to a hospice in an outpatient setting, individuals referred from an inpatient hospital setting had more than six times the odds of a referral in the last 3 days of life (OR=6.5, 95% CI 4.4 to 9.8) versus a referral more than 90 days before death. CONCLUSION Timeliness of hospice referral is not improving over time despite opportunities for earlier referral across multiple clinical settings. Future work delineating how to capitalize on these opportunities is essential for improving the timeliness of hospice care.
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Affiliation(s)
- Megan A Mullins
- Peter O'Donnell Jr. School of Public Health, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Julie Ruterbusch
- Karmanos Cancer Insitute, Wayne State University, Detroit, Michigan, USA
| | - Michele L Cote
- Simon Comprehensive Cancer Center, Indiana University, Indianapolis, Indiana, USA
- Richard M. Fairbanks School of Public Health, Indiana University Purdue University Indianapolis (IUPUI), Indianapolis, Indiana, USA
| | - Shitanshu Uppal
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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11
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Romero K, Widera E, Wachterman MW. Breaking the Link Between Enrollment in Hospice and Discontinuation of Dialysis. JAMA Intern Med 2023; 183:177-178. [PMID: 36716017 PMCID: PMC10149342 DOI: 10.1001/jamainternmed.2022.6390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This Viewpoint discusses Medicare coverage regarding hospice care for patients receiving dialysis at the end of life.
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Affiliation(s)
- Kai Romero
- By the Bay Health, San Francisco, California.,Division of Palliative Medicine, University of California-San Francisco
| | - Eric Widera
- Division of Geriatrics, University of California-San Francisco.,San Francisco Veterans Affairs Healthcare System, San Francisco, California
| | - Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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12
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Ankuda CK, Belanger E, Bunker J, Gozalo P, Keohane L, Meyers D, Trivedi A, Teno JM. Comparison of the Pathway to Hospice Enrollment Between Medicare Advantage and Traditional Medicare. JAMA HEALTH FORUM 2023; 4:e225457. [PMID: 36800194 PMCID: PMC9938424 DOI: 10.1001/jamahealthforum.2022.5457] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/14/2022] [Indexed: 02/18/2023] Open
Abstract
Importance Older adults in Medicare Advantage (MA) enroll in hospice at higher rates than those in traditional Medicare (TM), but it is unclear whether the pathway of care prior to hospice use differs between MA and TM. Objective To examine the site of care prior to hospice enrollment for MA beneficiaries compared with those in TM. Design, Setting, and Participants This population-based, retrospective cross-sectional study used Medicare claims data for decedents in calendar years 2011, 2013, 2016, and 2018 who enrolled in hospice in the last 90 days of life. Data were analyzed from February 11, 2022, to October 24, 2022. Exposures Enrollment in MA or TM in the last month of life. Main Outcomes and Measures The main outcome was the site of care prior to hospice enrollment, defined as hospital, nursing home, and home with or without home health, dichotomized as community vs hospital in a logistic regression model. Covariates included decedent demographics, hospice primary diagnosis, and county-level MA penetration. Differences in hospice length of stay between MA beneficiaries and TM beneficiaries were assessed using linear and logistic regression models. Results In this study of 3 164 959 decedents, mean (SD) age was 83.1 (8.6) years, 55.8% were female, and 28.8% were enrolled in MA. Decedents in MA were more likely to enroll in hospice from a community setting than were those in TM, although the gap narrowed over time from an unadjusted 11.1% higher rate of community enrollment in MA vs TM in 2011 (50.1% vs 39.0%) to 8.1% in 2018 (46.4% vs 38.3%). In the primary adjusted analysis over the entire study period, MA enrollment was associated with an 8.09-percentage point (95% CI, 7.96-8.21 percentage points) higher rate of hospice enrollment from the community vs all other sites. This association remained in multiple sensitivity analyses to account for potential differences in the populations enrolled in MA vs TM. The mean overall hospice length of stay was 0.29 days (95% CI, 0.24-0.34 days) longer for MA decedents compared with TM decedents. Conclusions and Relevance Compared with TM beneficiaries, those in MA were more likely to enroll in hospice from community settings vs following inpatient stays. However, hospice length of stay was not substantially different between MA and TM. Further research is needed to understand how MA plans influence hospice use and the direct association with quality of end-of-life care as reported by older adults and their families.
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Affiliation(s)
- Claire K. Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jennifer Bunker
- Brown School of Public Health, Brown University, Providence, Rhode Island
| | - Pedro Gozalo
- Brown School of Public Health, Brown University, Providence, Rhode Island
| | - Laura Keohane
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Meyers
- Brown School of Public Health, Brown University, Providence, Rhode Island
| | - Amal Trivedi
- Brown School of Public Health, Brown University, Providence, Rhode Island
| | - Joan M. Teno
- Brown School of Public Health, Brown University, Providence, Rhode Island
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Cheung KL. Building an Evidence Base for Active Medical Management without Dialysis: Tale of Two Programs. KIDNEY360 2023; 4:114-116. [PMID: 36638232 PMCID: PMC10101594 DOI: 10.34067/kid.0000000000000031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 01/15/2023]
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14
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Bursic AE, Schell JO. Hospice Care in Conservative Kidney Management. Semin Nephrol 2023; 43:151398. [PMID: 37524007 DOI: 10.1016/j.semnephrol.2023.151398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Hospice care offers multidisciplinary expertise to optimize symptom management and quality of life for patients with limited life expectancy and help ensure that patients receive care that reflects their personal goals and values. Many patients receiving conservative kidney management (CKM) and their loved ones can benefit from the additional support that hospice provides, particularly as symptom burdens and functional status worsen over the last few months of life. We provide an overview of hospice services and how they may benefit patients receiving CKM, describe the evolution of optimal CKM strategies and collaboration between nephrology and hospice clinicians over the course of disease progression, and explore challenges to effective hospice care delivery for patients with chronic kidney disease and how to address them.
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Affiliation(s)
- Alexandra E Bursic
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Jane O Schell
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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15
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Lakin JR, Sciacca K, Leiter R, Killeen K, Gelfand S, Tulsky JA, Anderson S, Zupanc SN, Williams T, Mandel EI. Creating KidneyPal: A Specialty-Aligned Palliative Care Service for People with Kidney Disease. J Pain Symptom Manage 2022; 64:e331-e339. [PMID: 36058402 DOI: 10.1016/j.jpainsymman.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/02/2022] [Accepted: 08/18/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with kidney disease have notable unmet palliative care needs and represent an underserved population for specialty palliative care teams. INTERVENTION We designed a specialty-aligned interprofessional palliative care service called KidneyPal that is aimed at improving delivery of palliative care to patients with kidney disease through focus groups and iterative improvement cycles. MEASURES We iteratively measured the development of KidneyPal through clinical process metrics: percent of the inpatient nephrology census followed by KidneyPal, patient demographics, consult origin, clinician feedback, and self-reported team interventions. OUTCOMES KidneyPal saw 314 unique patients from January 2019 to January 2021. The majority of consultations came from nephrology services though the source of consultation changed over time. We consulted on an average of 13.5% of the entire inpatient nephrology patient hospital census with highest involvement with patients on the inpatient nephrology hemodialysis service (mean of 29.9%). KidneyPal was rated highly by surveyed nephrology clinicians and provided high rates of psychosocial support and goals of care interventions. LESSONS LEARNED The creation of KidneyPal led to us to serve a new cohort of patients with specialty palliative care. We grew over time to serve the full range of patients with kidney disease as defined by our nephrology service lines. We succeeded in doing so by embedding in nephrology and building relationships with those caring for people with kidney disease while tailoring our service and interventions over time.
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Affiliation(s)
- Joshua R Lakin
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts.
| | - Kate Sciacca
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Richard Leiter
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts
| | - Kelsey Killeen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Samantha Gelfand
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts; Division of Renal Medicine, Brigham and Women's Hospital (S.G., E.I.M.), Boston, Massachusetts
| | - James A Tulsky
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Trey Williams
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Ernest I Mandel
- Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts; Division of Renal Medicine, Brigham and Women's Hospital (S.G., E.I.M.), Boston, Massachusetts
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Bullard JT, Kowalkowski M, Sparling A, Roberge J, Barkley JE. A Retrospective Evaluation of the Impacts of a Multidisciplinary Care Model for Managing Patients with Advanced Illness on Acute Care Utilization and Quality of Care at End of Life. J Palliat Med 2022; 25:1835-1843. [PMID: 36137010 DOI: 10.1089/jpm.2022.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: A home-based goal-concordant care model targeting patients with advanced illnesses may reduce acute care utilization and improve quality outcomes at end of life. Aim: Study aim was to determine impact of the Advanced Illness Management (AIM) program on end-of-life utilization and quality of care. Design: A retrospective observational study design using propensity score fine stratum weighting methodologies was applied to decedent patients identified for AIM enrollment/eligibility in 2018 to 2019. Setting/Participants: A total of 3859 decedents, 216 of whom were AIM enrollees, were identified from a metropolitan health system's electronic medical records (EMR) and met study eligibility criteria. Results: Compared with usual care, AIM enrollees spent more days away from acute care in the last 30, 90, and 180 days of life. Furthermore, AIM enrollees were less likely to expire in an acute care hospital. Conclusions: Enrollment in programs such as AIM should be considered for patients with advanced illnesses approaching end of life.
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Affiliation(s)
- Jarrod T Bullard
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Marc Kowalkowski
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Alica Sparling
- Health Economics, Novant Health, Charlotte, North Carolina, USA
| | - Jason Roberge
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - John E Barkley
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
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17
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Haug K, Buffington A, Zelenski A, Hanlon BM, Stalter L, Kwekkeboom KL, Rathouz P, Bansal AD, Cheung K, Crews D, Frazier R, Koncicki H, Lam D, Moss A, Rao M, Wolfgram DF, Yi J, Brill C, Kendrick R, Campbell TC, Jhagroo R, Schwarze M. Best Case/Worst Case: protocol for a multisite randomised clinical trial of a scenario planning intervention for patients with kidney failure. BMJ Open 2022; 12:e067258. [PMID: 36328383 PMCID: PMC9639110 DOI: 10.1136/bmjopen-2022-067258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Given the burdens of treatment and poor prognosis, older adults with kidney failure would benefit from improved decision making and palliative care to clarify goals, address symptoms, and reduce unwanted procedures. Best Case/Worst Case (BC/WC) is a communication tool that uses scenario planning to support patients' decision making. This article describes the protocol for a multisite, cluster randomised trial to test the effect of training nephrologists to use the BC/WC communication tool on patient receipt of palliative care, and quality of life and communication. METHODS AND ANALYSIS We are enrolling attending nephrologists, at 10 study sites in the USA, who see outpatients with advanced chronic kidney disease considering dialysis. We aim to enrol 320 patients with an estimated glomerular filtration rate of ≤24 mL/min/1.73 m2 who are age 60 and older and have a predicted survival of 18 months or less. Nephrologists will be randomised in a 1:1 ratio to receive training to use the communication tool (intervention) at study initiation or after study completion (wait-list control). Patients in the intervention group will receive care from a nephrologist trained to use the BC/WC communication tool. Patients in the control group will receive usual care. Using chart review and surveys of patients and caregivers, we will test the efficacy of the BC/WC intervention with receipt of palliative care as the primary outcome. Secondary outcomes include intensity of treatment at the end of life, the effect of the intervention on quality of communication (QOC) between nephrologists and patients (using the QOC scale), the change in quality of life (using the Functional Assessment of Chronic Illness Therapy-Palliative Care scale) and receipt of dialysis. ETHICS AND DISSEMINATION Approvals have been granted by the Institutional Review Board at the University of Wisconsin (ID: 2022-0193), with each study site ceding review to the primary IRB. All nephrologists will be consented and given a copy of the consent form. No patients or caregivers will be recruited or consented until their nephrology provider has chosen to participate in the study. Results will be disseminated via submission for publication in a peer-reviewed journal and at national meetings. TRIAL REGISTRATION NUMBER NCT04466865.
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Affiliation(s)
- Karlie Haug
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Anne Buffington
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Amy Zelenski
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bret M Hanlon
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Lily Stalter
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Kristine L Kwekkeboom
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- School of Nursing, University of Wisconsin, Madison, WI, USA
| | - Paul Rathouz
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Amar D Bansal
- Division of Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katharine Cheung
- Division of Nephrology, University of Vermont, Burlington, Vermont, USA
| | - Deidra Crews
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rebecca Frazier
- Division of Nephrology, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Holly Koncicki
- Division of Nephrology, Mount Sinai Health System, New York, New York, USA
| | - Daniel Lam
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Alvin Moss
- Section of Nephrology, West Virginia University, Morgantown, West Virginia, USA
| | - Maya Rao
- Division of Nephrology, Columbia University, New York, New York, USA
| | - Dawn F Wolfgram
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeniann Yi
- Department of Surgery, University of Colorado Health, Aurora, Colorado, USA
| | | | | | - Toby C Campbell
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Roy Jhagroo
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Margaret Schwarze
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Rajasekaran A, Prakash A, Hatch S, Lu Y, Cutter GR, Zarjou A. Advocating for in-center hemodialysis patients via anonymous survey. Medicine (Baltimore) 2022; 101:e30937. [PMID: 36254033 PMCID: PMC9575770 DOI: 10.1097/md.0000000000030937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We conducted an anonymous survey in 9 of our university affiliated outpatient dialysis units to address the concern that many in-center hemodialysis patients may not feel comfortable sharing their experiences. Major goals of this study: Investigating level of patient satisfaction with their care; Evaluating the subjective perception of the level of understanding of patients regarding pertinent issues of their disease and its management; Identifying potential avenues for care improvement. Survey was conducted in English, paper-based, with answer choices to individual questions for patient satisfaction and education graded using a 5-point Likert scale. Regarding potential areas of improvement, patients were asked to choose as many areas as deemed appropriate. To ensure anonymity, the completed surveys were folded and dropped into a box. Overall, 253 out of 516 (49%) screened patients were eligible and completed the survey. Patients expressed favorable responses regarding satisfaction (mean rating > 4 in each of 14 questions) and education (mean rating > 4 in 8 questions, > 3.5 in 2 questions) regarding hemodialysis. About 62% of overall study participants identified at least one area where they felt additional information would result in improvement of care. Our results indicate that patients undergoing outpatient hemodialysis were overall satisfied and had a good perceptive understanding about their health. Based on the patients' input, strategies focused on addressing pain and discomfort, privacy, providing information about palliative care/hospice, mental health resources, and the process of kidney transplantation may promote improvement in overall quality of care.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Anand Prakash
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Spencer Hatch
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Yan Lu
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Gary R. Cutter
- Division of Biostatistics, University of Alabama at Birmingham, AL, USA
| | - Abolfazl Zarjou
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
- *Correspondence: Abolfazl Zarjou, Assistant Professor of Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, 618 Zeigler Research Building, 703 South 19th Street Birmingham, AL 35294, USA (e-mail: )
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Wachterman MW, Corneau EE, O’Hare AM, Keating NL, Mor V. Association of Hospice Payer With Concurrent Receipt of Hospice and Dialysis Among US Veterans With End-stage Kidney Disease: A Retrospective Analysis of a National Cohort. JAMA HEALTH FORUM 2022; 3:e223708. [PMID: 36269338 PMCID: PMC9587478 DOI: 10.1001/jamahealthforum.2022.3708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Importance For many patients with end-stage kidney disease (ESKD), the Medicare Hospice Benefit precludes concurrent receipt of hospice and dialysis services, forcing patients to choose between continuing dialysis or enrolling in hospice. Whether the more liberal hospice eligibility criteria of the Veterans Health Administration's (VA) are associated with improved access to concurrent dialysis and hospice care for patients with ESKD is not known. Objective To examine the frequency of concurrent hospice and dialysis care among US veterans by hospice payer and examine the payer for concurrent dialysis. Design, Setting, and Participants This was a retrospective cross-sectional study of all 70 577 VA enrollees in the US Renal Data System registry who initiated maintenance dialysis and died in 2007 to 2016. Data were analyzed from April 2021 to August 2022. Exposures Hospice payer, either Medicare, VA inpatient hospice, or VA-financed community-based hospice ("VA community care"). Primary hospice diagnosis-ESKD vs non-ESKD. Main Outcomes and Measures Concurrent receipt of hospice and dialysis services ("concurrent care"). Results There were 18 420 (26%) eligible veterans with ESKD who received hospice services (mean [SD] age, 75.4 [10.0] years; 17 457 [94.8%] men; 2997 [16.3%] Black, 15 162 [82.3%] White, and 261 (1.4%) individuals of other races). Most of the sample (n = 16 465; 89%) received hospice services under Medicare and 5231 (28%) continued to receive dialysis after hospice initiation. The adjusted proportion of veterans receiving concurrent care was higher for those enrolled in VA inpatient hospice or VA community care hospice than it was for those enrolled in Medicare hospice (57% and 41% vs 24%, respectively; both P < .001). Regardless of hospice payer, the majority (87%) of the dialysis treatments after hospice initiation were financed by the VA, including for Medicare beneficiaries who had a hospice diagnosis other than ESKD. Median hospice length of stay was 43 days for veterans who received concurrent dialysis vs 4 days for those who did not. Conclusions and Relevance In this retrospective cross-sectional study of US veterans with ESKD, a substantially higher proportion of veterans in VA-financed hospice received 1 or more dialysis treatments after hospice initiation than those enrolled in Medicare-financed hospice. Regardless of hospice payer, the VA financed most concurrent dialysis treatments. Hospice users who received concurrent dialysis care had substantially longer hospice lengths of stay than those who did not. These findings suggest that Medicare hospice policy may substantially restrict access to concurrent hospice and dialysis care among veterans with ESKD.
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Affiliation(s)
- Melissa W. Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Emily E. Corneau
- Long Term Services and Supports Center of Innovation, Veterans Affairs Providence Health Care System, Providence, Rhode Island
| | - Ann M. O’Hare
- Department of Medicine and Kidney Research Institute, University of Washington, Seattle
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Nancy L. Keating
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Vincent Mor
- Long Term Services and Supports Center of Innovation, Veterans Affairs Providence Health Care System, Providence, Rhode Island
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
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Butler CR, Wachterman MW, O’Hare AM. Concurrent Hospice and Dialysis: Proof of Concept. J Am Soc Nephrol 2022; 33:1808-1810. [PMID: 36096635 PMCID: PMC9528330 DOI: 10.1681/asn.2022080919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Catherine R. Butler
- Kidney Research Institute and Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington
- Hospital and Specialty Medicine Service and Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Melissa W. Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ann M. O’Hare
- Kidney Research Institute and Department of Medicine, Division of Nephrology, University of Washington, Seattle, Washington
- Hospital and Specialty Medicine Service and Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
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21
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Ernecoff NC, Bursic AE, Motter EM, Lagnese K, Taylor R, Schell JO. Description and Outcomes of an Innovative Concurrent Hospice-Dialysis Program. J Am Soc Nephrol 2022; 33:1942-1950. [PMID: 35820784 PMCID: PMC9528329 DOI: 10.1681/asn.2022010064] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/21/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Compared with the general Medicare population, patients with ESKD have worse quality metrics for end-of-life care, including a higher percentage experiencing hospitalizations and in-hospital deaths and a lower percentage referred to hospice. We developed a Concurrent Hospice and Dialysis Program in which patients may receive palliative dialysis alongside hospice services. The Program aims to improve access to quality end-of-life care and, ultimately, improve the experiences of patients, caregivers, and clinicians. OBJECTIVES We sought to describe (1) the Program and (2) enrollment and utilization characteristics of Program participants. METHODS We conducted a quantitative description of demographics, patient characteristics, and utilization of Program enrollees. RESULTS Of 43 total enrollees, 44% received at least one dialysis treatment, whereas 56% received no dialysis. The median (range) hospice length of stay was 9 (1-76) days for all participants and 13 (4-76) days for those who received at least one dialysis treatment. The average number of dialysis treatments was 3.5 (range 1-9) for hemodialysis and 19.2 (range 3-65) for peritoneal dialysis. Sixty-five percent of enrollees died at home, 23% in inpatient hospice, and 12% in a nursing facility; no patients died in the hospital. CONCLUSIONS Our 3-year experience with the Program demonstrated that enrollees had a longer median hospice stay than the previously reported 5-day median for patients with ESKD. Most patients received no further dialysis treatments despite the option to continue dialysis. Our experience provides evidence to support future work testing the effectiveness of such clinical programs to improve patient and utilization outcomes.
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Affiliation(s)
| | - Alexandra E. Bursic
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erica M. Motter
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Jane O. Schell
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Kurella Tamura M, Holdsworth L, Stedman M, Aldous A, Asch SM, Han J, Harbert G, Lorenz KA, Malcolm E, Nicklas A, Moss AH, Lupu DE. Implementation and Effectiveness of a Learning Collaborative to Improve Palliative Care for Seriously Ill Hemodialysis Patients. Clin J Am Soc Nephrol 2022; 17:1495-1505. [PMID: 36104084 PMCID: PMC9528276 DOI: 10.2215/cjn.00090122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Limited implementation of palliative care practices in hemodialysis may contribute to end-of-life care that is intensive and not patient centered. We determined whether a learning collaborative for hemodialysis center providers improved delivery of palliative care best practices. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Ten US hemodialysis centers participated in a pre-post study targeting seriously ill patients between April 2019 and September 2020. Three practices were prioritized: screening for serious illness, goals of care discussions, and use of a palliative dialysis care pathway. The collaborative educational bundle consisted of learning sessions, communication skills training, and implementation support. The primary outcome was change in the probability of complete advance care planning documentation among seriously ill patients. Health care utilization was a secondary outcome, and implementation outcomes of acceptability, adoption, feasibility, and penetration were assessed using mixed methods. RESULTS One center dropped out due to the coronavirus disease 2019 pandemic. Among the remaining nine centers, 20% (273 of 1395) of patients were identified as seriously ill preimplementation, and 16% (203 of 1254) were identified as seriously ill postimplementation. From the preimplementation to postimplementation period, the adjusted probability of complete advance care planning documentation among seriously ill patients increased by 34.5 percentage points (95% confidence interval, 4.4 to 68.5). There was no difference in mortality or in utilization of palliative hemodialysis, hospice referral, or hemodialysis discontinuation. Screening for serious illness was widely adopted, and goals of care discussions were adopted with incomplete integration. There was limited adoption of a palliative dialysis care pathway. CONCLUSIONS A learning collaborative for hemodialysis centers spanning the coronavirus disease 2019 pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Pathways Project: Kidney Supportive Care, NCT04125537.
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Affiliation(s)
- Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
- Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Laura Holdsworth
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Margaret Stedman
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Annette Aldous
- Milkin Institute School of Public Health, George Washington University, Washington, DC
| | - Steven M. Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Jialin Han
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Glenda Harbert
- School of Nursing, George Washington University, Washington, DC
| | - Karl A. Lorenz
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Elizabeth Malcolm
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, DC
| | - Alvin H. Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Dale E. Lupu
- School of Nursing, George Washington University, Washington, DC
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23
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Ethical Challenges When Caring for African American Older Adults Requesting to Withdraw From Dialysis. J Hosp Palliat Nurs 2022; 24:209-217. [PMID: 35488364 DOI: 10.1097/njh.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The number of African American adults 65 years and older with end-stage kidney disease receiving maintenance hemodialysis is increasing. The high symptom burden (ie, pain, fatigue, depression) can make it challenging for many to continue dialysis, which can lead to request to withdraw from dialysis. This can present ethical challenges when someone has diminished decision-making capacity and no advance directives or family to assist with this complex decision. This article will provide a brief overview of ethical issues to consider when responding to an older adult's request to withdraw from a life-sustaining treatment such as dialysis. Suggestions for research to address the gaps in knowledge will be presented.
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24
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Bursic AE, Schell JO, Ernecoff NC, Bansal AD. Delivery of Active Medical Management without Dialysis through an Embedded Kidney Palliative Care Model. KIDNEY360 2022; 3:1881-1889. [PMID: 36514399 PMCID: PMC9717629 DOI: 10.34067/kid.0001352022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/15/2022] [Indexed: 01/12/2023]
Abstract
Background Patients with CKD have high symptom burden, low rates of advance care planning (ACP), and frequently receive care that is not goal concordant. Improved integration of palliative care into nephrology and access to active medical management without dialysis (AMMWD) have the potential to improve outcomes through better symptom management and enhanced shared decision making. Methods We describe the development of a kidney palliative care (KPC) clinic and how palliative care practices are integrated within an academic nephrology clinic. We performed a retrospective electronic health record (EHR) review for patients seen in this clinic between January 2015 and February 2019 to describe key clinical activities and delivery of AMMWD. Results A total of 165 patients were seen in the KPC clinic (139 with CKD and 26 who were already receiving dialysis). Fatigue, mobility issues, and pain were the three most prevalent symptoms (85%, 66%, 58%, respectively). Ninety-one percent of patients had a surrogate decision maker documented in the EHR; 87% of patients had a goals-of-care conversation documented in the EHR. Of the 139 patients with CKD, 67 (48%) chose AMMWD as their disease progressed. Sixty-eight percent (41 of 60) of patients who died during the study were referred to hospice. Conclusions Our findings suggest that the integration of palliative care into nephrology can assist in identification of symptoms, lead to high rates of ACP, and provide a mechanism for patients to choose and receive AMMWD. The percentage of patients choosing AMMWD in our study suggests that increased shared decision making may lower rates of dialysis initiation in the United States. Additional prospective research and registries for assessing the effects of AMMWD have the potential to improve care for people living with CKD.
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Affiliation(s)
- Alexandra E. Bursic
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane O. Schell
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Amar D. Bansal
- Renal Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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25
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Ankuda CK, Moreno J, Teno JM, Aldridge MD. Transitions from Home Health to Hospice: The Role of Agency Affiliation. J Palliat Med 2022; 25:873-879. [PMID: 34964665 PMCID: PMC9360178 DOI: 10.1089/jpm.2021.0390] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 01/31/2023] Open
Abstract
Background: Home health agencies (HHAs) are often affiliated with hospice agencies and commonly care for patients with serious illness within the Medicare program. HHAs may therefore provide a potential opportunity to facilitate timely referral to hospice when appropriate. Objectives: To determine if patients cared for by HHAs affiliated with hospice agencies experience differential hospice use and care patterns. Design: Nationally representative cohort study. Setting/Subjects: 1431 decedents in the 2002 to 2017 Medicare Current Beneficiary Survey who received home health in the last year of life in the United States. Measurements: Primary independent variable was HHA hospice affiliation. Primary dependent variable was hospice enrollment; secondary dependent variables were hospice live discharge and length of stay. Results: The 27.3% of decedents cared for by a HHA affiliated with a hospice had greater education levels and wealth and were more likely to live in the Midwest and Northeast. In adjusted models, HHA-hospice affiliated decedents had greater odds of enrolling in hospice compared to those cared for by HHAs not affiliated with a hospice, corresponding to a hospice enrollment rate of 51.0% for those cared for by HHAs affiliated with hospices versus 39.7% for HHAs not affiliated (p = 0.004). There were no differences in hospice length of stay or live discharge rate by hospice affiliation. Conclusion: Medicare beneficiaries cared for by HHAs affiliated with hospices are more likely to enroll in hospice at the end of life. This has implications for improving hospice access through home health incentives and models of care.
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Affiliation(s)
- Claire K. Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Melissa D. Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters Bronx Veterans Affairs Medical Center, Bronx, New York, USA
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26
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Ho YY, Yung TSH, See YP, Koh M. Palliative dialysis in hospice: A paradox or promising answer? ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:384-385. [PMID: 35786762 DOI: 10.47102/annals-acadmedsg.2021475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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27
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Chen HC, Wu CY, Hsieh HY, He JS, Hwang SJ, Hsieh HM. Predictors and Assessment of Hospice Use for End-Stage Renal Disease Patients in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:85. [PMID: 35010349 PMCID: PMC8751193 DOI: 10.3390/ijerph19010085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Hospice and early palliative care are generally considered as an alternative and supportive care to offer symptoms relief and optimize the quality of life among end-stage renal disease (ESRD) patients, but hospice care remains underutilized. This study aimed to examine patient and health system characteristics and develop a patient assessment scale to evaluate ESRD patients for hospice care after the implementation of non-cancer hospice care reimbursement policy in 2009 in Taiwan. METHOD We conducted a retrospective cohort study using nationwide population-based datasets. Adult long-term dialysis patients between 2009 and 2012 were included. Multivariable logistic regression and the Firth penalized likelihood estimation were used to estimate the likelihood of receiving hospice care. A receiver operating characteristic curve (ROC) analysis and C-statistic were calculated to determine the optimal models for a patient assessment of hospice use. RESULTS Patients who were older, comorbid with anemia (odds ratio [OR] 3.53, 95% CI 1.43-8.70) or sepsis (OR 1.62, 95% CI 1.08-2.44), with longer dialysis durations, more hospitalizations (OR 4.68, 95% CI 2.56-8.55), or primary provider care with hospice (OR 5.15, 95% CI 2.80-9.45) were more likely to receive hospice care. The total score of the patient assessment scale of hospice care was 0-28 with a cut-off value of 19 based on the results of the receiver operating characteristic curve. CONCLUSION Given the "Patient Right to Autonomy Act" implemented in Taiwan in 2019 to promote the concept of a "good quality of death", this patient assessment scale may help health professionals target ESRD patients for hospice care and engage in shared decision making and the advance care planning process.
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Affiliation(s)
- Hung-Cheng Chen
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (H.-C.C.); (H.-Y.H.)
| | - Chien-Yi Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Hui-Ya Hsieh
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (H.-C.C.); (H.-Y.H.)
| | - Jiun-Shiuan He
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Hui-Min Hsieh
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
- Department of Public Health, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Community Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Center for Big Data Research, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
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28
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Park YT, Chang H, Shin H. Factors of Hospitals Associated With an Independent Hospice Care Unit: A Quantitative Empirical Study. J Hosp Palliat Nurs 2021; 23:584-590. [PMID: 34587619 PMCID: PMC8560152 DOI: 10.1097/njh.0000000000000806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Few studies have examined why some hospitals operate independent hospice units (IHUs) and others do not. This study aims to investigate the organizational factors of hospitals having IHU. The units of analysis were individual hospitals. The study had a cross-sectional design and used health insurance claims data of 349 hospitals in Korea from January 1 to December 31, 2019. The dependent variable was whether a hospital operated an IHU. The independent variables were the percentage of patients with cancer, overall severity of patients, percentage of patients 60 years and older, health care cost per patient, percentage of inpatients, and nurse staffing level. Independent hospice units were present at 21.2% of the hospitals (74/349). The odds of having an IHU were significantly associated with the following factors: the percentage of patients with cancer (odds ratio [OR], 1.228; 95% confidence interval [CI], 1.071-1.408; P = .003), disease severity (OR, 5.129; 95% CI, 2.477-10.622; P < .001), percentage of patients 60 years and older (OR, 1.053; 95% CI, 1.015-1.092; P = .006), health care cost per patient (OR, 1.018; 95% CI, 1.009-1.027; P < .001), and nurse staffing level (OR, 0.439; 95% CI, 0.292-0.661; P < .001). The organizational factors of hospitals operating IHUs were similar to those of hospice facilities.
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29
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High-dose versus low-dose iron sucrose in individuals undergoing maintenance haemodialysis: a retrospective study. BMC Nephrol 2021; 22:350. [PMID: 34706660 PMCID: PMC8550635 DOI: 10.1186/s12882-021-02570-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous iron sucrose is becoming a prevailing treatment for individuals undergoing maintenance haemodialysis, but comparisons of dosing regimens are lacking. The aim of this retrospective review was to evaluate the safety and efficacy of proactively administered high-dose iron sucrose versus reactively administered low-dose iron sucrose in patients undergoing maintenance haemodialysis. METHODS We analysed the data of 1500 individuals with maintenance haemodialysis who were treated with either high-dose iron sucrose that was proactively administered (Group HD) or low-dose iron sucrose that was reactively administered (Group LD) at the First Affiliated Hospital of Chongqing Medical University from Jan 1, 2008, to Dec 31, 2020. The primary endpoints were the cumulative doses of iron and erythropoiesis-stimulating agent; the secondary endpoints were the events of nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, infection rate, and death from any cause. RESULTS Of the 2124 individuals, 624 individuals were excluded because they met one or more of the exclusion criteria, thus resulting in 1500 individuals who were eligible for inclusion in the study (Group HD, n = 760 and Group LD, n = 740). The median follow-up for the two cohorts was 32 months (range: 25-36). A significant median difference was detected in the monthly iron dose between the groups (1121 mg [range: 800-1274] in the HD group vs. 366 mg [range: 310-690] in the LD group; p < 0.05). The median dose of an erythropoiesis-stimulating agent was 26,323 IU/month (range: 17,596-44,712) in the HD group and 37,934 IU/month (range: 22,402-59,380) in the LD group (median difference: - 7901 IU/month; 95% CI: - 9632--5013; p = 0.000). A significant difference was detected in the secondary endpoints (266 events in 320 cases in the HD group vs. 344 events in 385 cases in the LD group) (HR: 0.62; 95% CI: 0.51-0.79; p < 0.001). A significant difference was not observed in death from any cause (HR: 0.57; 95% CI: 0.48-1.00; p = 0.361). CONCLUSIONS For individuals undergoing maintenance haemodialysis, high-dose iron sucrose that was proactively administered may be superior to low-dose iron sucrose that was reactively administered with low doses of erythropoiesis-stimulating agent.
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30
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Orman ES, Johnson AW, Ghabril M, Sachs GA. Hospice care for end stage liver disease in the United States. Expert Rev Gastroenterol Hepatol 2021; 15:797-809. [PMID: 33599185 PMCID: PMC8282639 DOI: 10.1080/17474124.2021.1892487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life. AREAS COVERED In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness. EXPERT OPINION Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine,Corresponding author: Eric S. Orman, Address: Division of Gastroenterology & Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202,
| | - Amy W. Johnson
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine
| | - Marwan Ghabril
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine
| | - Greg A. Sachs
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine,Indiana University Center for Aging Research, Regenstrief Institute, Inc
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31
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Ramer SJ, Viola M, Maciejewski PK, Reid MC, Prigerson HG. Suffering and Symptoms At the End of Life in ICU Patients Undergoing Renal Replacement Therapy. Am J Hosp Palliat Care 2021; 38:1509-1515. [PMID: 33827273 DOI: 10.1177/10499091211005707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We know little about the end-of-life suffering and symptoms of intensive care unit (ICU) decedents in general and those who undergo renal replacement therapy (RRT) in particular. OBJECTIVES To examine differences in end-of-life suffering and various symptoms' contribution to suffering between ICU decedents who did not undergo RRT, those who underwent RRT for end-stage kidney disease (ESKD), and those who underwent RRT for acute kidney injury (AKI). METHODS This is a cross-sectional study conducted at a quaternary-level referral hospital September 2015-March 2017. Nurses completed interviews about ICU patients' suffering and symptoms in their final week. We dichotomized overall suffering into elevated and non-elevated and each symptom as contributing or not to a patient's suffering. RESULTS Sixty-four nurses completed interviews on 165 patients. Median patient age was 67 years (interquartile range 57, 78); 41% were female. In a multivariable model, undergoing RRT for AKI (odds ratio [OR] 2.95, 95% confidence interval [CI] 1.34-6.49) was significantly associated with elevated suffering compared to no RRT; undergoing RRT for ESKD was not. Adjusting for length of stay, AKI-RRT patients were more likely than non-RRT patients to have fecal incontinence (OR 2.21, 95% CI 1.00-4.93), painful broken skin (OR 2.41, 95% CI 1.14-5.12), and rashes (OR 3.61, 95% CI 1.35-9.67) contributing to their suffering. CONCLUSIONS Undergoing RRT for AKI was associated with elevated suffering in the last week of life in ICU decedents. Painful broken skin, rashes, and fecal incontinence were more likely to contribute to suffering in AKI-RRT patients than in non-RRT patients. How to reduce suffering associated with AKI-RRT in ICU patients merits further study.
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Affiliation(s)
- Sarah J Ramer
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA
| | - Martin Viola
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA.,Center for Research on End-of-Life Care, Weill Cornell Medicine, NY, USA
| | - Paul K Maciejewski
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA.,Center for Research on End-of-Life Care, Weill Cornell Medicine, NY, USA.,Department of Radiology, Weill Cornell Medicine, NY, USA
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA.,Translational Research Institute on Pain in Later Life, Weill Cornell Medicine, NY, USA
| | - Holly G Prigerson
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY, USA.,Center for Research on End-of-Life Care, Weill Cornell Medicine, NY, USA
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32
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de Avila V, Paik JM, de Avila L, Henry L, Mohess D, Roche-Green A, Younossi ZM. Hospice care utilisation among elderly patients who died with hepatocellular carcinoma in the United States. JHEP Rep 2021; 3:100236. [PMID: 33748729 PMCID: PMC7970151 DOI: 10.1016/j.jhepr.2021.100236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/08/2020] [Accepted: 12/28/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND & AIMS The benefits of hospice care in Medicare recipients with hepatocellular carcinoma (HCC) have not been fully evaluated, which we aimed to study. METHODS We used nationally representative samples of the Medicare beneficiaries in the USA (2011-2016) to assess the impact of hospice care on the outcomes of patients with HCC. Hospice care benefits on the survival time, length of stay (LOS), 30-day readmissions, and daily charges during the last year and month of life were assessed by logistic regression and generalised linear regression. RESULTS Among 2,230 Medicare beneficiaries with HCC (mean age, 74.9 years; non-Hispanic White 79.1%; male 66.6%), median survival from HCC diagnosis was 68 days; 556 (24.9%) received hospice services; median hospice LOS was 12 days (4-35 days). Hospice users increased from 20.1% to 31.1% over time, driven by enrolment ≤15 days (45.1-59.2%, respectively). In the last year of life, hospice users (vs. no hospice care) had longer median survival time (76.5 vs. 66 days), lower in-hospital mortality (1.1% vs. 25.5%) and lower median daily charges ($951 vs. $1,004) despite more inpatient admissions and higher comorbid diseases. Hospice enrolment was associated with 48.6% reduction in daily charges (95% CI: -54.9% to -41.5%). Longer hospice LOS was associated with lower rates of healthcare utilisation. Patients with chronic liver disease were less likely to enrol in hospice care (odds ratio = 0.18, 95% CI: 0.14-0.24). CONCLUSIONS Although hospice provides a significant decrease in healthcare utilisation and some benefit in survival, most care is given in the last 2 weeks of life. Efforts to encourage earlier use of hospice services must continue. LAY SUMMARY The purpose of hospice care is to provide comfort and lessen suffering at the end of life. Hospice care allows one to die outside the hospital environment which is the wish of most people. However, we found that among persons aged 65 years and older who were diagnosed with liver cancer (which has a poor prognosis), only 25% were enrolled in hospice care and the majority used a hospice only in the last weeks of life. This is a disheartening finding as liver cancer patients with longer hospice enrolment had lower costs and improved survival. We suggest that healthcare practitioners consider discussion of palliative and hospice care routinely with patients suffering from liver cancer.
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Affiliation(s)
- Victor de Avila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - James M. Paik
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
- Center for Liver Disease and Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Leyla de Avila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Linda Henry
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Denise Mohess
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Alva Roche-Green
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Zobair M. Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
- Center for Liver Disease and Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
- Inova Medicine, Inova Health Systems, Falls Church, VA, USA
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33
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Schell JO, Johnson DS. Challenges with Providing Hospice Care for Patients Undergoing Long-Term Dialysis. Clin J Am Soc Nephrol 2021; 16:473-475. [PMID: 33037019 PMCID: PMC8011021 DOI: 10.2215/cjn.10710720] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Jane O. Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania,Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania
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34
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Rice DR, Hyer JM, Diaz A, Pawlik TM. End-of-Life Hospice Use and Medicare Expenditures Among Patients Dying of Hepatocellular Carcinoma. Ann Surg Oncol 2021; 28:5414-5422. [PMID: 33528708 DOI: 10.1245/s10434-021-09606-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The increasing incidence of hepatocellular carcinoma (HCC) coupled with rising health care costs contributes to high end-of-life expenditures. The current study aimed to characterize health care expenditures and hospice use among patients with HCC using a large, national database. METHODS The Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was used to identify patients with HCC. Logistic regression was used to identify factors associated with overall hospice use and end-of-life expenditures among individuals who died of HCC. RESULTS Among 14,369 Medicare beneficiaries with HCC, 8069 (63.7 %) used hospice. Racial/ethnic minority patients were less likely to use hospice services during the last year of life than white patients (no hospice: n = 2034 [44.3 %] vs. hospice: n = 2513 [31.1 %]). Social vulnerability also had an impact on the likelihood of patients using hospice services; in particular, the probability of hospice use among patients declined as social vulnerability increased (P < 0.05). Hospice use was associated with an approximate $10,000 decrease in inpatient expenditures (hospice: US$7900 [IQR, US$0-26,600] vs. no hospice: US$18,000 [IQR $400-49,100]; P < 0.001) and $1300 decrease in outpatient expenditures (hospice: US$900 [IQR, US$0-4500] vs. non-hospice: US$2200 [IQR, US$200-7900; P < 0.001) compared with individuals who did not use hospice. CONCLUSIONS Minority patients and individuals residing in high-vulnerability areas were less likely to use hospice. Patients who used hospice at the end of life had a reduction in inpatient and outpatient Medicare claims. Patients with HCC in need of hospice services should be ensured timely referral regardless of race/ethnicity or social vulnerability.
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Affiliation(s)
- Daniel R Rice
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adrian Diaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Comparison of out-of-pocket expenditure and catastrophic health expenditure for severe disease by the health security system: based on end-stage renal disease in South Korea. Int J Equity Health 2021; 20:6. [PMID: 33407535 PMCID: PMC7789567 DOI: 10.1186/s12939-020-01311-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 10/27/2020] [Indexed: 11/18/2022] Open
Abstract
Background Korea’s health security system named the National Health Insurance and Medical Aid has revolutionized the nation’s mandatory health insurance and continues to reduce excessive copayments. However, few studies have examined healthcare utilization and expenditure by the health security system for severe diseases. This study looked at reverse discrimination regarding end-stage renal disease by the National Health Insurance and Medical Aid. Methods A total of 305 subjects were diagnosed with end-stage renal disease in the Korea Health Panel from 2008 to 2013. Chi-square, t-test, and ANCOVA were conducted to identify the healthcare utilization rate, out-of-pocket expenditure, and the prevalence of catastrophic expenditure. Mixed effect panel analysis was used to evaluate total out-of-pocket expenditure by the National Health Insurance and Medical Aid over a 6-year period. Results There were no significant differences in the healthcare utilization rate for emergency room visits, admissions, or outpatient department visits between the National Health Insurance and Medical Aid because these healthcare services were essential for individuals with serious diseases, such as end-stage renal disease. Meanwhile, each out-of-pocket expenditure for an admission and the outpatient department by the National Health Insurance was 2.6 and 3.1 times higher than that of Medical Aid (P < 0.05). The total out-of-pocket expenditure, including that for emergency room visits, admission, outpatient department visits, and prescribed drugs, was 2.9 times higher for the National Health Insurance than Medical Aid (P < 0.001). Over a 6-year period, in terms of total of out-of-pocket expenditure, subjects with the National Health Insurance spent more than those with Medical Aid (P < 0.01). If the total household income decile was less than the median and subjects were covered by the National Health Insurance, the catastrophic health expenditure rate was 92.2%, but it was only 58.8% for Medical Aid (P < 0.001). Conclusion Individuals with serious diseases, such as end-stage renal disease, can be faced with reverse discrimination depending on the type of insurance that is provided by the health security system. It is necessary to consider individuals who have National Health Insurance but are still poor.
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Cross SH, Lakin JR, Mendu M, Mandel EI, Warraich HJ. Trends in Place of Death for Individuals With Deaths Attributed to Advanced Chronic or End-Stage Kidney Disease in the United States. J Pain Symptom Manage 2021; 61:112-120.e1. [PMID: 32791183 DOI: 10.1016/j.jpainsymman.2020.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/29/2020] [Accepted: 08/05/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT An important aspect of end-of-life care, place of death is understudied in advanced chronic (CKD) and end-stage kidney disease (ESKD). OBJECTIVE We sought to examine trends and factors associated with where advanced CKD/ESKD patients die. METHODS We conducted a retrospective cross-sectional study using mortality data from 2003 to 2017 for deaths attributed primarily to advanced CKD/ESKD in the United States. RESULTS Between 2003 and 2017, 222,247 deaths were attributed to advanced CKD/ESKD. From 2003 to 2017, deaths occurring in hospitals declined from 56.0% (n = 5356) to 35.6% (n = 7764), whereas increases occurred in deaths at home (13.5% [n = 1292] to 24.3% [n = 5306]), nursing facilities (18.6% [n = 1776] to 19.3% [n = 4221]), and hospice facilities (0.3% [n = 29] to 13.4% [n = 2917]). Nonwhite race was associated with increased odds of hospital death (Black [OR = 1.59; 95% CI = 1.55, 1.62]; Native American [OR = 1.47; 95% CI = 1.32, 1.63]; Asian [OR = 1.43; 95% CI = 1.32, 1.55] and reduced odds of nursing facility (Black [OR = 0.622; 95% CI = 0.600, 0.645]; Native American [OR = 0.638; 95% CI = 0.572, 0.712]; Asian [OR = 0.574; 95% CI = 0.533, 0.619], or hospice facility death (Black [OR = 0.843; 95% CI = 0.773, 0.918]; Native American [OR = 0.380; 95% CI = 0.289, 0.500]; Asian [OR = 0.609; 95% CI = 0.502, 0.739]). Older age was associated with reduced odds of hospital death (≥85 [OR = 0.334; 95% CI = 0.312, 0.358]) and increased odds of home (≥85 [OR = 1.55; 95% CI = 1.43, 1.68]), nursing facility (≥85 [OR = 3.09; 95% CI = 2.76, 3.45]) or hospice facility death (≥85 [OR = 1.60; 95% CI = 1.49, 1.72]). CONCLUSIONS Hospitals remain the most common place of death from advanced CKD/ESKD; however, the proportion of home, nursing facility, and hospice facility deaths have increased.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA.
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Mallika Mendu
- Harvard Medical School, Boston, Massachusetts, USA; Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ernest I Mandel
- Harvard Medical School, Boston, Massachusetts, USA; Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Haider J Warraich
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiology Section, Department of Medicine, Boston VA Healthcare System, Boston, Massachusetts, USA
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Paredes AZ, Hyer JM, Palmer E, Lustberg MB, Pawlik TM. Racial/Ethnic Disparities in Hospice Utilization Among Medicare Beneficiaries Dying from Pancreatic Cancer. J Gastrointest Surg 2021; 25:155-161. [PMID: 32193849 DOI: 10.1007/s11605-020-04568-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/02/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND We sought to define the incidence and characterize the timing of hospice utilization among racial/ethnic minority patients following pancreatectomy for pancreatic cancer. METHODS The Medicare Standard Analytic Files from 2013 to 2017 were used to identify patients with pancreatic cancer who underwent a pancreatectomy. Logistic regression was utilized to identify the association between race and patterns of hospice utilization among deceased individuals. RESULTS Among the 14,495 individuals (median age 73; 52.3% female; 6.8% racial/ethnic minority) who underwent a pancreatectomy for pancreatic cancer, 47% (n = 6859) died by the end of the follow-period. Among deceased individuals, three-fourths of patients (n = 4978, 72.6%) used hospice leading up to the time of death. Racial/ethnic minority patients were less likely, however, to have used hospice services compared with white patients (racial/ethnic minorities n = 301, 67% vs. whites: n = 4677, 73%; p = 0.024). On multivariable analysis, after controlling for clinical factors, racial/ethnic minority patients remained 22% less likely than whites to initiate hospice services prior to death (OR 0.78, 95% CI 0.63-0.96). Despite overall lower use of hospice, racial/ethnic minority patients had comparable odds of late hospice utilization (i.e., within 3 days of death) versus white patients (OR 1.5, 95% CI 0.73-1.50). DISCUSSION While most patients undergoing pancreatectomy for pancreatic cancer utilized hospice services prior to death, racial/ethnic minorities were less likely to use hospice services than whites.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Elizabeth Palmer
- Department of Surgery, Division of Surgical Oncology, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Maryam B Lustberg
- Division of Medical Oncology, Medical Director, Supportive Care Services, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1250 Lincoln Tower, Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.
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O'Halloran P, Noble H, Norwood K, Maxwell P, Murtagh F, Shields J, Mullan R, Matthews M, Cardwell C, Clarke M, Morton R, Shah K, Forbes T, Brazil K. Nurse-led advance care planning with older people who have end-stage kidney disease: feasibility of a deferred entry randomised controlled trial incorporating an economic evaluation and mixed methods process evaluation (ACReDiT). BMC Nephrol 2020; 21:478. [PMID: 33187506 PMCID: PMC7663906 DOI: 10.1186/s12882-020-02129-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/26/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Advance Care Planning is recommended for people with end-stage kidney disease but evidence is limited. Robust clinical trials are needed to investigate the impact of advance care planning in this population. There is little available data on cost-effectiveness to guide decision makers in allocating resources for advance care planning. Therefore we sought to determine the feasibility of a randomised controlled trial and to test methods for assessing cost-effectiveness. METHODS A deferred entry, randomised controlled feasibility trial, incorporating economic and process evaluations, with people with end-stage kidney disease, aged 65 years or older, receiving haemodialysis, in two renal haemodialysis units in Northern Ireland, UK. A nurse facilitator helped the patient make an advance care plan identifying: a surrogate decision-maker; what the participant would like to happen in the future; any advance decision to refuse treatment; preferred place of care at end-of-life. RESULTS Recruitment lasted 189 days; intervention and data collection 443 days. Of the 67 patients invited to participate 30 (45%) declined and 36 were randomised to immediate or deferred advance care plan groups. Twenty-two (61%) made an advance care plan and completed data collection at 12 weeks; 17 (47.2%) were able to identify a surrogate willing to be named in the advance care plan document. The intervention was well-received and encouraged end-of-life conversations, but did not succeed in helping patients to fully clarify their values or consider specific treatment choices. There was no significant difference in health system costs between the immediate and deferred groups. CONCLUSIONS A trial of advance care planning with participants receiving haemodialysis is feasible and acceptable to patients, but challenging. A full trial would require a pool of potential participants five times larger than the number required to complete data collection at 3 months. Widening eligibility criteria to include younger (under 65 years of age) and less frail patients, together with special efforts to engage and retain surrogates may improve recruitment and retention. Traditional advance care planning outcomes may need to be supplemented with those that are defined by patients, helping them to participate with clinicians in making medical decisions. TRIAL REGISTRATION Registered December 16, 2015. ClinicalTrials.gov Identifier: NCT02631200 .
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Affiliation(s)
- Peter O'Halloran
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK.
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Kelly Norwood
- School of Psychology, Ulster University, Cromore Road, Coleraine, Co. Londonderry, BT52 1SA, UK
| | - Peter Maxwell
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast, BT9 7BL, UK
- Regional Nephrology Unit, Belfast City Hospital, 51 Lisburn Road, Belfast, BT9 7AB, UK
| | - Fliss Murtagh
- Hull York Medical School, University of Hull, Allam Medical Building, Hull, HU6 7RX, UK
| | - Joanne Shields
- Regional Nephrology Unit, Belfast City Hospital, 51 Lisburn Road, Belfast, BT9 7AB, UK
| | - Robert Mullan
- Renal Unit, Antrim Area Hospital, Bush Road, Antrim, BT41 2RL, UK
| | - Michael Matthews
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
- Renal Unit, Antrim Area Hospital, Bush Road, Antrim, BT41 2RL, UK
| | - Christopher Cardwell
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Mike Clarke
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Sciences, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Rachael Morton
- NHMRC Clinical Trials Centre, University of Sydney, Medical Foundation Building, 92-94 Parramatta Rd, Camperdown, NSW, 2050, Australia
| | - Karan Shah
- NHMRC Clinical Trials Centre, University of Sydney, Medical Foundation Building, 92-94 Parramatta Rd, Camperdown, NSW, 2050, Australia
| | - Trisha Forbes
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Kevin Brazil
- School of Nursing and Midwifery, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
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Abbas A, Madison Hyer J, Pawlik TM. Race/Ethnicity and County-Level Social Vulnerability Impact Hospice Utilization Among Patients Undergoing Cancer Surgery. Ann Surg Oncol 2020; 28:1918-1926. [PMID: 33057860 DOI: 10.1245/s10434-020-09227-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Integration of palliative care services into the surgical treatment plan is important for holistic patient care. We sought to examine the association between patient race/ethnicity and county-level vulnerability relative to patterns of hospice utilization. PATIENTS AND METHODS Medicare Standard Analytic Files were used to identify patients undergoing lung, esophageal, pancreatic, colon, or rectal cancer surgery between 2013 and 2017. Data were merged with the Centers for Disease Control and Prevention's social vulnerability index (SVI). Logistic regression was utilized to identify factors associated with overall hospice utilization among deceased individuals. RESULTS A total of 54,256 Medicare beneficiaries underwent lung (n = 16,645, 30.7%), esophageal (n = 1427, 2.6%), pancreatic (n = 6183, 11.4%), colon (n = 26,827, 49.4%), or rectal (n = 3174, 5.9%) cancer resection. Median patient age was 76 years (IQR 71-82 years), and 28,887 patients (53.2%) were male; the majority of individuals were White (91.1%, n = 49,443), while a smaller subset was Black or Latino (racial/ethnic minority: n = 4813, 8.9%). Overall, 35,416 (65.3%) patients utilized hospice services prior to death. Median SVI was 52.8 [interquartile range (IQR) 30.3-71.2]. White patients were more likely to utilize hospice care compared with minority patients (OR 1.24, 95% CI 1.17-1.31, p < 0.001). Unlike White patients, there was reduced odds of hospice utilization (OR 0.97, 95% CI 0.96-0.99) and early hospice initiation (OR 0.94, 95% CI 0.91-0.97) as SVI increased among minority patients. CONCLUSIONS Patients residing in counties with high social vulnerability were less likely to be enrolled in hospice care at the time of death, as well as be less likely to initiate hospice care early. The effects of increasing social vulnerability on hospice utilization were more profound among minority patients.
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Affiliation(s)
- Alizeh Abbas
- Department of Surgery, The Ohio State University Wexner Medical Center and the James Cancer Hospital, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and the James Cancer Hospital, Columbus, OH, USA.
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and the James Cancer Hospital, Columbus, OH, USA
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Starr LT, Ulrich CM, Junker P, Huang L, O'Connor NR, Meghani SH. Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis. Am J Hosp Palliat Care 2020; 37:767-778. [PMID: 32602349 PMCID: PMC8962013 DOI: 10.1177/1049909120934292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Early palliative care consultation ("PCC") to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed. OBJECTIVE To identify risk factor patient profiles associated with PCC timing before death. METHODS Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables. RESULTS Of 1141 patients, 54% had PCC "close to death" (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or "Other" race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity. CONCLUSIONS A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.
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Affiliation(s)
- Lauren T Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Center for Bioethics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Connie M Ulrich
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Liming Huang
- BECCA Lab, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Nina R O'Connor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Danziger J, Ángel Armengol de la Hoz M, Celi LA, Cohen RA, Mukamal KJ. Use of Do-Not-Resuscitate Orders for Critically Ill Patients with ESKD. J Am Soc Nephrol 2020; 31:2393-2399. [PMID: 32855209 DOI: 10.1681/asn.2020010088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/01/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Despite having high comorbidity rates and shortened life expectancy, patients with ESKD may harbor unrealistically optimistic expectations about their prognoses. Whether this affects resuscitation orders is unknown. METHODS To determine whether do-not-resuscitate (DNR) orders differ among patients with ESKD compared with other critically ill patients, including those with diseases of other major organs, we investigated DNR orders on admission to intensive care units (ICUs) among 106,873 patients in the United States. RESULTS Major organ disease uniformly associated with increased risk of hospital mortality, particularly for cirrhosis (adjusted odds ratio [aOR], 2.67; 95% confidence interval [95% CI], 2.30 to 3.08), and ESKD (aOR, 1.47; 95% CI, 1.31 to 1.65). Compared with critically ill patients without major organ disease, patients with stroke, cancer, heart failure, dementia, chronic obstructive pulmonary disease, and cirrhosis were statistically more likely to have a DNR order on ICU admission; those with ESKD were not. Findings were similar when comparing patients with a single organ disease with those without organ disease. The disconnect between prognosis and DNR use was most notable among Black patients, for whom ESKD (compared with no major organ disease) was associated with a 62% (aOR, 1.62; 95% CI, 1.27 to 2.04) higher odds of hospital mortality, but no appreciable difference in DNR utilization (aOR, 1.06; 95% CI, 0.66 to 1.62). CONCLUSIONS Unlike patients with diseases of other major organs, critically ill patients with ESKD were not more likely to have a DNR order than patients without ESKD. Whether this reflects a greater lack of advance care planning in the nephrology community, as well as a missed opportunity to minimize potentially needless patient suffering, requires further study.
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Affiliation(s)
- John Danziger
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Miguel Ángel Armengol de la Hoz
- Cardiovascular Research Center, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.,Massachusetts Institute of Technology Critical Data, Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Biomedical Engineering and Telemedicine Group, Center for Biomedical Technology, Escuela Tecnica Superior de Ingenieros Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Leo Anthony Celi
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Massachusetts Institute of Technology Critical Data, Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Robert A Cohen
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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O'Hare AM, Butler CR, Taylor JS, Wong SPY, Vig EK, Laundry RS, Wachterman MW, Hebert PL, Liu CF, Rios-Burrows N, Richards CA. Thematic Analysis of Hospice Mentions in the Health Records of Veterans with Advanced Kidney Disease. J Am Soc Nephrol 2020; 31:2667-2677. [PMID: 32764141 DOI: 10.1681/asn.2020040473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/29/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with advanced kidney disease are less likely than many patients with other types of serious illness to enroll in hospice. Little is known about real-world clinical decision-making related to hospice for members of this population. METHODS We used a text search tool to conduct a thematic analysis of documentation pertaining to hospice in the electronic medical record system of the Department of Veterans Affairs, for a national sample of 1000 patients with advanced kidney disease between 2004 and 2014 who were followed until October 8, 2019. RESULTS Three dominant themes emerged from our qualitative analysis of the electronic medical records of 340 cohort members with notes containing hospice mentions: (1) hospice and usual care as antithetical care models: clinicians appeared to perceive a sharp demarcation between services that could be provided under hospice versus usual care and were often uncertain about hospice eligibility criteria. This could shape decision-making about hospice and dialysis and made it hard to individualize care; (2) hospice as a last resort: patients often were referred to hospice late in the course of illness and did not so much choose hospice as accept these services after all treatment options had been exhausted; and (3) care complexity: patients' complex care needs at the time of hospice referral could complicate transitions to hospice, stretch the limits of home hospice, and promote continued reliance on the acute care system. CONCLUSIONS Our findings underscore the need to improve transitions to hospice for patients with advanced kidney disease as they approach the end of life.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, University of Washington, Seattle, Washington .,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | | | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - Susan P Y Wong
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth K Vig
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ryan S Laundry
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Paul L Hebert
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Chuan-Fen Liu
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Nilka Rios-Burrows
- Chronic Kidney Disease Initiative, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Claire A Richards
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,School of Nursing, University of Washington, Seattle, Washington
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Burns RB, Waikar SS, Wachterman MW, Kanjee Z. Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2020; 173:217-225. [PMID: 32745449 PMCID: PMC10585656 DOI: 10.7326/m20-2640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
About 15% of adults in the United States-37 million persons-have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts-a nephrologist and a general internist-palliative care physician-reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.
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Affiliation(s)
- Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
| | - Sushrut S Waikar
- Boston University Medical Center, Boston, Massachusetts (S.S.W.)
| | | | - Zahir Kanjee
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., Z.K.)
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Bernacki GM, Engelberg RA, Curtis JR, Kurella Tamura M, Brumback LC, Lavallee DC, Vig EK, O’Hare AM. Cardiopulmonary Resuscitation Preferences of People Receiving Dialysis. JAMA Netw Open 2020; 3:e2010398. [PMID: 32833017 PMCID: PMC7445594 DOI: 10.1001/jamanetworkopen.2020.10398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Whether the cardiopulmonary resuscitation (CPR) preferences of patients receiving dialysis align with their values and other aspects of end-of-life care is not known. OBJECTIVE To describe the CPR preferences of patients receiving dialysis and how these preferences are associated with their responses to questions about other aspects of end-of-life care. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey study of a consecutive sample of patients receiving dialysis at 31 nonprofit dialysis facilities in 2 US metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 22, 2015, and October 2, 2018. Analyses for this article were conducted between December 2018 and April 2020. EXPOSURES Participants were asked to respond to the question "If you had to decide right now, would you want CPR if your heart were to stop beating?" Those who indicated they would probably or definitely want CPR were categorized as preferring CPR. MAIN OUTCOMES AND MEASURES This study examined the association between preference for CPR and other treatment preferences, engagement in advance care planning, values, desired place of death, expectations about prognosis, symptoms, and palliative care needs. RESULTS Of the 1434 individuals invited to complete the survey, 1009 agreed to participate, and 876 were included in the analytic cohort (61.1%). The final cohort had a mean (SD) age of 62.6 (14.0) years; 492 (56.2%) were men, and 528 (60.3%) were White individuals. Among 738 of 876 participants (84.2%) who indicated that they would definitely or probably want CPR (CPR group), 555 (75.2%) wanted mechanical ventilation vs 13 of 138 (9.4%) of those who did not want CPR (do not resuscitate [DNR] group) (P < .001). A total of 249 of 738 participants (33.7%) in the CPR group vs 84 of 138 (60.9%) in the DNR group had documented treatment preferences (P < .001). In terms of values about future care, 171 participants (23.2%) in the CPR group vs 5 of 138 (3.6%) in the DNR group valued life prolongation (P < .001); 320 in the CPR group (43.4%) vs 109 of 138 in the DNR group (79.0%) valued comfort (P < .001); and 247 participants (33.5%) in the CPR group vs 24 of 138 (17.4%) in the DNR group were unsure about their wishes for future care (P < .001). In the CPR group, 207 (28.0%) had thought about stopping dialysis vs 62 of 138 (44.9%) in the DNR group (P < .001), and 181 (24.5%) vs 58 of 138 (42.0%) had discussed stopping dialysis (P = .001). No statistically significant associations were observed between CPR preference and documentation of a surrogate decision maker, thoughts or discussion of hospice, preferred place of death, expectations about prognosis, reported symptoms, or palliative care needs. CONCLUSIONS AND RELEVANCE The CPR preferences of patients receiving dialysis were associated with some, but not all, other aspects of end-of-life care. How participants responded to questions about these other aspects of end-of-life care were not always aligned with their CPR preference. More work is needed to integrate discussions about code status with bigger picture conversations about patients' values, goals, and preferences for end-of-life care.
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Affiliation(s)
- Gwen M. Bernacki
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A. Engelberg
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - J. Randall Curtis
- Department of Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Manjula Kurella Tamura
- Department of Medicine, Stanford University Medical Center, Palo Alto, California
- Division of Nephrology, Geriatric Research, Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
| | | | | | - Elizabeth K. Vig
- Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Geriatrics, VA Puget Sound Health Care System, Seattle, Washington
| | - Ann M. O’Hare
- Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
- Kidney Research Institute, University of Washington, Seattle
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Sedhom R, Gupta A, Smith TJ. Short Hospice Length of Service in a Comprehensive Cancer Center. J Palliat Med 2020; 24:257-260. [PMID: 32302497 DOI: 10.1089/jpm.2019.0634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The benefits of hospice for patients with advanced cancer are well established. Short hospice length of service (LOS) is a marker of poor quality care and patient and family dissatisfaction. Interventions based on behavioral science might reduce suboptimal hospice use. Objective: To assess effects of peer comparisons on rates of short hospice LOS for cancer patients at a tertiary comprehensive cancer center. Design: Pre-post design utilizing a peer-comparison feedback intervention comparing individual oncologist hospice data. Setting: Urban, academic, comprehensive cancer center in Maryland. Measurements: Hospice enrollment rate. Median hospice LOS and percentage short hospice LOS (defined as ≤7 days). Results: Sixty oncologists received the intervention. Before the intervention, 394 patients enrolled in hospice for a period of 21 months (18.76 enrollments per month). Median hospice LOS was 14.5 days. After the intervention, 418 patients enrolled in hospice for 14 months (29.85 enrollments per month). Median hospice LOS was nine days. The percentage of patients experiencing a short hospice LOS increased from 33.3% to 43.5%. Conclusions: The methods are not sufficient to conclude that the intervention does not improve hospice use. A substantial number of patients with cancer who used hospice had LOS ≤7 days, a marker of poor quality. Using peer comparison in combination with additional behavioral interventions should be considered to improve end-of-life care.
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Affiliation(s)
- Ramy Sedhom
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | - Arjun Gupta
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | - Thomas J Smith
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
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Zimmermann CJ, Jhagroo RA, Wakeen M, Schueller K, Zelenski A, Tucholka JL, Fox DA, Baggett ND, Buffington A, Campbell TC, Johnson SK, Schwarze ML. Opportunities to Improve Shared Decision Making in Dialysis Decisions for Older Adults with Life-Limiting Kidney Disease: A Pilot Study. J Palliat Med 2020; 23:627-634. [PMID: 31930929 DOI: 10.1089/jpm.2019.0340] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Lack of awareness about the life-limiting nature of renal failure is a significant barrier to palliative care for older adults with end-stage renal disease. Objective: To train nephrologists to use the best case/worst case (BC/WC) communication tool to improve shared decision making about dialysis initiation for older patients with limited life expectancy. Design: This is a pre-/postinterventional pilot study. Setting/Subjects: There were 16 nephrologists and 30 patients of age 70 years and older with estimated glomerular filtration rate (eGFR) <20 mL/min per 1.73 m2 in outpatient nephrology clinics, in Madison, WI. Measurements: Performance of tool elements, content of communication about dialysis, shared decision making, acceptability of the intervention, decisions to pursue dialysis, and palliative care referrals were measured. Results: Fifteen of 16 nephrologists achieved competence performing the BC/WC tool with standardized patients, executing at least 14 of 19 items. Nine nephrologists met with 30 patients who consented to audio record their clinic visit. Before training, clinic visits focused on laboratory results and preparation for dialysis. After training, nephrologists noted that declining kidney function was "bad news," presented dialysis and "no dialysis" as treatment options, and elicited patient preferences. Observer-measured shared decision-making (OPTION 5) scores improved from a median of 20/100 (interquartile range [IQR] 15-35) before training to 58/100 (IQR 55-65). Patients whose nephrologist used the BC/WC tool were less likely to make a decision to initiate dialysis and were more likely to be referred to palliative care. Conclusions: Nephrologists can learn to use the BC/WC tool with older patients to improve shared decision making about dialysis, which may increase access to palliative care.
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Affiliation(s)
- Christopher J Zimmermann
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Roy A Jhagroo
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Maureen Wakeen
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Kathryn Schueller
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Amy Zelenski
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jennifer L Tucholka
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Daniel A Fox
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nathan D Baggett
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Anne Buffington
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Toby C Campbell
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sara K Johnson
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Margaret L Schwarze
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medical History and Bioethics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Richards CA, Hebert PL, Liu CF, Ersek M, Wachterman MW, Taylor LL, Reinke LF, O’Hare AM. Association of Family Ratings of Quality of End-of-Life Care With Stopping Dialysis Treatment and Receipt of Hospice Services. JAMA Netw Open 2019; 2:e1913115. [PMID: 31603487 PMCID: PMC6804019 DOI: 10.1001/jamanetworkopen.2019.13115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/23/2019] [Indexed: 12/01/2022] Open
Abstract
Importance Approximately 1 in 4 patients receiving maintenance dialysis for end-stage renal disease eventually stop treatment before death. Little is known about the association of stopping dialysis and quality of end-of-life care. Objectives To evaluate the association of stopping dialysis before death with family-rated quality of end-of-life care and whether this association differed according to receipt of hospice services at the time of death. Design, Setting, and Participants This survey study included data from 3369 patients who were treated with maintenance dialysis at 111 Department of Veterans Affairs medical centers and died between October 1, 2009, to September 30, 2015. Data set construction and analyses were conducted from September 2017 to July 2019. Exposure Cessation of dialysis treatment before death. Main Outcomes and Measures Bereaved Family Survey ratings. Results Among 3369 patients included, the mean (SD) age at death was 70.6 (10.2) years, and 3320 (98.5%) were male. Overall, 937 patients (27.8%) stopped dialysis before death and 2432 patients (72.2%) continued dialysis treatment until death. Patients who stopped dialysis were more likely to have been receiving hospice services at the time of death than patients who continued dialysis (544 patients [58.1%] vs 430 patients [17.7%]). Overall, 1701 patients (50.5%) had a family member who responded to the Bereaved Family Survey. In adjusted analyses, families were more likely to rate overall quality of end-of-life care as excellent if the patient had stopped dialysis (54.9% vs 45.9%; risk difference, 9.0% [95% CI, 3.3%-14.8%]; P = .002) or continued to receive dialysis but also received hospice services (60.5% vs 40.0%; risk difference, 20.5% [95% CI, 12.2%-28.9%]; P < .001). Conclusions and Relevance This survey study found that families rated overall quality of end-of-life care higher for patients who stopped dialysis before death or continued dialysis but received concurrent hospice services. More work to prepare patients for end-of-life decision-making and to expand access to hospice services may help to improve the quality of end-of-life care for patients with end-stage renal disease.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Paul L. Hebert
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Chuan-Fen Liu
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center–Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Melissa W. Wachterman
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leslie L. Taylor
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
| | - Lynn F. Reinke
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- School of Nursing, Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
| | - Ann M. O’Hare
- Health Services Research and Development, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
- University of Washington School of Medicine, Seattle
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O'Hare AM, Kurella Tamura M, Lavallee DC, Vig EK, Taylor JS, Hall YN, Katz R, Curtis JR, Engelberg RA. Assessment of Self-reported Prognostic Expectations of People Undergoing Dialysis: United States Renal Data System Study of Treatment Preferences (USTATE). JAMA Intern Med 2019; 179:1325-1333. [PMID: 31282920 PMCID: PMC6618699 DOI: 10.1001/jamainternmed.2019.2879] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Prognostic understanding can shape patients' treatment goals and preferences. Patients undergoing dialysis in the United States have limited life expectancy and may receive end-of-life care directed at life extension. Little is known about their prognostic expectations. OBJECTIVE To understand the prognostic expectations of patients undergoing dialysis and how these relate to care planning, goals, and preferences. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey study of 996 eligible patients treated with regular dialysis at 31 nonprofit dialysis facilities in 2 metropolitan areas (Seattle, Washington, and Nashville, Tennessee) between April 2015 and October 2018. After a pilot phase, 1434 eligible patients were invited to participate (response rate, 69.5%). To provide a context for interpreting survey participants' prognostic estimates, United States Renal Data System standard analysis files were used to construct a comparison cohort of 307 602 patients undergoing in-center hemodialysis on January 1, 2006, and followed for death through July 31, 2017. Final analyses for this study were conducted between November 2018 and March 2019. EXPOSURES Responses to the question "How long would you guess people your age with similar health conditions usually live?" (<5 years, 5-10 years, >10 years, or not sure). MAIN OUTCOMES AND MEASURES Self-reported (1) documentation of a surrogate decision-maker, (2) documentation of treatment preferences, (3) values around life prolongation, (4) preferences for receipt of cardiopulmonary resuscitation and mechanical ventilation, and (5) desired place of death. RESULTS Of the 996 survey respondents, the mean (SD) age was 62.7 (13.9) years, and 438 (44.0%) were women. Overall, 112 (11.2%) survey respondents selected a prognosis of fewer than 5 years, 150 (15.1%) respondents selected 5 to 10 years, 330 (33.1%) respondents selected more than 10 years, and 404 (40.6%) were not sure. By comparison, 185 427 (60.3%) prevalent US in-center patients undergoing hemodialysis died within 5 years, 58 437 (19.0%) died within 5 to 10 years, and 63 738 (20.7%) lived more than 10 years. In analyses adjusted for participant characteristics, survey respondents with a prognostic expectation of more than 10 years (vs <5 years) were less likely to report documentation of a surrogate decision-maker (adjusted odds ratio [aOR], 0.6; 95% CI, 0.4-0.9) and treatment preferences (aOR, 0.4; 95% CI, 0.2-0.6) and to value comfort over life extension (aOR, 0.1; 95% CI, 0.04-0.3), and were more likely to want cardiopulmonary resuscitation (aOR, 5.3; 95% CI, 3.2-8.7) and mechanical ventilation (aOR, 2.2; 95% CI, 1.2-3.7). The respondents who reported that they were not sure about prognosis had similar associations. CONCLUSIONS AND RELEVANCE Uncertain and overly optimistic prognostic expectations may limit the benefit of advance care planning and contribute to high-intensity end-of-life care in patients undergoing dialysis.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, University of Washington, Seattle.,Kidney Research Institute, University of Washington, Seattle.,VA Puget Sound Health Care System, Seattle, Washington
| | - Manjula Kurella Tamura
- Stanford University Medical Center, Palo Alto, California.,Division of Nephrology, Geriatric Research, Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
| | | | - Elizabeth K Vig
- Department of Medicine, University of Washington, Seattle.,VA Puget Sound Health Care System, Seattle, Washington
| | | | - Yoshio N Hall
- Department of Medicine, University of Washington, Seattle.,Kidney Research Institute, University of Washington, Seattle
| | - Ronit Katz
- Department of Medicine, University of Washington, Seattle.,Kidney Research Institute, University of Washington, Seattle
| | - J Randall Curtis
- Department of Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Ruth A Engelberg
- Department of Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
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Richards CA, Liu CF, Hebert PL, Ersek M, Wachterman MW, Reinke LF, Taylor LL, O’Hare AM. Family Perceptions of Quality of End-of-Life Care for Veterans with Advanced CKD. Clin J Am Soc Nephrol 2019; 14:1324-1335. [PMID: 31466952 PMCID: PMC6730503 DOI: 10.2215/cjn.01560219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/24/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the quality of end-of-life care for patients with advanced CKD. We describe the relationship between patterns of end-of-life care and dialysis treatment with family-reported quality of end-of-life care in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We designed a retrospective observational study among a national cohort of 9993 veterans with advanced CKD who died in Department of Veterans Affairs facilities between 2009 and 2015. We used logistic regression to evaluate associations between patterns of end-of-life care and receipt of dialysis (no dialysis, acute dialysis, maintenance dialysis) with family-reported quality of end-of-life care. RESULTS Overall, 52% of cohort members spent ≥2 weeks in the hospital in the last 90 days of life, 34% received an intensive procedure, and 47% were admitted to the intensive care unit, in the last 30 days, 31% died in the intensive care unit, 38% received a palliative care consultation in the last 90 days, and 36% were receiving hospice services at the time of death. Most (55%) did not receive dialysis, 12% received acute dialysis, and 34% received maintenance dialysis. Patients treated with acute or maintenance dialysis had more intensive patterns of end-of-life care than those not treated with dialysis. After adjustment for patient and facility characteristics, receipt of maintenance (but not acute) dialysis and more intensive patterns of end-of-life care were associated with lower overall family ratings of end-of-life care, whereas receipt of palliative care and hospice services were associated with higher overall ratings. The association between maintenance dialysis and overall quality of care was attenuated after additional adjustment for end-of-life treatment patterns. CONCLUSIONS Among patients with advanced CKD, care focused on life extension rather than comfort was associated with lower family ratings of end-of-life care regardless of whether patients had received dialysis.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Chuan-Fen Liu
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Paul L. Hebert
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Health Services, School of Public Health
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa W. Wachterman
- Section of General Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lynn F. Reinke
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, and
| | - Leslie L. Taylor
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Ann M. O’Hare
- Health Services Research and Development, Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
- School of Medicine, University of Washington, Seattle, Washington
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Abstract
PURPOSE OF REVIEW Care near the end of life is expensive and frequently not aligned with the expressed preferences of decedents, creating an opportunity to improve value, or increase quality while lowering cost. This review examines publications from 2017 and 2018 on interventions and policies associated with high-value end-of-life care. Innovations in video and web-based advance care planning are promising to improve preference-congruent care at low cost. RECENT FINDINGS The patterns of care within hospice and in particular increased investment in patient care in hospice are shown to improve value. A meta-analysis demonstrated the role of inpatient palliative care consultations in decreasing hospitalization costs, as did several studies on inpatient palliative care units. Internationally, a range of home-based palliative care programs, implemented at the population level, demonstrated cost savings and reduced intensive care near the end of life. Finally, public policies that funded medical and long-term care and address broader inequalities were demonstrated to decrease low-value care near the end of life. SUMMARY This review demonstrates the efficacy of a range of approaches to improve value of care at the end of life, both within the health system and across public policy sectors.
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