Hospitalization of Hospice Patients with Cancer

Concurrent Care as the Next Frontier in End-of-Life Care

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.

Cost-effectiveness of management strategies for patients with recurrent ovarian cancer and inoperable malignant bowel obstruction

OBJECTIVES

Patients with recurrent platinum-resistant ovarian cancer often present with inoperable malignant bowel obstruction (MBO) from a large burden of abdominal disease. Interventions such as total parenteral nutrition (TPN) and chemotherapy may be used in this setting. We aim to describe the relative cost-effectiveness of these interventions to inform clinical decision making.

METHODS

Four strategies for management of platinum-resistant recurrent ovarian cancer with inoperable MBO were compared from a societal perspective using a Monte Carlo simulation: (1) hospice, (2) TPN, (3) chemotherapy, and (4) TPN + chemotherapy. Survival, hospitalization rates, end-of-life (EOL) setting, and MBO-related utilities were obtained from literature review: hospice (survival 38 days, 6% hospitalization), chemotherapy (42 days, 29%), TPN (55 days, 25%), TPN + chemotherapy (74 days, 47%). Outcomes were the average cost per strategy and incremental cost-effectiveness ratios (ICERs) in US dollars per quality-adjusted life year (QALY) gained.

RESULTS

In the base case scenario, TPN + chemotherapy was the most costly strategy (mean; 95% CI) ($49,741; $49,329-$50,162) and provided the highest QALYs (0.089; 0.089-0.090). The lowest cost strategy was hospice ($14,591; $14,527-$14,654). The TPN alone and chemotherapy alone strategies were dominated by a combination of hospice and TPN + chemotherapy. The ICER of TPN + chemotherapy was $918,538/QALY compared to hospice. With a societal willingness to pay threshold of $150,000/QALY, hospice was the strategy of choice in 71.6% of cases, chemotherapy alone in 28.4%, and TPN-containing strategies in 0%.

CONCLUSIONS

TPN with or without chemotherapy is not cost-effective in management of inoperable malignant bowel obstruction and platinum-resistant ovarian cancer.

Advanced imaging and hospice use in end-of-life cancer care

INTRODUCTION

Advanced imaging can inform prognosis and may be a mechanism to de-escalate unnecessary end-of-life care in patients with cancer. Associations between greater use of advanced imaging and less-aggressive end-of-life care in real-world practice has not been examined.

METHODS

We conducted a retrospective analysis of SEER-Medicare data on patients who died from breast, lung, colorectal, or prostate cancer between 2002 and 2007. Hospital referral region (HRR)-level use of computerized tomography (CT), magnetic resonance imaging, and positron emission tomography was categorized by tertile of imaging use and correlated with hospice enrollment overall and late hospice enrollment using multivariable logistic regression.

RESULTS

A total of 55,058 patients met study criteria. Hospice use ranged from 50.8% (colorectal cancer) to 62.1% (prostate cancer). In multivariable analyses, hospital referral regions (HRRs) with high rates of CT imaging were associated with lower odds of hospice enrollment (odds ratio, 0.80; 95% CI, 0.70-0.90) and late enrollment among those who did enroll (odds ratio, 1.49; 95% CI, 1.26-1.76). HRRs with the highest rates of CT use were predominantly located in the Midwest and Northeast and associated with higher percentage population of black patients (14.5 vs 5.6%), greater comorbidity (28.4 vs 23.7%), metropolitan residence (93.9 vs 78.5%), and less than high school education (26.4 vs 19.3%).

CONCLUSION

In this population-based retrospective study, we did not observe evidence that overall and timely hospice are associated with higher rates of imaging near the end of life. An observed association between higher rates of imaging, particularly CT, may be explained in part by HRR-level differences in practice patterns and patient demographic characteristics. Further research is warranted to explore the ability of oncologic imaging to appropriately de-escalate care.

Inpatient utilization and disparities: The last year of life of adolescent and young adult oncology patients in California

BACKGROUND

Studies of adolescent and young adult (AYA) oncology end-of-life care utilization are critical because cancer is the leading cause of nonaccidental AYA death and end-of-life care contributes significantly to health care expenditures. This study was designed to determine the quantity of and disparities in inpatient utilization in the last year of life of AYAs with cancer.

METHODS

The California Office of Statewide Health Planning and Development administrative discharge database, linked to death certificates, was used to perform a population-based analysis of cancer patients aged 15 to 39 years who died in 2000-2011. The number of hospital days and the inpatient costs were determined for each patient in the last year of his or her life, as were clinical and sociodemographic factors associated with high inpatient utilization. Admission patterns as death approached were also evaluated.

RESULTS

The 12,883 patients were admitted for 40 days on average in the last year of life, and this cost $151,072 per patient in inpatient costs. As death approached, the admission rates and the percentage of all admissions occurring at nonspecialty centers increased. Five percent of patients used 20% of bed days in the last year (high utilizers). Factors associated with high utilization included younger age (15-30 years), Hispanic ethnicity, non-health maintenance organization insurance, and hematologic malignancies.

CONCLUSIONS

AYA oncology decedents were admitted for 40 days in their last year of life. Subgroups with high utilization had distinct sociodemographic and clinical characteristics, and nonspecialty center admissions increased as death approached. This demonstrates the need for palliative care at nonspecialty centers. Future studies need to determine whether these patterns are goal-concurrent, include high utilizers, and monitor the effects of health care reform. Cancer 2018;124:1819-27. © 2018 American Cancer Society.

Risk Factor Assessment of Hospice Patients Readmitted within 7 Days of Acute Care Hospital Discharge

Factors surrounding readmission rates for hospice patients within seven days are still relatively unknown. The present study specifically investigates the seven-day readmission rate of patients newly discharged to hospice, and the predictive factors associated with readmission for this population. In a retrospective case-control study, we seek to identify potential predictors by comparing the characteristics of patients discharged to hospice and readmitted within one week to patients who were not readmitted. Cases (n = 46) were patients discharged to home hospice and readmitted to the hospital within seven days. Controls (n = 117) were patients discharged to home hospice and not readmitted to the hospital within seven days. Significant risk factors for readmission within seven days were found to be: age (p < 0.01), race (p < 0.001), language (p < 0.001), and insurance (p < 0.001). Further study of these predictors may identify opportunities for interventions that address patient and family concerns that may lead to readmission.

Risk Factors for Hospitalization of Home Hospice Enrollees Development and Validation of a Predictive Tool

BACKGROUND

Over 10% of hospice patients experience at least 1 care transition 6 months prior to death. Transitions at the end of life, particularly from hospice to hospital, result in burdensome and fragmented care for patients and families. Little is known about factors that predict hospitalization in this population.

OBJECTIVES

To develop and validate a model predictive of hospitalization after enrollment into home hospice using prehospice admission risk factors.

DESIGN

Retrospective cohort study using Medicare fee-for-service claims.

PARTICIPANTS

Patients enrolled into the Medicare hospice benefit were ≥18 years old in 2012.

OUTCOME MEASURED

Hospitalization within 2 days from a hospice discharge.

RESULTS

We developed a predictive model using 61 947 hospice enrollments, of which 3347 (5.4%) underwent a hospitalization. Seven variables were associated with hospitalization: age 18 to 55 years old (adjusted odds ratio [95% confidence interval]: 2.94 [2.41-3.59]), black race (2.13 [1.93-2.34]), east region (1.97 [1.73-2.24]), a noncancer diagnosis (1.32 [1.21-1.45]), 4 or more chronic conditions (8.11 [7.19-9.14]), 2 or more prior hospice enrollments (1.75 [1.35-2.26]), and enrollment in a not-for-profit hospice (2.01 [1.86-2.18]). A risk scoring tool ranging from 0 to 29 was developed, and a cutoff score of 18 identified hospitalized patients with a positive predictive value of 22%.

CONCLUSIONS

Reasons for hospitalization among home hospice patients are complex. Patients who are younger, belong to a minority group, and have a greater number of chronic conditions are at increased odds of hospitalization. Our newly developed predictive tool identifies patients at risk for hospitalization and can serve as a benchmark for future model development.

Examining the Role of Primary Care Physicians and Challenges Faced When Their Patients Transition to Home Hospice Care

BACKGROUND

The transition into home hospice care is often a critical time in a patient's medical care. Studies have shown patients and caregivers desire continuity with their physicians at the end of life (EoL). However, it is unclear what roles primary care physicians (PCPs) play and what challenges they face caring for patients transitioning into home hospice care.

OBJECTIVES

To understand PCPs' experiences, challenges, and preferences when their patients transition to home hospice care.

DESIGN

Nineteen semi-structured phone interviews with PCPs were conducted. Study data were analyzed using standard qualitative methods.

PARTICIPANTS

Participants included PCPs from 3 academic group practices in New York City. Measured: Physician recordings were transcribed and analyzed using content analysis.

RESULTS

Most PCPs noted that there was a discrepancy between their actual role and ideal role when their patients transitioned to home hospice care. Primary care physicians expressed a desire to maintain continuity, provide psychosocial support, and collaborate actively with the hospice team. Better establishment of roles, more frequent communication with the hospice team, and use of technology to communicate with patients were mentioned as possible ways to help PCPs achieve their ideal role caring for their patients receiving home hospice care.

CONCLUSIONS

Primary care physicians expressed varying degrees of involvement during a patient's transition to home hospice care, but many desired to be more involved in their patient's care. As with patients, physicians desire to maintain continuity with their patients at the EoL and solutions to improve communication between PCPs, hospice providers, and patients need to be explored.

Social determinants, multimorbidity, and patterns of end-of-life care in older adults dying from cancer

OBJECTIVE

Most prior studies on aggressive end-of-life care in older patients with cancer have accounted for social determinants of health (e.g., race, income, and education), but rarely for multimoribidity (MM). In this study, we examine the association between end-of-life care and each of the social determinants of health and MM, hypothesizing that higher MM is associated with less aggressive care.

METHODS

From the linked 1991-2008 Health and Retirement Study, Medicare data, and the National Death Index, we identified fee-for-service patients age ≥66years who died from cancer (n=835). MM was defined as the occurrence or co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. Aggressive care was based on claims-derived measures of receipt of cancer-directed treatment in the last two weeks of life; admission to the hospital and/or emergency department (ED) within the last month; and in-hospital death. We also identified patients enrolled in hospice. In multivariable logistic regression models, we analyzed the associations of interest, adjusting for potential confounders.

RESULTS

While 61.2% of the patients enrolled in hospice, 24.6% underwent cancer-directed treatment; 55.1% were admitted to the hospital and/or ED; and 21.7% died in the hospital. We observed a U-shaped distribution between income and in-hospital death. Chronic conditions and geriatric syndromes were associated with some outcomes, but not with others.

CONCLUSIONS

To improve quality end-of-life care and curtail costs incurred by dying patients, relevant interventions need to account for social determinants of health and MM in a nuanced fashion.

Understanding Palliative Care and Hospice: A Review for Primary Care Providers

Palliative care provides invaluable clinical management and support for patients and their families. For most people, palliative care is not provided by hospice and palliative medicine specialists, but rather by their primary care providers. The recognition of hospice and palliative medicine as its own medical subspecialty in 2006 highlighted the importance of palliative care to the practice of medicine, yet many health care professionals harbor misconceptions about palliative care, which may be a barrier to ensuring that the palliative care needs of their patients are identified and met in a timely fashion. When physicians discuss end-of-life concerns proactively, many patients choose more comfort-focused care and receive care more aligned with their values and goals. This article defines palliative care, describes how it differs from hospice, debunks some common myths associated with hospice and palliative care, and offers suggestions on how primary care providers can integrate palliative care into their practice.

Why Do Home Hospice Patients Return to the Hospital? A Study of Hospice Provider Perspectives

BACKGROUND

Hospice provides an opportunity for patients to receive care at home at the end of life (EOL); however, approximately 25% of patients who disenroll from hospice are hospitalized. Hospitalization can lead to poor care transitions and result in unwarranted care and adverse patient outcomes. Research examining reasons for hospitalization in this patient population is limited.

OBJECTIVE

The objective was to understand the reasons for hospitalization among home hospice patients through the perspectives of hospice interdisciplinary team (IDT) members.

METHODS

This was a qualitative study using a grounded theory approach. Seven semistructured focus group were conducted to solicit reasons for hospitalization among home hospice patients. Participants consisted of 73 home hospice IDT members from a not-for-profit hospice agency in New York City. Focus group recordings were transcribed and analyzed using content analysis.

RESULTS

Eight major themes were identified: (1) not fully understanding hospice, (2) lack of clarity about disease prognosis, (3) desire to continue receiving care from nonhospice physicians and hospital, (4) caregiver burden, (5) distressing/difficult-to-manage signs and symptoms, (6) caregivers' reluctance to administer morphine, (7) 911's faster response time compared to hospice, and (8) families' difficulty accepting patients' mortality.

CONCLUSIONS

Reasons for hospitalization in home hospice patients are multifactorial and complex. Our study highlights barriers and challenges that patients, families, physicians, and hospices face around home hospice care and hospitalization. More research is needed to elucidate these issues and develop viable strategies to address them.

ICU Deaths in Patients With Advanced Cancer

BACKGROUND

A significant number of advanced cancer admissions to the intensive care unit (ICU) are inappropriate in that they do not result in prolonged survival. No clear consensus criteria for reasonable admissions of advanced cancer patients have been developed.

METHOD

We established four criteria for reasonable admissions to ICU in patients who suffered from advanced, incurable cancer: post procedure complication, recent notification of cancer, ECOG performance status of 0-1, and life expectancy of more than 6 months. Based on these criteria, we reviewed the charts of all patients who died in the ICU at the University of Tennessee Health Science Center (UTHSC) affiliated Veteran's Affairs Medical Center between 10/2005 and 10/2010. We identified patients with advanced, incurable cancer and performed an in depth review of their charts.

RESULTS

In the 421 charts of patients who died in our ICU between October 2005 and October 2010 we identified 52 patients admitted to the ICU with advanced, incurable cancer. 14 patients were diagnosed with cancer one month or less prior to admission. 21 patients had ECOG performance status of 0-1. 14 patients had life expectancy of more than 6 months and 8 patients were admitted for post procedure complication. 47% of patients who did not satisfy any of our reasonable admission criteria had APDs.

CONCLUSIONS

Incorporating proposed admission criteria in ICU admission guidelines may prevent 37% of inappropriate, advanced cancer admissions to the ICU. A simple increase in numbers of APDs would not likely change significantly the numbers of inappropriate ICU admissions.

Transitions Between Healthcare Settings of Hospice Enrollees at the End of Life

OBJECTIVES

To characterize the number and types of care transitions in the last 6 months of life of individuals who used hospice and to examine factors associated with having multiple transitions in care.

DESIGN

Retrospective cohort study.

SETTING

One hundred percent fee-for-service Medicare decedent claims data.

PARTICIPANTS

Medicare beneficiaries aged 66 and older who died between July 1, 2011, and December 31, 2011, and were enrolled in hospice at some time during the last 6 months of life.

MEASUREMENTS

Hierarchical generalized linear modeling was used to identify individual, hospice, and regional factors associated with transitions. The sequence of transitions across healthcare settings was described. Healthcare transitions after hospice enrollment included from and to the hospital, skilled nursing facility, home health agency program, hospice, or home without receiving any service in these four healthcare settings.

RESULTS

Of 311,090 hospice decedents, 31,675 (10.2%) had at least one transition after hospice enrollment, and this varied substantially across the United States; 6.6% of all decedents had more than one transition in care after hospice enrollment (range 2-19 transitions). Of hospice users with transitions, 53.4% were admitted to hospitals, 17.7% were admitted to skilled nursing facilities, 9.6% used home health agencies, and 25.8% had transitions to home without receiving the services from the healthcare settings examined. In adjusted analyses, decedents who were younger, nonwhite, enrolled in a for-profit or small hospice program, or had less access to hospital-based palliative care had significantly higher odds of having at least one transition.

CONCLUSION

A notable proportion of hospice users experience at least one transition in care in the last 6 months of life, suggesting that further research on the effect of transitions on users and families is warranted.

Measuring intensity of end of life care: a systematic review

Background

Many studies have measured the intensity of end of life care. However, no summary of the measures used in the field is currently available.

Objectives

To summarise features, characteristics of use and reported validity of measures used for evaluating intensity of end of life care.

Methods

This was a systematic review according to PRISMA guidelines. We performed a comprehensive literature search in Ovid Medline, Embase, The Cochrane Library of Systematic Reviews and reference lists published between 1990-2014. Two reviewers independently screened titles, abstracts, full texts and extracted data. Studies were eligible if they used a measure of end of life care intensity, defined as all quantifiable measures describing the type and intensity of medical care administered during the last year of life.

Results

A total of 58 of 1590 potentially eligible studies met our inclusion criteria and were included. The most commonly reported measures were hospitalizations (n = 44), intensive care unit admissions (n = 39) and chemotherapy use (n = 27). Studies measured intensity of care in different timeframes ranging from 48 hours to 12 months. The majority of studies were conducted in cancer patients (n = 31). Only 4 studies included information on validation of the measures used. None evaluated construct validity, while 3 studies considered criterion and 1 study reported both content and criterion validity.

Conclusions

This review provides a synthesis to aid in choosing intensity of end of life care measures based on their previous use but simultaneously highlights the crucial need for more validation studies and consensus in the field.

Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review

BACKGROUND

There has been an increase in observational studies using health administrative data to examine the nature, quality, and costs of care at life's end, particularly in cancer care.

AIM

To synthesize retrospective observational studies on resource utilization and/or costs at the end of life in cancer patients. We also examine the methods and outcomes of studies assessing the quality of end-of-life care.

DESIGN

A systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) methodology.

DATA SOURCES

We searched MEDLINE, Embase, CINAHL, and York Centre for Research and Dissemination (1990-2011). Independent reviewers screened abstracts of 14,424 articles, and 835 full-text manuscripts were further reviewed. Inclusion criteria were English-language; at least one resource utilization or cost outcome in adult cancer decedents with solid tumors; outcomes derived from health administrative data; and an exclusive end-of-life focus.

RESULTS

We reviewed 78 studies examining end-of-life care in over 3.7 million cancer decedents; 33 were published since 2008. We observed exponential increases in service use and costs as death approached; hospital services being the main cost driver. Palliative services were relatively underutilized and associated with lower expenditures than hospital-based care. The 15 studies using quality indicators demonstrated that up to 38% of patients receive chemotherapy or life-sustaining treatments in the last month of life and up to 66% do not receive hospice/palliative services.

CONCLUSION

Observational studies using health administrative data have the potential to drive evidence-based palliative care practice and policy. Further development of quality care markers will enhance benchmarking activities across health care jurisdictions, providers, and patient populations.

Predictors of emergency room visits or acute hospital admissions prior to death among hospice palliative care clients in Ontario: a retrospective cohort study

BACKGROUND

Hospice palliative care (HPC) is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients' symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues; therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. This study examines predictors of ERVH prior to death among HPC home care clients.

METHODS

A retrospective cohort study of a sample of 764 HPC home care clients who received services from a community care access centre (CCAC) in southern Ontario, Canada. All clients were assessed using the Resident Assessment Instrument for Palliative Care (interRAI PC) as part of normal clinical practice between April 2008 and July 2010. The Andersen-Newman framework for health service utilization was used as a conceptual model for the basis of this study. Logistic regression and Cox regression analyses were carried out to identify predictors of ERVH.

RESULTS

Half of the HPC clients had at least one or more ERVH (n = 399, 52.2%). Wish to die at home (OR = 0.54) and advanced care directives (OR = 0.39) were protective against ERVH. Unstable health (OR = 0.70) was also associated with reduced probability, while infections such as prior urinary tract infections (OR = 2.54) increased the likelihood of ERVH. Clients with increased use of formal services had reduced probability of ERVH (OR = 0.55).

CONCLUSIONS

Findings of this study suggest that predisposing characteristics are nearly as important as need variables in determining ERVH among HPC clients, which challenges the assumption that need variables are the most important determinants of ERVH. Ongoing assessment of HPC clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients' changing health needs and end of life preferences.

Association of hospice patients' income and care level with place of death

IMPORTANCE

Terminally ill patients with lower incomes are less likely to die at home, even with hospice care.

OBJECTIVES

To examine the relationship between income and transfer from home before death and the interaction between income and level of hospice care as a predictor of transfer from home in patients admitted to routine home hospice care.

DESIGN

We matched zip codes to US census tracts to generate median annual household incomes and divided the measure into $10,000 increments (≤$20,000 to >$50,000). We abstracted data from the central administrative and clinical database of a hospice care provider. We analyzed the relationship between income and transfer from home before death using logistic regression adjusted for demographics, diagnosis, region, and length of stay. Level of hospice care was examined as any continuous care vs none. Unlike routine care, which includes periodic visits by hospice, continuous care is a higher level of care used for short periods of crisis to keep a patient at home and includes hospice services in the home at least 8 hours in a 24-hour period.

SETTING

A for-profit hospice provider, VITAS Healthcare, operating 26 programs in 8 states.

PARTICIPANTS

Hospice patients admitted to routine care in a private residence from January 1, 1999, through December 31, 2003.

MAIN OUTCOME MEASURE

Transfer from hospice care in a private residence to hospice care in a site outside the home before death.

RESULTS

Of the 61,063 enrollees admitted to routine care in a private residence, 13,804 (22.61%) transferred from home to another location (ie, inpatient hospice unit or nursing home) with hospice care before death. Patients who transferred had a lower mean median household income ($42,585 vs $46,777; P < .001) and were less likely to have received any continuous care (49.38% vs 30.61%; P < .001). The median number of days of continuous care was 4. For patients who did not receive continuous care, the odds of transfer from home before death increased with decreasing median annual household incomes (odds ratio range, 1.26-1.76). For patients who received continuous care, income was not a predictor of transfer from home.

CONCLUSIONS AND RELEVANCE

Patients with limited resources may be less likely to die at home, especially if they are not able to access needed support beyond what is available with routine hospice care.

End-of-life care for Medicare beneficiaries with cancer is highly intensive overall and varies widely

Studies have shown that cancer care near the end of life is more aggressive than many patients prefer. Using a cohort of deceased Medicare beneficiaries with poor-prognosis cancer, meaning that they were likely to die within a year, we examined the association between hospital characteristics and eleven end-of-life care measures, such as hospice use and hospitalization. Our study revealed a relatively high intensity of care in the last weeks of life. At the same time, there was more than a twofold variation within hospital groups with common features, such as cancer center designation and for-profit status. We found that these hospital characteristics explained little of the observed variation in intensity of end-of-life cancer care and that none reliably predicted a specific pattern of care. These findings raise questions about what factors may be contributing to this variation. They also suggest that best practices in end-of-life cancer care can be found in many settings and that efforts to improve the quality of end-of-life care should include every hospital category.

Opioid pain medication orders and administration in the last days of life

CONTEXT

Most patients with serious and life-limiting illness experience pain at some point in the illness trajectory.

OBJECTIVES

To describe baseline pain management practices for imminently dying patients in Veterans Administration Medical Centers (VAMCs) and examine factors associated with these processes, including presence of opioid orders at the time of death and medication administration in the last seven days, 48 hours, and 24 hours of life.

METHODS

Data on orders and administration of opioid pain medication at the end of life were abstracted from the medical records of veterans who died in six VAMC hospitals in 2005.

RESULTS

Of 1068 patient records, 686 (64.2%) had an active order for an opioid medication at the time of death. Of these, 69.8% of patients had received the medication at some time within the last seven days of life, 61.2% within the last 48 hours, and 47.0% within the last 24 hours. In multivariable models, presence of an order for opioid pain medication at the time of death and administration within the last 24 hours were both significantly associated with having a Do Not Resuscitate (DNR) order (P < 0.0001/0.0002), terminal condition (P < 0.0001/< 0.0001), family presence (P < 0.0001/0.0023), location of death (P = 0.003/0.0005), and having pain noted in the care plan (P = 0.0073/0.0007).

CONCLUSION

Findings indicate a need for improving availability of opioids for end-of-life care in the inpatient setting. Modifiable factors, such as family presence and goals-of-care discussions, suggest potential targets for intervention to improve recognition of the dying process and proactive planning for pain control.

Disparity in hospice utilization by African American patients with cancer

Patients with cancer represent the largest group of hospice users, making this population critically important in hospice research studies. Despite the potential benefits of hospice, many studies have noted lower levels of utilization among African Americans. The goal of this literature review was to determine whether this disparity exists within this population of patients with cancer. The largest studies focusing on multiple cancers found lower hospice use among African American patients with cancer. Disparities also existed after entry into hospice. Age, gender, geographic location, preference for aggressive care, and knowledge of hospice influenced hospice use by these patients. Since African American patients with cancer evidently use hospice at a lower rate, future studies should explore potential barriers to participation by this patient population and methods to remove these obstacles.

End-of-life care for lung cancer patients in the United States and Ontario

BACKGROUND

Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems.

METHODS

We identified care for non-small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999-2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)-Medicare data (N = 13,533) and the Ontario Cancer Registry (N = 8100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. We estimated rates per person-months (PM) for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided.

RESULTS

Rates of chemotherapy use were statistically significantly higher for SEER-Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER-Medicare, 33.2 patients per 100 PM vs Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI = 18.3 to 29.1 per 100 PM, P < .001; longer-term survivors at 5 months before death: SEER-Medicare, 24.4 patients per 100 PM vs Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI = 7.7 to 12.1 per 100 PM, P <. 001). During the last 30 days of life, fewer SEER-Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI = 22.9 to 34.4 per 100 PM, P <. 001; longer-term survivors, 44.1 vs 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI = 18.5 to 27.5 per 100 PM, P < .001).

CONCLUSIONS

NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns.

Characterizing care of hospice patients in the hospital setting

BACKGROUND

One measure of quality hospice care is minimization of hospitalization. Few studies have explored reasons for hospitalization and characteristics of care received by hospice patients in the hospital.

OBJECTIVES

To characterize the experience of hospice patients in the hospital and determine factors associated with high intensiveness of care.

DESIGN

Retrospective review of patient medical records in the Mayo Hospice Program in 2007.

RESULTS

Of 263 hospice patients, 17% were hospitalized in 2007. Of those hospitalized, 42% percent died in the hospital. Average length of stay was 4 days. Almost half were admitted through the emergency department. Common reasons for admission included delirium, pain, and falls. Most patients (52%) received care of a moderate level of intensity, with 18% receiving the most intensive level of care. Receiving care of high intensity was associated with emergency department admission. Charges to patient accounts averaged over $9,000 per stay. Concordance of care in the hospital to preexisting patient goals was high, but could not be determined in 39% of cases due to lack of documentation of patient goals.

CONCLUSIONS

Hospitalization of hospice patients is costly to the health care system. Most care was of low or moderate intensiveness. Quality improvements focusing on concise communication of patient goals and prevention of pain, delirium, and falls have the potential for the greatest impact on reducing hospitalizations and minimizing care that is discordant with patient goals.

Spirituality and end-of-life care in disadvantaged men dying of prostate cancer

Purpose

Despite the positive influence of spiritual coping on the acceptance of a cancer diagnosis, higher spirituality is associated with receipt of more high intensity care at the end of life. The purpose of our study was to assess the association between spirituality and type of end-of-life care received by disadvantaged men with prostate cancer.

Methods

We studied low-income, uninsured men in IMPACT, a state-funded public assistance program, who had died since its inception in 2001. Of the 60 men who died, we included the 35 who completed a spirituality questionnaire at program enrollment. We abstracted sociodemographic and clinical information as well as treatment within IMPACT, including zolendroic acid, chemotherapy, hospice use, and palliative radiation therapy. We measured spirituality with the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being questionnaire (FACIT-Sp) and compared end-of-life care received between subjects with low and high FACIT-Sp scores using chi-squared analyses.

Results

A higher proportion of men with high (33%) versus low (13%) spirituality scores enrolled in hospice, although our analysis was not adequately powered to demonstrate statistical significance. Likewise, we saw a trend toward increased receipt of palliative radiation among those with higher spirituality (37% vs. 25%, P = 0.69). The differences in end-of-life care received among those with low and high spirituality varied little by the FACIT-Sp peace and faith subscales.

Conclusions

End-of-life care was similar between men with lower and higher spirituality. Men with higher spirituality trended toward greater hospice use, suggesting that they redirected the focus of their care from curative to palliative goals.

Characteristics of the last hospital stay in terminal patients at an acute care hospital in Colombia

In Colombia, most palliative care is provided in acute care hospitals. In those settings, a palliative care approach could be limited because of a disease-oriented approach instead of patient-centered care.

PURPOSE

To know the framework of a typical Colombian university hospital that provides palliative care services.

MATERIAL AND METHODS

In a retrospective manner, the medical records of deceased patients during 2006 were revisited.

RESULTS

Most patients were not treated by palliative care specialists, so curative-oriented treatment were common among these patients.

CONCLUSION

In acute hospitals, palliative care teams should participate in the care of patients at the start of treatment.

Trends in healthcare utilization among older Americans with colorectal cancer: a retrospective database analysis

Background

Analyses of utilization trends (cost drivers) allow us to understand changes in colorectal cancer (CRC) costs over time, better predict future costs, identify changes in the use of specific types of care (eg, hospice), and provide inputs for cost-effectiveness models. This retrospective cohort study evaluated healthcare resource use among US Medicare beneficiaries diagnosed with CRC between 1992 and 2002.

Methods

Cohorts included patients aged 66+ newly diagnosed with adenocarcinoma of the colon (n = 52,371) or rectum (n = 18,619) between 1992 and 2002 and matched patients from the general Medicare population, followed until death or December 31, 2005. Demographic and clinical characteristics were evaluated by cancer subsite. Resource use, including the percentage that used each type of resource, number of hospitalizations, and number of hospital and skilled nursing facility days, was evaluated by stage and subsite. The number of office, outpatient, and inpatient visits per person-year was calculated for each cohort, and was described by year of service, subsite, and treatment phase. Hospice use rates in the last year of life were calculated by year of service, stage, and subsite for CRC patients who died of CRC.

Results

CRC patients (mean age: 77.3 years; 44.9% male) used more resources than controls in every category (P < .001), with the largest differences seen in hospital days and home health use. Most resource use (except hospice) remained relatively steady over time. The initial phase was the most resource intense in terms of office and outpatient visits. Hospice use among patients who died of CRC increased from 20.0% in 1992 to 70.5% in 2004, and age-related differences appear to have evened out in later years.

Conclusion

Use of hospice care among CRC decedents increased substantially over the study period, while other resource use remained generally steady. Our findings may be useful for understanding CRC cost drivers, tracking trends, and forecasting resource needs for CRC patients in the future.

Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting

BACKGROUND

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program was designed to ensure the full range of patient treatment preferences are honored throughout the health care system. Data are lacking about the use of POLST in the hospice setting.

OBJECTIVE

To assess use of the POLST by hospice programs, attitudes of hospice personnel toward POLST, the effect of POLST on the use of life-sustaining treatments, and the types of treatments options selected by hospice patients.

DESIGN

A telephone survey was conducted of all hospice programs in three states (Oregon, Wisconsin, and West Virginia) to assess POLST use. Staff at hospices reporting POLST use (n = 71) were asked additional questions about their attitudes toward the POLST. Chart reviews were conducted at a subsample of POLST-using programs in Oregon (n = 8), West Virginia (n = 5), and Wisconsin (n = 2).

RESULTS

The POLST is used widely in hospices in Oregon (100%) and West Virginia (85%) but only regionally in Wisconsin (6%). A majority of hospice staff interviewed believe the POLST is useful at preventing unwanted resuscitation (97%) and at initiating conversations about treatment preferences (96%). Preferences for treatment limitations were respected in 98% of cases and no one received unwanted cardiopulmonary resuscitation (CPR), intubation, intensive care, or feeding tubes. A majority of hospice patients (78%) with do-not-resuscitate (DNR) orders wanted more than the lowest level of treatment in at least one other category such as antibiotics or hospitalization.

CONCLUSIONS

The POLST is viewed by hospice personnel as useful, helpful, and reliable. It is effective at ensuring preferences for limitations are honored. When given a choice, most hospice patients want the option for more aggressive treatments in selected situations.

Utilisation of specialist care in patients with incurable rectal cancer. a population-based study from Western Norway

INTRODUCTION

About 25% of patients with rectal cancer have incurable disease at the time of diagnosis. In the current study from Western Norway (population of 981 000) we focused on the utilisation of specialist care in patients with primarily incurable rectal cancer.

PATIENTS AND METHODS

Between 1997 and 2002, 1 167 patients were diagnosed with rectal cancer, of whom 297 (25%) had incurable disease, according to consecutive and prospective reporting to the Norwegian Colorectal Cancer Registry. Consumption of specialist care facilities was studied with regard to outpatient contacts, hospital admissions, and various treatment modalities. Data were analysed with regard to age, sex, marital status, type of residence, and geographical access to hospital facilities. Data were available for 287 patients (97%).

RESULTS

The median age was 77 years. Elderly patients (>77 years) more often lived in nursing homes without a spouse. About 60% of the patients were treated with major surgery, chemotherapy or radiotherapy, either alone or in combination. Of those who did not receive such treatment, 87% were elderly. Oncological treatment, either alone or combined with surgery, predicted increased hospital admissions and outpatient contacts. Age >77 years predicted fewer hospital admissions. Survival varied statistically significantly with the various treatment modalities, and was highest for major resections combined with oncological treatment. The majority of the patients living at home died in hospitals (54%) and only 26% died in their homes, while two-thirds of residents of nursing homes died there.

DISCUSSION

Patients with primary incurable rectal cancer are heterogeneous with regard to their needs of treatment. While younger patients receive extensive tumour-related treatment, elderly patients are most commonly treated according to their symptoms. Prospective studies of the effect of various treatment options on the ease of symptoms and improved quality of life in unselected populations are needed.

Causes of death at autopsy in an inpatient hospice program

BACKGROUND

Although postmortem examination has been reported in a variety of settings and diseases, the medical literature only makes sparse mention of postmortem findings regarding the manner of death in terminally ill patients receiving palliative care. We sought to identify causes of death in an inpatient hospice program as determined by autopsy.

METHODS

A retrospective chart review of all deaths from January 1998 through June 2000 of the inpatient hospice unit at Audie L. Murphy Veterans Affairs Hospital in San Antonio, Texas, was conducted. Autopsies were routinely offered to survivors of all deceased patients during this period. Basic demographic and clinical characteristics were collected for all patients, and pathologic reports were reviewed.

RESULTS

Forty-eight autopsies were conducted out of 260 deaths in the unit (18%). Patients who had autopsies were similar to nonautopsied patients in age, gender, length of stay, presence of cancer and whether this cancer was treated or not. Nonhispanic white patients were more likely to receive an autopsy and African American patients were less likely to receive one (p = 0.027). Most deaths were directly or indirectly related to the primary diagnosis. Pneumonia was present in 79% of all patients (n = 38), and appeared to be the major cause of death in 44% of patients (n = 21). Other deaths were determined to be due to cancer's direct effects, sepsis, ischemic heart disease, hepatic or renal failure, obstructive uropathy, subdural hemorrhage, pulmonary embolism, hypercalcemia and endocarditis.

CONCLUSION

Pneumonia is the most frequent cause of death in patients in this inpatient hospice program.

Hospital stay frequency and duration of patients with advanced cancer diseases ? differences between the most frequent tumour diagnoses: a secondary data analysis

The differences in the number and duration of hospital stays of cancer patients in an advanced stage of disease were to be examined with regard to the most frequent cancer diagnoses. Therefore, routinely compiled data of the largest health insurance company in the State of Lower Saxony, Germany, were analysed. Patients with lung, colon, breast and prostate cancer were included, who died in the year of 2004. The parameters of frequency (case numbers) and duration (days) of inpatient hospital stays were examined for the 5-year period of 2000-2004, with special focus on the years 2003/2004. 355 patients were included. On average, the number of inpatient hospital stays amounted to 2.7 cases and 29 days per patient. 87.5% of the hospital stays within the study period occurred in 2003/2004. The patient groups differed significantly both in the average number of cases and in the duration of hospital stays (Kruskal-Wallis test: P<0001), whereby patients with lung cancer underwent inpatient hospital treatment most frequently (3.3 times), and for the longest periods (35 days). This study shows that patients in an advanced stage of lung cancer are a particular important target group for reducing hospitalization at the end of life. They should receive special attention when structures of palliative care are extended.

The aggressiveness of cancer care in the last three months of life: a retrospective single centre analysis

BACKGROUND

There is concern that terminally ill cancer patients are over treated with chemotherapy, even when such treatment is unlikely to palliate symptoms. The study objective was to evaluate the use of chemotherapy in the last three months of life in a cohort of adult patients with advanced solid tumours.

METHODS

All adult patients with solid tumours who died in our hospital in 2003 and received chemotherapy for advanced cancer, were included. Detailed data concerning chemotherapy and toxicity, in the last three months of life, were collected from patients' clinical charts.

RESULTS

A total of 319 patients were included. Median age was 61 years. Median time from diagnosis of metastatic disease to death was 11 months. The proportion of patients who received chemotherapy in the last three months of life was 66% (n = 211), in the last month 37% and in the last two weeks 21%. Among patients who received chemotherapy in the last three months of life, 50% started a new chemotherapy regimen in this period and 14% in the last month. There was an increased probability of receiving chemotherapy in the last three months of life in younger patients and in patients with breast, ovarian and pancreatic carcinomas.

CONCLUSION

There was a large proportion of patients who received chemotherapy in the last three months of life, including initiation of a new regimen within the last 30 days. Thus, further study is needed to evaluate if such aggressive attitude results in better palliation of symptoms at the end of life.

Is there no place like home? Caregivers recall reasons for and experience upon transfer from home hospice to inpatient facilities

OBJECTIVE

To describe caregivers' reasons for transfer from home hospice to inpatient facilities, preferences for site of care and death, and their experiences during these transfers.

DESIGN

Retrospective qualitative analysis of interviews with caregivers of deceased hospice patients who had undergone transfer.

SETTING

A university-affiliated community hospice provider.

SUBJECTS

Caregivers of deceased hospice patients who transferred to an acute care hospital, a freestanding inpatient hospice facility, or a nursing home while enrolled in hospice and died between January 2003 and February 2004.

MEASUREMENTS

A semistructured interview protocol was developed and used for all interviews. Interviews were coded for reasons for transfer, preferences for site of care and death, and experience upon transfer using a grounded theory approach.

RESULTS

Patients transferred because of an acute medical event, an uncontrolled symptom, imminent death, or inability to provide needed care safely at home. Although all caregivers expressed a strong preference for care at home, other concerns such as pain and symptom control, safety, and quality and quantity of life became more important with time. We found significant variation in specific preferences regarding care and site of death. Satisfaction with care at the transfer facilities was determined by clarifying goals of care, following treatment preferences, providing personalized care, and the patient's environment.

CONCLUSIONS

Hospice patients usually transfer to facilities to accomplish goals consistent with good end-of-life care. We can improve their experience by treating patients and their caregivers as unique individuals, exploring and respecting treatment preferences, and creating a pleasant physical environment.

Dispelling Myths About Palliative Care and Older Adults

OBJECTIVES

To explore the myths about palliative care and older adults with cancer.

DATA SOURCES

Research literature and review articles.

CONCLUSION

Several myths about older adults exist: older adults are the same as younger adults, older adults are all the same, and optimizing function and quality of life are not important outcomes. Little research has focused on older adults receiving palliative care and their families.

IMPLICATIONS FOR NURSING PRACTICE

The Oncology Nursing Society and Geriatric Oncology Consortium published the Joint Position Statement on Cancer Care in Older Adults acknowledging the unique needs of older adults with cancer. Application of this statement may be helpful in guiding inquiry and practice in the care for older adults receiving palliative care.

A national framework for cancer surveillance in the United States

Enhancements to cancer surveillance systems are needed for meeting increased demands for data and for developing effective program planning, evaluation, and research on cancer prevention and control. Representatives from the American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, National Cancer Registrars Association, and North American Association of Central Cancer Registries have worked together on the National Coordinating Council for Cancer Surveillance to develop a national framework for cancer surveillance in the United States. The framework addresses a continuum of disease progression from a healthy state to the end of life and includes primary prevention (factors that increase or decrease cancer occurrence in healthy populations), secondary prevention (screening and diagnosis), and tertiary prevention (factors that affect treatment, survival, quality of life, and palliative care). The framework also addresses cross-cutting information needs, including better data to monitor disparities by measures of socioeconomic status, to assess economic costs and benefits of specific interventions for individuals and for society, and to study the relationship between disease and individual biologic factors, social policies, and the environment. Implementation of the framework will require long-term, extensive coordination and cooperation among these major cancer surveillance organizations.