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Kim H(D, Duberstein PR, Lin H, Wu B, Zafar A, Jarrín OF. Home Health Care and Hospice Use Among Medicare Beneficiaries With and Without a Diagnosis of Dementia. J Palliat Med 2024; 27:776-783. [PMID: 38359388 PMCID: PMC11310562 DOI: 10.1089/jpm.2023.0583] [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] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Background: Home health care is a core benefit of Medicare and Medicaid insurance programs and includes services to improve health, maintain health, or slow health decline. Objective: To examine the relationship between home health care use during the last three years of life and hospice use in the last six months of life among Medicare beneficiaries with and without dementia. Design: Nationally representative retrospective cohort study. Setting/Subjects: Medicare beneficiaries with at least three years of continuous enrollment who died in 2019 in the United States (n = 2,169,422). Measurements: The primary outcome was hospice use, and the secondary outcome was hospice duration. The independent variable was a composite of the presence and timing of home health care initiation during the last three years of life. Results: Home health care was used by 46.4% of Medicare beneficiaries and hospice care was used by 53.1% of beneficiaries, with 28.3% using both. Compared with beneficiaries who did not use home health care, those who started home health care before the last year of life (odds ratio [OR] = 1.57, 95% confidence interval [CI] = 1.56-1.58) or during the last year of life (OR = 1.75, 95% CI = 1.74-1.77) were more likely to use hospice. The effects were stronger in those without a diagnosis of dementia (OR = 1.92, 95% CI = 1.90-1.94) compared with those without a dementia diagnosis (OR = 1.34, 95% CI = 1.32-1.35) who started home health in the final year of life. Conclusions: Receiving home health care in the final years of life is associated with increased hospice use at the end-of-life in Medicare beneficiaries with and without a dementia diagnosis.
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Affiliation(s)
| | - Paul R. Duberstein
- School of Public Health, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Haiqun Lin
- School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Bei Wu
- Rory Meyers College of Nursing, New York, New York, USA
- NYU Aging Incubator, New York University, New York, New York, USA
| | - Anum Zafar
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Olga F. Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
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Hooker ER, Chapa J, Vranas KC, Niederhausen M, Goodlin SJ, Slatore CG, Sullivan DR. Intersection of Palliative Care and Hospice Use Among Patients With Advanced Lung Cancer. J Palliat Med 2023; 26:1474-1481. [PMID: 37262128 PMCID: PMC10658737 DOI: 10.1089/jpm.2023.0040] [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] [Accepted: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
Background: Hospice and palliative care (PC) are important components of lung cancer care and independently provide benefits to patients and their families. Objective: To better understand the relationship between hospice and PC and factors that influence this relationship. Methods: A retrospective cohort study of patients diagnosed with advanced lung cancer (stage IIIB/IV) within the U.S. Veterans Health Administration (VA) from 2007 to 2013 with follow-up through 2017 (n = 22,907). Mixed logistic regression models with a random effect for site, adjustment for patient variables, and propensity score weighting were used to examine whether the association between PC and hospice use varied by U.S. region and PC team characteristics. Results: Overall, 57% of patients with lung cancer received PC, 69% received hospice, and 16% received neither. Of those who received hospice, 60% were already enrolled in PC. Patients who received PC had higher odds of hospice enrollment than patients who did not receive PC (adjusted odds ratio = 3.25, 95% confidence interval: 2.43-4.36). There were regional differences among patients who received PC; the predicted probability of hospice enrollment was 85% and 73% in the Southeast and Northeast, respectively. PC team and facility characteristics influenced hospice use in addition to PC; teams with the shortest duration of existence, with formal team training, and at lower hospital complexity were more likely to use hospice (all p < 0.05). Conclusions: Among patients with advanced lung cancer, PC was associated with hospice enrollment. However, this relationship varied by geographic region, and PC team and facility characteristics. Our findings suggest that regional PC resource availability may contribute to substitution effects between PC and hospice for end-of-life care.
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Affiliation(s)
- Elizabeth R. Hooker
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
| | - Joaquin Chapa
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Portland Veterans Affairs Medical Center, Divisions of Pulmonary Critical Care Medicine, Portland, Oregon, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health and Science University—Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Sarah J. Goodlin
- Geriatrics Section, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Donald R. Sullivan
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
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Wang X(J, Teno JM, Rosendaal N, Smith L, Thomas KS, Dosa D, Gozalo PL, Carder P, Belanger E. State Regulations and Assisted Living Residents' Potentially Burdensome Transitions at the End of Life. J Palliat Med 2023; 26:757-767. [PMID: 36580545 PMCID: PMC10278021 DOI: 10.1089/jpm.2022.0360] [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] [Accepted: 11/04/2022] [Indexed: 12/31/2022] Open
Abstract
Background: Potentially burdensome transitions at the end of life (e.g., repeated hospitalizations toward the end of life and/or health care transitions in the last three days of life) are common among residential care/assisted living (RC/AL) residents, and are associated with lower quality of end-of-life care reported by bereaved family members. We examined the association between state RC/AL regulations relevant to end-of-life care delivery and the likelihood of residents experiencing potentially burdensome transitions. Methods: Retrospective cohort study combining RC/AL registries of states' regulations with Medicare claims data for residents in large RC/ALs (i.e., 25+ beds) in the United States on the 120th day before death (N = 129,153), 2017-2019. Independent variables were state RC/AL regulations relevant to end-of-life care, including third-party services, staffing, and medication management. Analyses included: (1) separate logistic regression models for each RC/AL regulation, adjusting for sociodemographic covariates; (2) separate logistic regression models with a Medicare fee-for-service (FFS) subgroup to control for comorbidities, and (3) multivariable regression analysis, including all regulations in both the overall sample and the Medicare FFS subgroup. Results: We found a lack of associations between potentially burdensome transitions and regulations regarding third-party services and staffing. There were small associations found between regulations related to medication management (i.e., requiring regular medication reviews, permitting direct care workers for injections, requiring/not requiring licensed nursing staff for injections) and potentially burdensome transitions. Conclusions: In this cross-sectional study, the associations of RC/AL regulations with potentially burdensome transitions were either small or not statistically significant, calling for more studies to explain the wide variation observed in end-of-life outcomes among RC/AL residents.
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Affiliation(s)
- Xiao (Joyce) Wang
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Joan M. Teno
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Nicole Rosendaal
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Lindsey Smith
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kali S. Thomas
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - David Dosa
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Pedro L. Gozalo
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Paula Carder
- Institute on Aging, Portland State University, Portland, Oregon, USA
- School of Public Health, Oregon Health and Science University - Portland State University, Portland, Oregon, USA
| | - Emmanuelle Belanger
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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Hunt LJ, Gan S, Boscardin WJ, Yaffe K, Ritchie CS, Aldridge MD, Smith AK. A national study of disenrollment from hospice among people with dementia. J Am Geriatr Soc 2022; 70:2858-2870. [PMID: 35670444 PMCID: PMC9588572 DOI: 10.1111/jgs.17912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with dementia (PWD) are at high risk for hospice disenrollment, yet little is known about patterns of disenrollment among the growing number of hospice enrollees with dementia. DESIGN Retrospective, observational cohort study of 100% Medicare beneficiaries with dementia aged 65 and older enrolled in the Medicare Hospice Benefit between July 2012 and December 2017. Outcome measures included hospice-initiated disenrollment for patients whose rate of decline ceased to meet the Medicare hospice eligibility guideline of "expected death within 6 months" (extended prognosis) and patient-initiated disenrollment (revocation). Hospice, regional, and patient risk factors and variation were assessed with multilevel mixed-effects logistic regression models. RESULTS Among 867,695 hospice enrollees with dementia, 70,945 (8.2%) were disenrolled due to extended prognosis and 43,133 (5.0%) revoked within 1-year of their index admission. There was substantial variation in hospice provider disenrollment due to extended prognosis (10th-90th percentile 4.5%-14.6%, adjusted median odds ratio (MOR) 1.86, 95% confidence interval (CI) 1.82, 1.91) and revocation (10th-90th percentile 2.5%-10.1%, MOR 2.09, 95% CI 2.03, 2.14). Among hospital referral regions (HRR), there was more variation in revocation (10th-90th percentile 3.5%-7.6%, MOR 1.4, 95% CI 1.34, 1.47) than extended prognosis (10th-90th percentile 7.0%-9.5%, MOR 1.23, 95% CI 1.18, 1.27), with much higher revocation rates noted in HRRs located in the Southeast and Southern California. A number of patient and hospice characteristics were associated with higher odds of both types of disenrollment (younger age, female sex, minoritized race and ethnicity, Medicaid dual eligibility, Medicare Part C enrollment), while some were associated with revocation only (more comorbidities, newer, smaller, and for-profit hospices). CONCLUSIONS In this nationally representative study of hospice enrollees with dementia, hospice disenrollment varied by type of hospice, geographic region, and patient characteristics including age, sex, race, and ethnicity. These findings raise important questions about whether and how the Medicare Hospice Benefit could be adapted to reduce disparities and better support PWD.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco
- Global Brain Health Institute, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, CA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kristine Yaffe
- Department of Psychiatry, University of California, San Francisco
- Department of Neurology, University of California, San Francisco
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, MA
- Mongan Institute for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
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Sullivan SS, Bo W, Li CS, Xu W, Chang YP. Predicting Hospice Transitions in Dementia Caregiving Dyads: An Exploratory Machine Learning Approach. Innov Aging 2022; 6:igac051. [PMID: 36452051 PMCID: PMC9701063 DOI: 10.1093/geroni/igac051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 10/19/2023] Open
Abstract
Background and Objectives Hospice programs assist people with serious illness and their caregivers with aging in place, avoiding unnecessary hospitalizations, and remaining at home through the end-of-life. While evidence is emerging of the myriad of factors influencing end-of-life care transitions among persons living with dementia, current research is primarily cross- sectional and does not account for the effect that changes over time have on hospice care uptake, access, and equity within dyads. Research Design and Methods Secondary data analysis linking the National Health and Aging Trends Study to the National Study of Caregiving investigating important social determinants of health and quality-of-life factors of persons living with dementia and their primary caregivers (n = 117) on hospice utilization over 3 years (2015-2018). We employ cutting-edge machine learning approaches (correlation matrix analysis, principal component analysis, random forest [RF], and information gain ratio [IGR]). Results IGR indicators of hospice use include persons living with dementia having diabetes, a regular physician, a good memory rating, not relying on food stamps, not having chewing or swallowing problems, and whether health prevents them from enjoying life (accuracy = 0.685; sensitivity = 0.824; specificity = 0.537; area under the curve (AUC) = 0.743). RF indicates primary caregivers' age, and the person living with dementia's income, census division, number of days help provided by caregiver per month, and whether health prevents them from enjoying life predicts hospice use (accuracy = 0.624; sensitivity = 0.713; specificity = 0.557; AUC = 0.703). Discussion and Implications Our exploratory models create a starting point for the future development of precision health approaches that may be integrated into learning health systems that prompt providers with actionable information about who may benefit from discussions around serious illness goals-for-care. Future work is necessary to investigate those not considered in this study-that is, persons living with dementia who do not use hospice care so additional insights can be gathered around barriers to care.
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Affiliation(s)
| | - Wei Bo
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Chin-Shang Li
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| | - Wenyao Xu
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Yu-Ping Chang
- School of Nursing, University at Buffalo, Buffalo, New York, USA
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Hung P, Cramer LD, Pollack CE, Gross CP, Wang S. Primary care physician continuity, survival, and end-of-life care intensity. Health Serv Res 2022; 57:853-862. [PMID: 34386976 PMCID: PMC9264461 DOI: 10.1111/1475-6773.13869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the associations of primary care physician (PCP) care continuity with cancer-specific survival and end-of-life care intensity. DATA SOURCES Surveillance, epidemiology, and end results linked to Medicare claims data from 2001 to 2015. STUDY DESIGN Cox proportional hazards models with mixed effects and hierarchical generalized logistic models were used to examine the associations of PCP care continuity with cancer-specific survival and end-of-life care intensity, respectively. PCP care continuity, defined as having visited the predominant PCP (who saw the patient most frequently before diagnosis) within 6 months of diagnosis. DATA EXTRACTION METHODS We identified Medicare patients diagnosed at age 66.5-94 years with stage-III or IV poor-prognosis cancer during 2001-2012 and followed them up until 2015. Patients who died within 6 months after diagnosis were excluded. PRINCIPAL FINDINGS Primary study cohort consisted of 85,467 patients (median survival 22 months), 71.7% of whom had PCP care continuity. Patients with PCP care continuity tended to be older, married, nonblack, non-Hispanic, and to have fewer comorbid conditions (p < 0.001 for all). Patients with PCP care continuity had lower cancer-specific mortality (adjusted hazard ratio: 0.93; 95% confidence interval [CI]: 0.91 to 0.95; p = 0.001) than did those without PCP care continuity. Findings of the 2001-2003 cohorts (nearly all of whom died by 2015) show no associations of overall end-of-life care intensity measures with PCP care continuity (adjusted marginal effects: 0.005; 95% CI: -0.016 to 0.026; p = 0.264). CONCLUSIONS Among Medicare beneficiaries with advanced poor-prognosis cancer, PCP continuity was associated with modestly improved survival without raising overall aggressive end-of-life care.
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Affiliation(s)
- Peiyin Hung
- Department of Health Services Policy and ManagementUniversity of South Carolina Arnold School of Public HealthColumbiaSouth CarolinaUSA
| | - Laura D. Cramer
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of MedicineNew HavenConnecticutUSA
| | - Craig E. Pollack
- Division of General Internal MedicineJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Departmental Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Cary P. Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of MedicineNew HavenConnecticutUSA
- Department of Chronic Disease EpidemiologyYale University School of Public HealthNew HavenConnecticutUSA
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Shi‐Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of MedicineNew HavenConnecticutUSA
- Department of Chronic Disease EpidemiologyYale University School of Public HealthNew HavenConnecticutUSA
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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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Cypher M, Axman LM. Determinants of Location of Death: A Secondary Analysis Utilizing Multinomial Logistic Regression. Am J Hosp Palliat Care 2022; 39:1397-1402. [PMID: 35232266 DOI: 10.1177/10499091221077883] [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
STATEMENT OF PROBLEM A discrepancy exists between where people would like to die and what actually occurs. More research about the factors influencing the location of death is required. Sources of Data and Research Design: Multinomial logistic regression was used to examine a sample taken from the fourth round of data collection performed by the National Health and Aging Trends Study conducted in 2014. Conclusions Reached: Census location, age, dementia, and use of hospice were found to have a statistically significant (P < .05) influence on the location of death (P = .000). The results suggest that the use of hospice increased the odds of dying at home (OR = 17.467, CI = 7.43-41.063) and in a nursing home (OR = 34.334, CI = 12.444-94.727) as compared to dying in the hospital. Further research is required on the topic of geographic location and place of death.
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Luo Q, Shi K, Hung P, Wang SY. Associations Between Health Literacy and End-of-Life Care Intensity Among Medicare Beneficiaries. Am J Hosp Palliat Care 2021; 38:626-633. [PMID: 33472379 DOI: 10.1177/1049909120988506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Despite well-documented disparities in end-of-life (EOL) care, little is known about whether patients with low health literacy (LHL) received aggressive EOL care. OBJECTIVE This study examined the association between health literacy (HL) and EOL care intensity among Medicare beneficiaries. METHOD We conducted a retrospective analysis of Medicare fee-for-service decedents who died in July-December, 2011. ZIP-code-level HL scores were estimated from the 2010-2011 Health Literacy Data Map, where a score of 225 or lower was defined as LHL. Aggressive EOL care measures included repeated hospitalizations within the last 30 days of life, no hospice enrollment within the last 6 months of life, in-hospital death, and any of above. Using hierarchical generalized linear models, we examined the association between HL and aggressive EOL care. RESULTS Of 649,556 decedents, the proportion of decedents who received any aggressive EOL care among those in LHL areas was 82.7%, compared to 72.7% in HHL areas. In multivariable analyses, decedents residing in LHL areas, compared to those in HHL areas, had 31% higher odds of aggressive EOL care (adjusted odds ratio [AOR] 1.31; 95% confidence interval [CI]:1.21-1.42), including higher odds of no hospice use (AOR 1.35; 95% CI: 1.27-1.44), repeated hospitalization (AOR 1.07; 95% CI: 1.01-1.14) and in-hospital death (AOR 1.21; 95% CI: 1.13-1.29). CONCLUSION Medicare beneficiaries who resided in LHL areas were likely to receive aggressive EOL care. Tailored efforts to improve HL and facilitate patient-provider communications in LHL areas could reduce EOL care intensity.
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Affiliation(s)
- Qingying Luo
- Department of Chronic Disease Epidemiology, 5755Yale University School of Public Health, New Haven, CT, USA
| | - Kewei Shi
- Department of Chronic Disease Epidemiology, 5755Yale University School of Public Health, New Haven, CT, USA
| | - Peiyin Hung
- Department of Health Services Policy and Management, Arnold School of Public Health, 5755University of South Carolina, SC, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and 5755Yale University School of Medicine, New Haven, CT, USA
| | - Shi-Yi Wang
- Department of Chronic Disease Epidemiology, 5755Yale University School of Public Health, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and 5755Yale University School of Medicine, New Haven, CT, USA
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10
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Hung P, Zahnd WE, Brandt HM, Adams SA, Wang S, Eberth JM. Cervical cancer treatment initiation and survival: The role of residential proximity to cancer care. Gynecol Oncol 2020; 160:219-226. [PMID: 33081985 DOI: 10.1016/j.ygyno.2020.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/06/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine the role of driving time to cancer care facilities on days to cancer treatment initiation and cause-specific survival for cervical cancer patients. METHODS A retrospective cohort analysis of patients diagnosed with invasive cervical cancer during 2001-2016, using South Carolina Central Cancer Registry data linked to vital records. Kaplan-Meier survival curves and Cox proportional hazards models were used to examine the association of driving times to both a patient's nearest and actual cancer treatment initiation facility with cause-specific survival and time to treatment initiation. RESULTS Of 2518 eligible patients, median cause-specific survival was 49 months (interquartile, 17-116) and time to cancer treatment initiation was 21 days (interquartile, 0-40). Compared to patients living within 15 min of the nearest cancer provider, those living more than 30 min away were less likely to receive initial treatment at teaching hospitals, Joint Commission accredited facilities, and/or Commission on Cancer accredited facilities. After controlling for patient, clinical, and provider characteristics, no significant associations existed between driving times to the nearest cancer provider and survival/time to treatment. When examining driving times to treatment initiation (rather than simply nearest) provider, patients who traveled farther than 30 min to their actual providers had delayed initiation of cancer treatment (hazard ratio, 0.81; 95% confidence interval, 0.73-0.90), including surgery (0.82; 95% CI, 0.72-0.92) and radiotherapy (0.82, 95% CI, 0.72-0.94). Traveling farther than 30 min to the first treating provider was not associated with worse cause-specific survival. CONCLUSIONS For cervical cancer patients, driving time to chosen treatment providers, but not to the nearest cancer care provider, was associated with prolonged time to treatment initiation. Neither was associated with survival.
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Affiliation(s)
- Peiyin Hung
- Department of Health Services Policy and Management, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America; Rural and Minority Health Research Center, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America.
| | - Whitney E Zahnd
- Rural and Minority Health Research Center, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America
| | - Heather M Brandt
- Rural and Minority Health Research Center, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America; Department of Health Promotion, Education, and Behavior, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America
| | - Swann A Adams
- Rural and Minority Health Research Center, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America; Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America; Cancer Survivorship Center, College of Nursing, University of South Carolina
| | - Shiyi Wang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, United States of America
| | - Jan M Eberth
- Rural and Minority Health Research Center, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America; Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, SC, United States of America
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11
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Chukwusa E, Yu P, Verne J, Taylor R, Higginson IJ, Wei G. Regional variations in geographic access to inpatient hospices and Place of death: A Population-based study in England, UK. PLoS One 2020; 15:e0231666. [PMID: 32302344 PMCID: PMC7164606 DOI: 10.1371/journal.pone.0231666] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/27/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is much variation in hospice use with respect to geographic factors such as area-based deprivation, location of patient's residence and proximity to services location. However, little is known about how the association between geographic access to inpatient hospice and hospice deaths varies by patients' region of settlement. STUDY AIM To examine regional differences in the association between geographic access to inpatient hospice and hospice deaths. METHODS A regional population-based observational study in England, UK. Records of patients aged ≥ 25 years (n = 123088) who died from non-accidental causes in 2014, were extracted from the Office for National Statistics (ONS) death registry. Our cohort comprised of patients who died at home and in inpatient hospice. Decedents were allocated to each of the nine government office regions of England (London, East Midlands, West Midlands, East, Yorkshire and The Humber, South West, South East, North West and North East) through record linkage with their postcode of usual residence. We defined geographic access as a measure of drive times from patients' residential location to the nearest inpatient hospice. A modified Poisson regression estimated the association between geographic access to hospice, comparing hospice deaths (1) versus home deaths (0). We developed nine regional specific models and adjusted for regional differences in patient's clinical & socio-demographic characteristics. The strength of the association was estimated with adjusted Proportional Ratios (aPRs). FINDINGS The percentage of deaths varied across regions (home: 86.7% in the North East to 73.0% in the South East; hospice: 13.3% in the North East to 27.0% in the South East). We found wide differences in geographic access to inpatient hospices across regions. Median drive times to hospice varied from 4.6 minutes in London to 25.9 minutes in the North East. We found a dose-response association in the East: (aPRs: 0.22-0.78); East Midlands: (aPRs: 0.33-0.63); North East (aPRs: 0.19-0.87); North West (aPRs: 0.69-0.88); South West (aPRs: 0.56-0.89) and West Midlands (aPRs: 0.28-0.92) indicating that decedents who lived further away from hospices locations (≥ 10 minutes) were less likely to die in a hospice. CONCLUSION The clear dose-response associations in six regions underscore the importance of regional specific initiatives to improve and optimise access to hospices. Commissioners and policymakers need to do more to ensure that home death is not due to limited geographic access to inpatient hospice care.
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Affiliation(s)
- Emeka Chukwusa
- Department of Palliative Care, Policy and Rehabilitation, King’s College London, Cicely Saunders Institute, London, United Kingdom
| | - Peihan Yu
- Department of Palliative Care, Policy and Rehabilitation, King’s College London, Cicely Saunders Institute, London, United Kingdom
| | - Julia Verne
- Knowledge & Intelligence (South West), National End of Life Care Intelligence Network, Public Health England, Bristol, United Kingdom
| | - Ros Taylor
- Royal Marsden NHS Hospital Trust, London, United Kingdom
- Hospice UK, London, United Kingdom
| | - Irene J. Higginson
- Department of Palliative Care, Policy and Rehabilitation, King’s College London, Cicely Saunders Institute, London, United Kingdom
| | - Gao Wei
- Department of Palliative Care, Policy and Rehabilitation, King’s College London, Cicely Saunders Institute, London, United Kingdom
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12
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Daugaard C, Neergaard MA, Vestergaard AHS, Nielsen MK, Goodman DC, Johnsen SP. Geographical variation in palliative cancer care in a tax-based healthcare system: drug reimbursement in Denmark. Eur J Public Health 2020; 30:223-229. [PMID: 31747006 DOI: 10.1093/eurpub/ckz211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In Denmark, a tax-based universal healthcare setting, drug reimbursement for terminal illness (DRTI) should be equally accessible for all terminally ill patients. Examining DRTI status by regions provides new knowledge on inequality in palliative care provision and associated factors. This study aims to investigate geographical variation in DRTI among terminally ill cancer patients. METHODS We linked socioeconomic and medical data from 135 819 Danish cancer decedents in the period 2007-15 to regional healthcare characteristics. We analyzed associations between region of residence and DRTI. Prevalence ratios (PR) for DRTI were estimated using generalized linear models adjusted for patient factors (age, gender, comorbidity and socioeconomic profile) and multilevel models adjusted for both patient factors and regional healthcare capacity (patients per general practitioner, numbers of hospital and hospice beds). RESULTS DRTI allocation differed substantially across Danish regions. Healthcare capacity was associated with DRTI with a higher probability of DRTI among patients living in regions with high compared with low hospice bed supply (PR 1.13, 95% CI 1.10-1.17). Also, the fully adjusted PR of DRTI was 0.94 (95% CI 0.91-0.96) when comparing high with low number of hospital beds. When controlled for both patient and regional healthcare characteristics, the PR for DRTI was 1.17 (95% CI 1.14-1.21) for patients living in the Central Denmark Region compared with the Capital Region. CONCLUSION DRTI status varied across regions in Denmark. The variation was associated with the distribution of healthcare resources. These findings highlight difficulties in ensuring equal access to palliative care even in a universal healthcare system.
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Affiliation(s)
- Cecilie Daugaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Mette Kjærgaard Nielsen
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - David C Goodman
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Saphire ML, Prsic EH, Canavan ME, Wang SYJ, Presley CJ, Davidoff AJ. Patterns of Symptom Management Medication Receipt at End-of-Life Among Medicare Beneficiaries With Lung Cancer. J Pain Symptom Manage 2020; 59:767-777.e1. [PMID: 31778783 PMCID: PMC7338983 DOI: 10.1016/j.jpainsymman.2019.11.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/26/2022]
Abstract
CONTEXT Older adults with advanced lung cancer experience high symptom burden at end of life (EOL), yet hospice enrollment often happens late or not at all. Receipt of medications to manage symptoms in the outpatient setting, outside the Medicare hospice benefit, has not been described. OBJECTIVES We examined patterns of symptom management medication receipt at EOL for older adults who died of lung cancer. METHODS This retrospective cohort used the Surveillance, Epidemiology, and End Results-Medicare database to identify decedents diagnosed with lung cancer at age 67 years and older between January 2008 and December 2013 who survived six months and greater after diagnosis. Using Medicare Part B and D claims, we identified monthly receipt of outpatient medications for symptomatic management of pain, emotional distress, fatigue, dyspnea, anorexia, and nausea/vomiting. Multivariable logistic regression estimated associations between medication receipt and patient demographic characteristics, comorbidity, and concurrent therapy. RESULTS Of the 16,246 included patients, large proportions received medications for dyspnea (70.7%), pain (62.5%), and emotional distress (49.4%), with lower prevalence for other symptoms. Medication receipt increased from six months to one month before death. Women and dual Medicaid enrolled were more likely to receive medications for pain, emotional distress, dyspnea, and nausea/vomiting. Receipt of symptom management medications decreased with increasing age and racial/ethnical minorities. CONCLUSION Symptom management medication receipt was common and increasing toward EOL. Lower use by males, older adults, and nonwhites may reflect poor access or poor patient-provider communication. Further research is needed to understand these patterns and assess adequacy of symptom management in the outpatient setting.
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Affiliation(s)
- Maureen L Saphire
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | | | - Maureen E Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA
| | - Shi-Yi J Wang
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA; Yale School of Public Health, New Haven, Connecticut, USA; Yale Cancer Center, New Haven, Connecticut, USA
| | - Carolyn J Presley
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA; Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA
| | - Amy J Davidoff
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA; Yale School of Public Health, New Haven, Connecticut, USA; Yale Cancer Center, New Haven, Connecticut, USA.
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14
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Gerson SM, Preston NJ, Bingley AF. Medical Aid in Dying, Hastened Death, and Suicide: A Qualitative Study of Hospice Professionals' Experiences From Washington State. J Pain Symptom Manage 2020; 59:679-686.e1. [PMID: 31678464 DOI: 10.1016/j.jpainsymman.2019.10.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/11/2019] [Accepted: 10/23/2019] [Indexed: 11/22/2022]
Abstract
CONTEXT Many jurisdictions around the world have passed medical aid in dying (MAID) laws allowing competent eligible individuals facing life-limiting illness to self-administer prescribed medication to control timing of death. These laws do not prevent some patients who are receiving hospice services from dying by suicide without assistance. OBJECTIVES To explore hospice professionals' experiences of patients who die by suicide or intentionally hasten death with or without legal assistance in an area where there is legalized MAID. METHODS Semistructured in-depth qualitative interviews were conducted with 21 home hospice professionals (seven nurses, seven social workers, four physicians, and three chaplains). Thematic analysis was carried out to analyze the data. RESULTS Three primary themes were identified from the interviews: 1) dealing with and differentiating between hastened death and suicide, 2) MAID access and affordability, and 3) how patients have hastened their own deaths. Analysis of these data indicates that there are some patients receiving hospice services who die by suicide because they are not eligible for, have no knowledge of, or lack access to legalized MAID. Hospice professionals do not consistently identify patients' deaths as suicide when they are self-inflicted and sometimes view these deaths as justified. CONCLUSION Suicide and hastened deaths continue to be an unexamined cause of death for some home hospice patients who may have requested MAID. Open communication and increased education and training is needed for palliative care professionals regarding legal options, issues of suicide, and suicide assessment.
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Affiliation(s)
- Sheri Mila Gerson
- Division of Health Research, International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom; School of Interdisciplinary Studies, University of Glasgow, Dumfries, Scotland, United Kingdom.
| | - Nancy J Preston
- Division of Health Research, International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
| | - Amanda F Bingley
- Division of Health Research, International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
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15
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Cagle JG, Lee J, Ornstein KA, Guralnik JM. Hospice Utilization in the United States: A Prospective Cohort Study Comparing Cancer and Noncancer Deaths. J Am Geriatr Soc 2019; 68:783-793. [DOI: 10.1111/jgs.16294] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/24/2019] [Accepted: 11/20/2019] [Indexed: 01/18/2023]
Affiliation(s)
- John G. Cagle
- University of Maryland School of Social Work Baltimore Maryland
| | - Joonyup Lee
- University of Maryland School of Social Work Baltimore Maryland
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16
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Dover LL, Dulaney CR, Williams CP, Fiveash JB, Jackson BE, Warren PP, Kvale EA, Boggs DH, Rocque GB. Hospice care, cancer-directed therapy, and Medicare expenditures among older patients dying with malignant brain tumors. Neuro Oncol 2019; 20:986-993. [PMID: 29156054 DOI: 10.1093/neuonc/nox220] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background End-of-life care for older adults with malignant brain tumors is poorly understood. The purpose of this study is to quantify end-of-life utilization of hospice care, cancer-directed therapy, and associated Medicare expenditures among older adults with malignant brain tumors. Methods This retrospective cohort study included deceased Medicare beneficiaries age ≥65 with primary malignant brain tumor (PMBT) or secondary MBT (SMBT) receiving care within a southeastern cancer community network including academic and community hospitals from 2012-2015. Utilization of hospice and cancer-directed therapy and total Medicare expenditures in the last 30 days of life were calculated using generalized linear and mixed effect models, respectively. Results Late (1-3 days prior to death) or no hospice care was received by 24% of PMBT (n = 383) and 32% of SMBT (n = 940) patients. SMBT patients received late hospice care more frequently than PMBT patients (10% vs 5%, P = 0.002). Cancer-directed therapy was administered to 18% of patients with PMBT versus 25% with SMBT (P = 0.003). Nonwhite race, male sex, and receipt of any hospital-based care in the final 30 days of life were associated with increased risk of late or no hospice care. The average decrease in Medicare expenditures associated with hospice utilization for patients with PMBT was $-12,138 (95% CI: $-18,065 to $-6210) and with SMBT was $-1,508 (95% CI: $-3,613 to $598). Conclusions Receiving late or no hospice care was common among older patients with malignant brain tumors and was significantly associated with increased total Medicare expenditures for patients with PMBT.
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Affiliation(s)
- Laura L Dover
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Caleb R Dulaney
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Courtney P Williams
- Department of Medicine, Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bradford E Jackson
- Center for Outcomes Research, John Peter Smith Hospital Health Network, Fort Worth, Texas
| | - Paula P Warren
- Department of Neurology, Division of Neuro-Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth A Kvale
- Department of Medicine, Division of Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Birmingham VA Medical Center, Birmingham Alabama
| | - D Hunter Boggs
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gabrielle B Rocque
- Department of Medicine, Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Medicine, Division of Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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17
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Turkman YE, Williams CP, Jackson BE, Dionne-Odom JN, Taylor R, Ejem D, Kvale E, Pisu M, Bakitas M, Rocque GB. Disparities in Hospice Utilization for Older Cancer Patients Living in the Deep South. J Pain Symptom Manage 2019; 58:86-91. [PMID: 30981781 PMCID: PMC6592766 DOI: 10.1016/j.jpainsymman.2019.04.006] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/05/2019] [Accepted: 04/08/2019] [Indexed: 02/07/2023]
Abstract
CONTEXT Hospice utilization is an end-of-life quality indicator. The Deep South has known disparities in palliative care that may affect hospice utilization. OBJECTIVES The objective of this study was to evaluate the association among Deep South patient and hospital characteristics and hospice utilization. METHODS This retrospective cohort study evaluated patient and hospital characteristics associated with hospice among Medicare cancer decedents aged ≥65 years in 12 southeastern cancer centers between 2012 and 2015. We examined patient-level characteristics (age, race, gender, cancer type, and received patient navigation) and hospital-level characteristics (board-certified palliative physician, inpatient palliative care beds, and hospice ownership). Outcomes included hospice (within 90 vs. three days of death). Relative risks (RRs) and 95% CIs evaluated the association between patient- and hospital-level characteristics and hospice outcomes using generalized log-linear models with Poisson distribution and robust variance estimates. RESULTS Of 12,725 cancer decedents, 4142 (33%) did not utilize hospice. "No hospice" was associated with nonwhite (RR 1.24, 95% CI 1.17-1.32) and nonnavigated patients (RR 1.17, 95% CI 1.10-1.25), and those at a hospital with inpatient palliative care beds (RR 1.15, 95% CI 1.10-1.21). "Late hospice" (20%; n = 1458) was associated with being male (RR 1.31, 95% CI 1.19-1.44) and seen at a hospital without inpatient palliative care beds (RR 0.82, 95% CI 0.75-0.90). CONCLUSIONS Hospice utilization differed by patient and hospital characteristics. Patients who were nonwhite, and nonnavigated, and hospitals with inpatient palliative care beds, were associated with no hospice. Research should focus on ways to improve hospice utilization in Deep South older cancer patients.
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Affiliation(s)
| | - Courtney P Williams
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - James Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard Taylor
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Elizabeth Kvale
- Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Maria Pisu
- Department of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabrielle B Rocque
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA; Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA; Comprehensive Cancer Center, UAB Medicine, Birmingham, Alabama, USA
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18
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Wang SY, Hsu SH, Aldridge MD, Cherlin E, Bradley E. Racial Differences in Health Care Transitions and Hospice Use at the End of Life. J Palliat Med 2019; 22:619-627. [PMID: 30615546 DOI: 10.1089/jpm.2018.0436] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Although the fragmentation of end-of-life care has been well documented, previous research has not examined racial and ethnic differences in transitions in care and hospice use at the end of life. Design and Subjects: Retrospective cohort study among 649,477 Medicare beneficiaries who died between July 2011 and December 2011. Measurements: Sankey diagrams and heatmaps to visualize the health care transitions across race/ethnic groups. Among hospice enrollees, we examined racial/ethnic differences in hospice use patterns, including length of hospice enrollment and disenrollment rate. Results: The mean number of care transitions within the last six months of life was 2.9 transitions (standard deviation [SD] = 2.7) for whites, 3.4 transitions (SD = 3.2) for African Americans, 2.8 transitions (SD = 3.0) for Hispanics, and 2.4 transitions (SD = 2.7) for Asian Americans. After adjusting for age and sex, having at least four transitions was significantly more common for African Americans (39.2%; 95% confidence interval [CI]: 38.8-39.6%) compared with whites (32.5%, 95% CI: 32.3-32.6%), and less common among Hispanics (31.2%, 95% CI: 30.4-32.0%), and Asian Americans (26.5%, 95% CI: 25.5-27.5%). Having no care transition was significantly more common for Asian Americans (33.0%, 95% CI: 32.0-34.1%) and Hispanics (28.8%, 95% CI: 28.0-29.6%), compared with African Americans (19.2%, 95% CI: 18.9-19.5%) and whites (18.9%, 95% CI: 18.8-19.0%). Among hospice users, whites, African Americans, and Hispanics had similar length of hospice enrollment, which was significantly longer than that of Asian Americans. Nonwhite patients were significantly more likely than white patients to experience hospice disenrollment. Conclusions: Racial/ethnic differences in patterns of end-of-life care are marked. Future studies to understand why such patterns exist are warranted.
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Affiliation(s)
- Shi-Yi Wang
- 1 Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut.,2 Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Sylvia H Hsu
- 1 Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut.,3 Schulich School of Business, York University, Toronto, Ontario, Canada
| | - Melissa D Aldridge
- 4 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,5 Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
| | - Emily Cherlin
- 6 Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
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19
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Grady PA, Gough LL. Using Nursing Science to Inform Health Policy: The Role of the National Institute of Nursing Research. ANNUAL REVIEW OF NURSING RESEARCH 2018; 36:131-149. [PMID: 30568017 DOI: 10.1891/0739-6686.36.1.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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20
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Factors Associated With Hospices' Nonparticipation in Medicare's Hospice Compare Public Reporting Program. Med Care 2018; 57:28-35. [PMID: 30489545 DOI: 10.1097/mlr.0000000000001016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To enhance the quality of hospice care and to facilitate consumers' choices, the Centers for Medicare and Medicaid Services (CMS) began the Hospice Quality Reporting Program, in which CMS posted the quality measures of participating hospices on its reporting website, Hospice Compare. Little is known about the participation rate and the types of nonparticipating hospices. OBJECTIVE To examine the factors associated with hospices' nonparticipation in Hospice Compare. RESEARCH DESIGN We analyzed data from the CMS 2016 Hospice Compare. "Nonparticipants" were those who did not submit any quality measure. With the data of the Provider of Service file, the Healthcare Cost Report Information System, and the Area Health Resources File, multivariate logistic regressions estimated the association between nonparticipants and hospice and market characteristics, including ownership, size, nurse staffing ratio, and market competition intensity. RESULTS Among the 4123 certified hospices subject to penalty from nonparticipation, 259 did not participate in Hospice Compare. California, New Mexico, Texas, and Wyoming had participation rates lower than 80%. Hospices that were for-profit, had no accreditation, had few nurses per patient day, provided no inpatient care, and were located in competitive markets were less likely to participate than other hospices. CONCLUSIONS Hospice Compare successfully motivated hospice in participating in the quality report program in most of states. For-profit hospices, hospices with less quality, and hospices located in competitive markets were less likely to participate. Further research is warranted to examine the quality of these nonparticipants, especially in the 4 states with a lower participation rate.
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21
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Allsop MJ, Ziegler LE, Mulvey MR, Russell S, Taylor R, Bennett MI. Duration and determinants of hospice-based specialist palliative care: A national retrospective cohort study. Palliat Med 2018; 32:1322-1333. [PMID: 29874525 DOI: 10.1177/0269216318781417] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Understanding service provision for patients with advanced disease is a research priority, with a need to identify barriers that limit widespread integration of palliative care. AIM To identify patient and organisational factors that influence the duration of hospice-based palliative care in the United Kingdom prior to death. DESIGN This is a retrospective cohort study. SETTING/PARTICIPANTS A total of 64 UK hospices providing specialist palliative care inpatient beds and community services extracted data for all adult decedents (aged over 17 years) with progressive, advanced disease, with a prior referral (e.g. inpatient, community teams, and outpatient) who died between 1 January 2015 and 31 December 2015. Data were requested for factors relating to both the patient and hospice site. RESULTS Across 42,758 decedents, the median time from referral to death was 48 days. Significant differences in referral to death days were found for those with cancer (53 days) and non-cancer (27 days) ( p < 0.0001). As age increases, the median days from referral to death decreases: for those under 50 years (78 days), 50-74 years (59 days), and 75 years and over (39 days) ( p = 0.0001). An adjusted multivariable negative binomial model demonstrated increasing age persisting as a significant predictor of fewer days of hospice care, as did being male, having a missing ethnicity classification and having a non-cancer diagnosis ( p < 0.001). CONCLUSION Despite increasing rhetoric around early referral, patients with advanced disease are receiving referrals to hospice specialist palliative care very late in their illness trajectory. Age and diagnosis persist as determinants of duration of hospice specialist palliative care before death.
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Affiliation(s)
- Matthew J Allsop
- 1 St Gemma's Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Lucy E Ziegler
- 1 St Gemma's Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew R Mulvey
- 1 St Gemma's Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - Michael I Bennett
- 1 St Gemma's Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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22
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Anhang Price R, Stucky B, Parast L, Elliott MN, Haas A, Bradley M, Teno JM. Development of Valid and Reliable Measures of Patient and Family Experiences of Hospice Care for Public Reporting. J Palliat Med 2018; 21:924-932. [DOI: 10.1089/jpm.2017.0594] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Brian Stucky
- Los Alamos National Laboratory, Santa Fe, New Mexico
| | | | | | - Ann Haas
- RAND Corporation, Pittsburgh, Pennsylvania
| | | | - Joan M. Teno
- Oregon Health & Science University, Portland, Oregon
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Unroe KT, Stump TE, Effler S, Tu W, Callahan CM. Quality of Hospice Care at Home Versus in an Assisted Living Facility or Nursing Home. J Am Geriatr Soc 2018; 66:687-692. [PMID: 29427519 PMCID: PMC6034702 DOI: 10.1111/jgs.15260] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe differences in perceived quality of hospice care for individuals living at home or in a nursing home (NH) or assisted living facility (ALF) through analysis of after-death surveys of family members. DESIGN Retrospective cohort study using hospice medical record data and Family Evaluation of Hospice Care (FEHC) survey data. SETTING Large, national hospice provider. PARTICIPANTS Individuals who died while receiving routine hospice care and family caregivers who completed after-death quality-of-care surveys. MEASUREMENTS Survey results for 7,510 individuals were analyzed using analysis of variance and chi-square tests. Logistic regression was used to assess relationship between location of care and overall service quality. RESULTS The overall survey response rate was 27%; 34.5% of families of individuals in ALFs in hospice, 27.4% of those at home, and 22.9% of those in NHs returned the survey (P < .001). Differences in return rate according to primary diagnosis were significant, although differences were not large. Most (84.3%) respondents reported that hospice referral had occurred at the right time, and 63.4% rated service quality as excellent. Hospice care in the NH was less likely to be perceived as excellent. CONCLUSION There were significant differences in characteristics of individuals whose family members did and did not return surveys, which has implications for use of after-death surveys to evaluate hospice quality. Lower perceived quality of hospice care in NHs may be related to general dissatisfaction with receiving care in this setting. Survey results have the potential to set priorities for quality improvement, choice of provider, and potentially reimbursement. Underlying causes of differences of perceived quality in different settings of care should be examined.
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Affiliation(s)
- Kathleen T. Unroe
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy E. Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shannon Effler
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Wanzhu Tu
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christopher M. Callahan
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Wang R, Zeidan AM, Halene S, Xu X, Davidoff AJ, Huntington SF, Podoltsev NA, Gross CP, Gore SD, Ma X. Health Care Use by Older Adults With Acute Myeloid Leukemia at the End of Life. J Clin Oncol 2017; 35:3417-3424. [PMID: 28783450 DOI: 10.1200/jco.2017.72.7149] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Little is known about the patterns and predictors of the use of end-of-life health care among patients with acute myeloid leukemia (AML). End-of-life care is particularly relevant for older adults with AML because of their poor prognosis. Methods We performed a population-based, retrospective cohort study of patients with AML who were ≥ 66 years of age at diagnosis and diagnosed during the period from 1999 to 2011 and died before December 31, 2012. Medicare claims were used to assess patterns of hospice care and use of aggressive treatment. Predictors of these end points were evaluated using multivariable logistic regression analyses. Results In the overall cohort (N = 13,156), hospice care after AML diagnosis increased from 31.3% in 1999 to 56.4% in 2012, but the increase was primarily driven by late hospice enrollment that occurred in the last 7 days of life. Among the 5,847 patients who enrolled in hospice, 47.4% and 28.8% started their first hospice enrollment in the last 7 and 3 days of life, respectively. Among patients who transferred in and out of hospice care, 62% received transfusions outside hospice. Additionally, the use of chemotherapy within the last 14 days of life increased from 7.7% in 1999 to 18.8% in 2012. Patients who were male and nonwhite were less likely to enroll in hospice and more likely to receive chemotherapy or be admitted to intensive care units at the end of life. Conversely, older patients were less likely to receive chemotherapy or have intensive care unit admission at the end of life, and were more likely to enroll in hospice. Conclusion End-of-life care for older patients with AML is suboptimal. Additional research is warranted to identify reasons for their low use of hospice services and strategies to enhance end-of-life care for these patients.
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Affiliation(s)
- Rong Wang
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Amer M Zeidan
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Stephanie Halene
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Xiao Xu
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Amy J Davidoff
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Scott F Huntington
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Nikolai A Podoltsev
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Cary P Gross
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Steven D Gore
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Xiaomei Ma
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
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Aldridge MD, Bradley EH. Epidemiology And Patterns Of Care At The End Of Life: Rising Complexity, Shifts In Care Patterns And Sites Of Death. Health Aff (Millwood) 2017; 36:1175-1183. [DOI: 10.1377/hlthaff.2017.0182] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Melissa D. Aldridge
- Melissa D. Aldridge ( ) is an associate professor in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, in New York City
| | - Elizabeth H. Bradley
- Elizabeth H. Bradley is president of and a professor of political science and science, technology, and society at Vassar College, in Poughkeepsie, New York
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Yim CK, Barrón Y, Moore S, Murtaugh C, Lala A, Aldridge M, Goldstein N, Gelfman LP. Hospice Enrollment in Patients With Advanced Heart Failure Decreases Acute Medical Service Utilization. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003335. [PMID: 28292824 DOI: 10.1161/circheartfailure.116.003335] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with advanced heart failure (HF) enroll in hospice at low rates, and data on their acute medical service utilization after hospice enrollment is limited. METHODS AND RESULTS We performed a descriptive analysis of Medicare fee-for-service beneficiaries, with at least one home health claim between July 1, 2009, and June 30, 2010, and at least 2 HF hospitalizations between July 1, 2009, and December 31, 2009, who subsequently enrolled in hospice between July 1, 2009, and December 31, 2009. We estimated panel-negative binomial models on a subset of beneficiaries to compare their acute medical service utilization before and after enrollment. Our sample size included 5073 beneficiaries: 55% were female, 45% were ≥85 years of age, 13% were non-white, and the mean comorbidity count was 2.38 (standard deviation 1.22). The median number of days between the second HF hospital discharge and hospice enrollment was 45. The median number of days enrolled in hospice was 15, and 39% of the beneficiaries died within 7 days of enrollment. During the study period, 11% of the beneficiaries disenrolled from hospice at least once. The adjusted mean number of hospital, intensive care unit, and emergency room admissions decreased from 2.56, 0.87, and 1.17 before hospice enrollment to 0.53, 0.19, and 0.76 after hospice enrollment. CONCLUSIONS Home health care Medicare beneficiaries with advanced HF who enrolled in hospice had lower acute medical service utilization after their enrollment. Their pattern of hospice use suggests that earlier referral and improved retention may benefit this population. Further research is necessary to understand hospice referral and palliative care needs of advanced HF patients.
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Affiliation(s)
- Cindi K Yim
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Yolanda Barrón
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Stanley Moore
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Chris Murtaugh
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Anuradha Lala
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Melissa Aldridge
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Nathan Goldstein
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Laura P Gelfman
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA.
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Abstract
OBJECTIVES Despite increased hospice use over the last decade, end-of-life care intensity continues to increase. To understand this puzzle, we sought to examine regional variation in intensive end-of-life care and determine its associations with hospice use patterns. METHODS Using Medicare claims for decedents aged 66 years and above in 2011, we assessed end-of-life care intensity in the last 6 months of life across hospital referral regions (HRRs) as measured by proportion of decedents per HRR experiencing hospitalization, emergency department use, intensive care unit (ICU) admission, and number of days spent in hospital (hospital-days) and ICU (ICU-days). Using hierarchical generalized linear models and adjusting for patient characteristics, we examined whether these measures were associated with overall hospice use, very short (≤7 d), medium (8-179 d), or very long (≥180 d) hospice enrollment, focusing on very short stay. RESULTS End-of-life care intensity and hospice use patterns varied substantially across HRRs. Regional-level end-of-life care intensity was positively correlated with very short hospice enrollment. Comparing HRRs in the highest versus the lowest quintiles of intensity in end-of-life care, regions with more intensive care had higher rates of very short hospice enrollment, with adjusted odds ratios (AOR) 1.14 [99% confidence interval (CI), 1.04-1.25] for hospitalization; AOR, 1.23 (CI, 1.12-1.36) for emergency department use; AOR, 1.25 (CI, 1.14-1.38) for ICU admission; AOR, 1.10 (CI, 1.00-1.21) for hospital-days; and AOR, 1.20 (CI, 1.08-1.32) for ICU-days. CONCLUSIONS At the regional level, increased end-of-life care intensity was consistently associated with very short hospice use.
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Ankuda CK, Mitchell SL, Gozalo P, Mor V, Meltzer D, Teno JM. Association of Physician Specialty with Hospice Referral for Hospitalized Nursing Home Patients with Advanced Dementia. J Am Geriatr Soc 2017; 65:1784-1788. [PMID: 28369754 DOI: 10.1111/jgs.14888] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Hospitalists hospice referral patterns have been unstudied. This study aims to examine hospice referral rates by attending type for hospitalized nursing home (NH) residents with advanced cognitive impairment (ACI) at the time of discharge between 2000 and 2010. DESIGN Retrospective cohort study. PARTICIPANTS Hospitalized NH residents age ≥66 drawn from the 20% sample of Medicare beneficiaries with ACI, 4 or more activities of daily living (ADL) impairments on last minimum data set (MDS) assessment completed within 120 days of admission (n = 128,989). MEASUREMENTS Hospice referral was defined as referral to hospice within 1 day after hospital discharge. Attending physician type was determined by Part B physician billing for 100% of the billings during that admission. Continuity of care was defined as the hospital physician also billing for an outpatient visit within 120 days of that hospital admission. Number of ADL impairments, cognitive measures, pre-admission illnesses and illness severity were derived from the MDS. RESULTS Of the 105,329 hospitalized patients with ACI that survived to discharge (72.3% white, 30.6% male), the hospice referral rate at the time of hospital discharge increased from 2.8% in 2000 to 11.2% in 2010. Using a multivariate, hospital fixed effects model examining changes in the distribution of inpatient attending physicians, hospitalists compared to generalist physicians were more likely to refer these patients to hospice at discharge (AOR 1.17, 95% CI 1.09-1.26). Continuity of physician care from the outpatient setting to the hospital was associated with lower hospice referral (AOR 0.78, 95% CI 0.73-0.85). CONCLUSION Hospice referrals for NH-dwelling persons with ACI admitted to the hospital increased between 2000 and 2011 and disproportionately so when the attending physician was a hospitalist.
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Affiliation(s)
- Claire K Ankuda
- Robert Wood Johnson Clinical Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Susan L Mitchell
- Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts
| | - Pedro Gozalo
- Health Services, Policy, and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
| | - Vince Mor
- Health Services, Policy, and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island.,Veterans Administration Medical Center, Providence, Rhode Island
| | - David Meltzer
- Section of Hospital Medicine, University of Chicago, Chicago, Illinois
| | - Joan M Teno
- Division of Gerontology and Geriatric Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
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Pearson C, Verne J, Wells C, Polato GM, Higginson IJ, Gao W. Measuring geographical accessibility to palliative and end of life (PEoLC) related facilities: a comparative study in an area with well-developed specialist palliative care (SPC) provision. BMC Palliat Care 2017; 16:14. [PMID: 28125994 PMCID: PMC5270238 DOI: 10.1186/s12904-017-0185-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 01/19/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Geographical accessibility is important in accessing healthcare services. Measuring it has evolved alongside technological and data analysis advances. High correlations between different methods have been detected, but no comparisons exist in the context of palliative and end of life care (PEoLC) studies. To assess how geographical accessibility can affect PEoLC, selection of an appropriate method to capture it is crucial. We therefore aimed to compare methods of measuring geographical accessibility of decedents to PEoLC-related facilities in South London, an area with well-developed SPC provision. METHODS Individual-level death registration data in 2012 (n = 18,165), from the Office for National Statistics (ONS) were linked to area-level PEoLC-related facilities from various sources. Simple and more complex measures of geographical accessibility were calculated using the residential postcodes of the decedents and postcodes of the nearest hospital, care home and hospice. Distance measures (straight-line, travel network) and travel times along the road network were compared using geographic information system (GIS) mapping and correlation analysis (Spearman rho). RESULTS Borough-level maps demonstrate similarities in geographical accessibility measures. Strong positive correlation exist between straight-line and travel distances to the nearest hospital (rho = 0.97), care home (rho = 0.94) and hospice (rho = 0.99). Travel times were also highly correlated with distance measures to the nearest hospital (rho range = 0.84-0.88), care home (rho = 0.88-0.95) and hospice (rho = 0.93-0.95). All correlations were significant at p < 0.001 level. CONCLUSIONS Distance-based and travel-time measures of geographical accessibility to PEoLC-related facilities in South London are similar, suggesting the choice of measure can be based on the ease of calculation.
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Affiliation(s)
- Clare Pearson
- King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
| | - Julia Verne
- Office for National Statistics, Life Events and Population Sources Division, Newport, NP10 8XG, UK
| | - Claudia Wells
- Public Health England, National End of Life Care Intelligence Network, 2 Rivergate, Temple Quay, Bristol, BS1 6EH, UK
| | - Giovanna M Polato
- Care Quality Commission, 151 Buckingham Palace Road, London, SW1W 9SZ, UK
| | - Irene J Higginson
- King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
| | - Wei Gao
- King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK.
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Oud L. Predictors of Transition to Hospice Care Among Hospitalized Older Adults With a Diagnosis of Dementia in Texas: A Population-Based Study. J Clin Med Res 2017; 9:23-29. [PMID: 27924171 PMCID: PMC5127211 DOI: 10.14740/jocmr2783w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Decedent older adults with dementia are increasingly less likely to die in a hospital, though escalation of care to a hospital setting, often including critical care, remains common. Although hospice is increasingly reported as the site of death in these patients, the factors associated with transition to hospice care during end-of-life (EOL) hospitalizations of older adults with dementia and the extent of preceding escalation of care to an intensive care unit (ICU) setting among those discharged to hospice have not been examined. METHODS We identified hospitalizations aged ≥ 65 years with a diagnosis of dementia in Texas between 2001 and 2010. Potential factors associated with discharge to hospice were evaluated using multivariate logistic regression modeling, and occurrence of hospice discharge preceded by ICU admission was examined. RESULTS There were 889,008 elderly hospitalizations with a diagnosis of dementia during study period, with 40,669 (4.6%) discharged to hospice. Discharges to hospice increased from 908 (1.5%) to 7,398 (6.3%) between 2001 and 2010 and involved prior admission to ICU in 45.2% by 2010. Non-dementia comorbidities were generally associated with increased odds of hospice discharge, as were development of organ failure, the number of failing organs, or use of mechanical ventilation. However, discharge to hospice was less likely among non-white minorities (lowest among blacks: adjusted odds ratio (aOR): 0.67; 95% confidence interval (CI): 0.65 - 0.70) and those with non-commercial primary insurance or the uninsured (lowest among those with Medicaid: aOR (95% CI): 0.41 (0.37 - 0.46)). CONCLUSIONS This study identified potentially modifiable factors associated with disparities in transition to hospice care during EOL hospitalizations of older adults with dementia, which persisted across comorbidity and severity of illness measures. The prevalent discharge to hospice involving prior critical care suggests that key discussions about goals-of-care likely took place following further escalation of care to ICU. Together these findings can inform system- and clinician-level interventions to facilitate timely and consistent use of hospice to meet patients' goals of care.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX 79763, USA.
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Wang SY, Aldridge MD, Canavan M, Cherlin E, Bradley E. Continuous Home Care Reduces Hospice Disenrollment and Hospitalization After Hospice Enrollment. J Pain Symptom Manage 2016; 52:813-821. [PMID: 27697564 PMCID: PMC5154927 DOI: 10.1016/j.jpainsymman.2016.05.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/20/2016] [Accepted: 05/25/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT Among the four levels of hospice care, continuous home care (CHC) is the most expensive care, and infrequently provided in practice. OBJECTIVES To identify hospice and patient characteristics associated with the use of CHC and to examine the associations between CHC utilization and hospice disenrollment or hospitalization after hospice enrollment. METHODS Using 100% fee-for-service Medicare claims data for beneficiaries aged 66 years or older who died between July and December 2011, we identified the percentage of hospice agencies in which patients used CHC in 2011 and determined hospice and patient characteristics associated with the use of CHC. Using multivariable analyses, we examined the associations between CHC utilization and hospice disenrollment and hospitalization after hospice enrollment, adjusted for hospice and patient characteristics. RESULTS Only 42.7% of hospices (1533 of 3592 hospices studied) provided CHC to at least one patient during the study period. Patients enrolled with for-profit, larger, and urban located hospices were more likely to use CHC (P < 0.001). Within these 1533 hospices, only 11.4% of patients used CHC. Patients who were white, had cancer, and had more comorbidities were more likely to use CHC. In multivariable models, compared with patients who did not use CHC, patients who used CHC were less likely to have hospice disenrollment (adjusted odds ratio 0.21; 95% CI 0.19, 0.23) and less likely to be hospitalized after hospice enrollment (adjusted odds ratio 0.37; 95% CI 0.34, 0.40). CONCLUSION Although a minority of patients uses CHC, such services may be protective against hospice disenrollment and hospitalization after hospice enrollment.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J. Peters VA Medical Center, Bronx, New York, USA
| | - Maureen Canavan
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Emily Cherlin
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Elizabeth Bradley
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
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Ballentine J, Kassner C, Byock I. Physician-Assisted Death Does Not Improve End-of-Life Care. J Palliat Med 2016; 19:479-80. [DOI: 10.1089/jpm.2016.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Ira Byock
- Institute for Human Caring, Providence Health and Services, Torrance, California
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Wang SY, Hall J, Pollack CE, Adelson K, Bradley EH, Long JB, Gross CP. Trends in end-of-life cancer care in the Medicare program. J Geriatr Oncol 2016; 7:116-25. [PMID: 26783015 PMCID: PMC5577563 DOI: 10.1016/j.jgo.2015.11.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 10/03/2015] [Accepted: 11/30/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To examine contemporary trends in end-of-life cancer care and geographic variation of end-of-life care aggressiveness among Medicare beneficiaries. MATERIALS AND METHODS Using the Surveillance, Epidemiology, and End Results-Medicare data, we identified 132,051 beneficiaries who died as a result of cancer in 2006-2011. Aggressiveness of end-of-life care was measured by chemotherapy received within 14 days of death, >1 emergency department (ED) visit within 30 days of death, >1 hospitalization within 30 days of death, ≥1 intensive care unit (ICU) admission within 30 days of death, in-hospital death, or hospice enrollment ≤3 days before death. Using hierarchical generalized linear models, we assessed potentially aggressive end-of-life care adjusting for patient demographics, tumor characteristics, and hospital referral region (HRR)-level market factors. RESULTS The proportion of beneficiaries receiving at least one potentially aggressive end-of-life intervention increased from 48.6% in 2006 to 50.5% in 2011 (P<.001). From 2006 to 2011, increases were apparent in repeated hospitalization (14.1% vs. 14.8%; P=.01), repeated ED visits (34.3% vs. 36.6%; P<.001), ICU admissions (16.2% vs. 21.3%; P<.001), and late hospice enrollment (11.2% vs. 12.9%; P<.001), whereas in-hospital death declined (23.5% vs. 20.9%; P<.001). End-of-life chemotherapy use (4.4% vs. 4.5%) did not change significantly over time (P=.12). The use of potentially aggressive end-of-life care varied substantially across HRRs, ranging from 40.3% to 58.3%. Few HRRs had a decrease in aggressive end-of-life care during the study period. CONCLUSIONS Despite growing focus on providing appropriate end-of-life care, there has not been an improvement in aggressive end-of-life cancer care in the Medicare program.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT, USA; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA.
| | - Jane Hall
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Craig E Pollack
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kerin Adelson
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA; Section of Medical Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Elizabeth H Bradley
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
| | - Jessica B Long
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Ornstein KA, Meier DE. Beyond Enrollment: Providing the Highest-Quality Care within Hospice. J Am Geriatr Soc 2016; 64:330-1. [PMID: 26889842 PMCID: PMC5417357 DOI: 10.1111/jgs.13945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Katherine A. Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn
School of Medicine at Mount Sinai, New York, New York
| | - Diane E. Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn
School of Medicine at Mount Sinai, New York, New York
- Center to Advance Palliative Care, New York, New York
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