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Sullivan DR, Jones KF, Wachterman MW, Griffin HL, Kinder D, Smith D, Thorpe J, Feder SL, Ersek M, Kutney-Lee A. Opportunities to Improve End-of-Life Care Quality among Patients with Short Terminal Admissions. J Pain Symptom Manage 2024:S0885-3924(24)00789-9. [PMID: 38810950 DOI: 10.1016/j.jpainsymman.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
CONTEXT Little is known about Veterans who die during a short terminal admission, which renders them ineligible for the Department of Veterans Affairs (VA) Bereaved Family Survey. OBJECTIVES We sought to describe this population and identify opportunities to improve end-of-life (EOL) care quality. METHODS Retrospective, cohort analysis of Veteran decedents who died in a VA inpatient setting between October 2018-September 2019. Veterans were dichotomized by short (<24 hours) and long (≥24 hours) terminal admissions; sociodemographics, clinical characteristics, VA and non-VA healthcare use, and EOL care quality indicators were compared. RESULTS Among 17,033 inpatient decedents, 723 (4%) had short terminal admissions. Patients with short compared to long terminal admissions were less likely to have a VA hospitalization (38% vs. 54%) in the last 90 days of life and were more likely to die in an intensive care (49% vs 21%) or acute care (27% vs 18%) unit. Patients with a short compared to long admission were about half as likely to receive hospice (33% vs 64%) or palliative care (33% vs 69%). Most patients with short admissions (76%) had a life-limiting condition (e.g., cancer, chronic obstructive pulmonary disease) and those with cancer were more likely to receive palliative care compared to those with non-cancer conditions. CONCLUSION Veterans with short terminal admissions are less likely to receive hospice or palliative care compared to patients with long terminal admissions. Many patients with short terminal admissions, such as those with life-limiting conditions (especially cancer), receive aspects of high-quality EOL care, however, opportunities for improvement exist.
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Affiliation(s)
- Donald R Sullivan
- Department of Medicine (D.R.S.), Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland Oregon, USA; Center to Improve Veteran Involvement in Care (D.R.S.), Portland Veteran Affairs Healthcare System, Portland Oregon, USA.
| | - Katie F Jones
- New England Geriatric Research Education and Clinical Center (K.F.J.), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA; Department of Medicine (K.F.J.), Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa W Wachterman
- Section of General Internal Medicine (M.W.), Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA; Division of General Internal Medicine (M.W.), Brigham and Women's Hospital, Boston MA, USA; Department of Psychosocial Oncology and Palliative Care (M.W.), Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Hilary L Griffin
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Daniel Kinder
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Dawn Smith
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua Thorpe
- Center for Health Equity Research and Promotion (J.M.T.), Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania, USA; University of North Carolina School of Pharmacy (J.M.T.), Chapel Hill, North Carolina, USA
| | - Shelli L Feder
- Yale University School of Nursing (S.L.F.), Orange, Connecticut, USA; West Haven Department of Veterans Affairs (S.L.F.), West Haven, Connecticut, USA
| | - Mary Ersek
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; Leonard Davis Institute (M.E.), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann Kutney-Lee
- Veteran Experience Center (H.G., D.K., D.G., M.E., A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; Center for Health Equity and Research Promotion (A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania (A.K.L.), School of Nursing, Philadelphia, Pennsylvania, USA
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2
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Robison J, Shugrue N, Dillon E, Migneault D, Charles D, Wakefield D, Richards B. Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents. JAMA HEALTH FORUM 2023; 4:e234240. [PMID: 38064239 PMCID: PMC10709774 DOI: 10.1001/jamahealthforum.2023.4240] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/03/2023] [Indexed: 12/18/2023] Open
Abstract
Importance Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population. Objective To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. Design, Setting, and Participants This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020. Exposure Race and ethnicity. Main Outcomes and Measures Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death. Results Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85). Conclusions and Relevance Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.
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Affiliation(s)
- Julie Robison
- UConn Health, Center on Aging, Farmington, Connecticut
| | | | - Ellis Dillon
- UConn Health, Center on Aging, Farmington, Connecticut
| | | | | | | | - Bradley Richards
- Connecticut Department of Social Services, Hartford, Connecticut
- Yale School of Medicine, New Haven, Connecticut
- Yale School of Management, New Haven, Connecticut
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3
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Lycan TW, Buckenheimer A, Ruiz J, Russell G, Dothard AS, Ahmed T, Grant S, Grey C, Petty WJ. Team-Based Hospice Referrals: A Potential Quality Metric for Lung Cancer in the Immunotherapy Era. Am J Hosp Palliat Care 2023; 40:10-17. [PMID: 35512681 PMCID: PMC9815203 DOI: 10.1177/10499091221091745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) can lead to durable responses in patients with lung cancer but may delay transitions to hospice at the end of life (EOL). We aimed to test the association of continuity of care with EOL outcomes in the ICI era. METHODS We collected retrospective data on all patients with lung cancer who started ICI treatment at a single comprehensive cancer center in the United States (1/1/14-5/1/18) and subsequently died. We defined a hospice referral as having continuity of care if placed by a provider from the patient's multidisciplinary cancer team (e.g., a medical oncologist, palliative care specialist, intensivist, and hospitalist). RESULTS In this cohort of 143 patients, 58% had a team-based hospice referral which was associated with a lower risk of death in the hospital. The most common reason patients declined hospice at EOL was an unwillingness to discontinue cancer-directed therapy. As compared to a similar historical cohort of patients treated with chemotherapy alone (2008-2010), there was a similar rate of hospice referral (68% vs 74%) but higher rates of new systemic therapy initiated within 30 days of death (17% vs 6%, p .001) and last dose within 14 days of death (13% vs 5%, p .005). CONCLUSIONS Future studies should test the continuity of care at EOL as a new quality metric for advanced NSCLC.
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Affiliation(s)
- Thomas W. Lycan
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alyssa Buckenheimer
- Hospice abd Palliative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jimmy Ruiz
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gregory Russell
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andy Shipe Dothard
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Tamjeed Ahmed
- Hematology and Oncology, Tennessee Oncology, Gallatin, TN, USA
| | - Stefan Grant
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Carl Grey
- Hospice abd Palliative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - William J. Petty
- Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Wolf A, Sant'Anna A, Vilhelmsson A. Using nudges to promote clinical decision making of healthcare professionals: A scoping review. Prev Med 2022; 164:107320. [PMID: 36283484 DOI: 10.1016/j.ypmed.2022.107320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/25/2022] [Accepted: 10/18/2022] [Indexed: 10/31/2022]
Abstract
Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.
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Affiliation(s)
- Axel Wolf
- University of Gothenburg, Centre for Person-Centred Care (GPCC), Sweden; University of Gothenburg, Institute of Health and Care Sciences, Sahlgrenska Academy, Sweden
| | | | - Andreas Vilhelmsson
- Lund University, Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Sweden.
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5
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Sedhom R, Blackford AL, Gupta A, Smith TJ, Shulman LN, Carducci MA. Oncologist Peer Comparisons as a Behavioral Science Strategy to Improve Hospice Utilization. JCO Oncol Pract 2022; 18:e1122-e1131. [PMID: 35377734 DOI: 10.1200/op.21.00738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hospice utilization metrics are essential for any serious effort to improve end-of-life care in oncology. However, oncologists do not routinely receive these personalized reports. We evaluated whether a behavioral science intervention, using peer comparisons coupled with social norms, was associated with improvements in hospice use. METHODS Oncologists at two academic practices of Johns Hopkins Medicine were randomly assigned to receive a peer comparison report by e-mail displaying individual hospice utilization metrics compared with top-performing peers or to receive no report. The data accrued for the intervention represented hospice utilization for the previous calendar year. The intervention period was from June 1, 2020, to December 30, 2020, and included oncologists from both the solid and hematologic malignancies programs. The primary outcome was the proportion of patients between groups with short hospice length of stay (LOS; defined as ≤ 7 days) after 6 months. Secondary outcomes included hospice referral rate, enrollment rate, and median LOS. RESULTS Forty-seven oncologists participated. The percent of patients with a short hospice stay in the intervention group was lower (17.4%) compared with patients treated by physicians in the usual care group (46.3%, difference = 21.8%; 95% CI, 16.0 to 41.6; P < .001). Receipt of peer comparisons was associated with a greater likelihood of enrolling in hospice (73.7% v 42.8%; difference = 31.1%; 95% CI, 20.4 to 41.7; P < .001) and a longer hospice LOS (37.2 v 18.3 days; difference = 17.2; 95% CI, 8.8 to 25.7 days; P < .001). CONCLUSION Peer comparisons improved hospice utilization metrics among a group of academic oncologists. Behavioral science offers one pragmatic strategy to overcome suboptimal oncologist decision-making biases related to hospice use.
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Affiliation(s)
- Ramy Sedhom
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | - Amanda L Blackford
- Division of Biostatistics and Bioinformatics, Department of Oncology, Johns Hopkins University, Baltimore, MD
| | - Arjun Gupta
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | - Thomas J Smith
- Section of Palliative Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD
| | - Lawrence N Shulman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | - Michael A Carducci
- Section of Palliative Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD
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Bigger SE, Haddad L, Ahluwalia SC, Glenn L. Advance Care Planning Protocols and Hospitalization Rates in Home Health Value-Based Purchasing. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2021. [DOI: 10.1177/10848223211021393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.
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Affiliation(s)
| | - Lisa Haddad
- East Tennessee State University, Johnson City, TN, USA
| | | | - Lee Glenn
- East Tennessee State University, Johnson City, TN, USA
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