Decreasing variation in the use of hospice among older adults with breast, colorectal, lung, and prostate cancer

Higher Admittance to Specialized Palliative Care for Patients with High Education and Income: A Nationwide Register-Based Study

Background: While associations between socioeconomic position, that is, income and education and admittance to specialized palliative care (SPC) have been investigated previously, no prior national studies have examined admittance to all types of SPC, that is, hospital-based palliative care team/units and hospice. Aim: To investigate whether cancer patients' education and income were associated with admittance to SPC (hospital-based palliative care team/unit, hospice). Design: Data sources were several nationwide registers. The association between SPC and education and income, respectively, was investigated using logistic regression analyses. Setting/Participants: Patients dying from cancer in Denmark 2010-12 (n = 41,741). Results: In the study population, 45% had lower secondary school, and 6% had an academic education. Patients with an academic education were more often admitted to SPC than those having lower secondary school (odds ratio [OR] = 1.69; 95% confidence interval [CI]: 1.51-1.89). Patients in the highest income quartile (Q4) were more often admitted than those in the lowest income quartile (Q1) (OR = 1.46; 95% CI: 1.37-1.56). This association was stronger for hospice (OR = 1.67 (95% CI: 1.54-1.81)) than for admittance to hospital-based palliative care team/unit (OR = 1.23 (95% CI: 1.14-1.31)). Compared with patients who had lower secondary school and the lowest income, the OR of admittance to SPC among the most affluent academics was 1.96 (95% CI: 1.71-2.25). Conclusion: This nationwide study indicates that admittance to SPC was clearly associated with education and income. We believe that the associations indicate inequity. Initiatives to improve access for patients with low education or income should be established.

Higher overall admittance of immigrants to specialised palliative care in Denmark: a nationwide register-based study of 99,624 patients with cancer

BACKGROUND

The population of immigrants in Europe is ageing. Accordingly, the number of immigrants with life-threatening diseases and need for specialised palliative care will increase. In Europe, immigrants' admittance to specialised palliative care is not well explored.

AIM

To investigate whether country of origin was associated with admittance to (I) palliative care team/unit, (II) hospice, and/or (III) specialised palliative care, overall (i.e. palliative care team/unit and/or hospice).

DESIGN

Data sources for the population cohort study were the Danish Palliative Care Database and several nationwide registers. We investigated the associations between country of origin and admittance to specialised palliative care, overall, and to type of palliative care using logistic regression analyses.

SETTING/PARTICIPANTS

In 2010-2016, 104,775 cancer patients died in Denmark: 96% were born in Denmark, 2% in other Western countries, and 2% in non-Western countries.

RESULTS

Overall admittance to specialised palliative care was higher for immigrants from other Western (OR = 1.13; 95%CI: 1.03-1.24) and non-Western countries (OR = 1.22; 95%CI: 1.08-1.37) than for the majority population. Similar results were found for admittance to palliative care teams. No difference in admittance to hospice was found for immigrants from other Western countries (OR = 1.04; 95%CI: 0.93-1.16) compared to the majority population, while lower admittance was found for non-Western immigrants (OR = 0.70; 95%CI: 0.60-0.81).

CONCLUSION

Admittance to specialised palliative care was higher for immigrants than for the majority population as higher admittance to palliative care teams for non-Western immigrants more than compensated for the lower hospice admittance. This may reflect a combination of larger needs and that hospital-based and home-based services are perceived as preferable by immigrants.

Time to End-of-Life of Patients Starting Specialised Palliative Care in Denmark: A Descriptive Register-Based Cohort Study

Increasing numbers of patients are being referred to specialised palliative care (SPC) which, in order to be beneficial, is recommended to last more than three months. This cohort study aimed to describe time to end-of-life after initiating SPC treatment and to explore potential regional variations. We used national register data from all Danish hospital SPC teams. We included patients who started SPC treatment from 2015-2018 to explore if time to end-of-life was longer than three months. Descriptive statistics were used to summarise the data and a generalised linear model was used to assess variations among the five Danish regions. A total of 27,724 patients were included, of whom 36.7% (95% CI 36.2-37.1%) had over three months to end-of-life. In the Capital Region of Denmark, 40.1% (95% CI 39.0-41.3%) had over three months to end-of-life versus 32.5% (95% CI 30.9-34.0%) in North Denmark Region. We conclude that most patients live for a shorter period of time than the recommended three months after initiating SPC treatment. This is neither optimal for patient care, nor the healthcare system. A geographical variation between regions was shown indicating different practices, patient groups or resources. These results warrant further investigation to promote optimal SPC treatment.

Trends, Sociodemographic and Hospital-Level Factors Associated With Palliative Care Utilization Among Multiple Myeloma Patients Using the National Inpatient Sample (2016-2018)

BACKGROUND

Several factors are reported to be associated with palliative care utilization among patients with various cancers, but literature is lacking on multiple myeloma (MM) specific factors. MM patients have a high symptom burden and early involvement of palliative could increase their quality of life. We examined factors associated with palliative care utilization among MM patients and explored prevalence trends in palliative care utilization among patients with MM.

METHODS

Cross-sectional analyses were conducted using the National Inpatient Sample data collected between 2016 and 2018. Descriptive analyses were used to explore prevalence trends in palliative care utilization over time. Multivariable logistic regression models were used to examine sociodemographic and hospital-level factors associated with palliative care utilization in MM patients.

RESULTS

Overall prevalence of palliative care utilization in our population was 7.7% with a trend of increasing use of palliative care from 7.3% in 2016 to 8.2% in 2018. MM patients aged 70 years and above had 1.30 times higher odds (95% CI: 1.20-1.42) of receiving palliative care relative to those younger than 70 years. Compared to non-Hispanic whites, non-Hispanic blacks (Adjusted odds ratio (AOR): 0.86; 95% CI: 0.79-0.94) were less likely to utilize palliative care. Patients on Medicaid (AOR: 1.27; 95% CI: 1.08-1.49), private insurance (AOR: 1.27; 95% CI: 1.16-1.39) and other insurance types (AOR: 2.10; 95% CI: 1.79-2.47) had significantly higher odds of receiving palliative care when compared to those on Medicare. Other factors identified were hospital region, location, patient disposition, admission type, length of stay, and number of comorbidities.

CONCLUSION

Our findings highlight the urgent need for education of hospital physicians on the need for early palliative care involvement in the care of hospitalized MM patients. Messaging interventions such as the delivery of pop-up messages in electronic medical records to serve as reminders for physicians can be explored as a potential way to increase palliative care consultations for patients who need them.

Hospice Utilization in Elderly Patients With Brain Metastases

BACKGROUND

Brain metastases are associated with considerable morbidity and mortality. Integration of hospice at the end of life offers patients symptom relief and improves quality of life, particularly for elderly patients who are less able to tolerate brain-directed therapy. Population-level investigations of hospice utilization among elderly patients with brain metastases are limited.

METHODS

Using the Surveillance, Epidemiology and End Results-Medicare database for primary cancer sites that commonly metastasize to the brain, we identified 50 148 patients (aged 66 years and older) diagnosed with brain metastases between 2005 and 2016. We calculated the incidence, timing, and predictors of hospice enrollment using descriptive techniques and multivariable logistic regression. All statistical tests were 2-sided.

RESULTS

The incidence of hospice enrollment was 71.4% (95% confidence interval [CI] = 71.0 to 71.9; P < .001), a rate that increased over the study period (P < .001). The odds of enrollment for black (odds ratio [OR] = 0.76, 95% CI = 0.71 to 0.82; P < .001), Hispanic (OR = 0.80, 95% CI = 0.72 to 0.87; P < .001), and Asian patients (OR = 0.52, 95% CI = 0.48 to 0.57; P < .001) were substantially lower than white patients; men were less likely to be enrolled in hospice than women (OR = 0.78, 95% CI = 0.74 to 0.81; P < .001). Among patients enrolled in hospice, 32.6% (95% CI = 32.1 to 33.1; P < .001) were enrolled less than 7 days prior to death, a rate that was stable over the study period.

CONCLUSIONS

Hospice is used for a majority of elderly patients with brain metastases although a considerable percentage of patients die without hospice services. Many patients enroll in hospice late and, concerningly, statistically significant sociodemographic disparities exist in hospice utilization. Further investigations to facilitate targeted interventions addressing such disparities are warranted.

Developing Predictive Models to Determine Patients in End-of-Life Care in Administrative Datasets

Introduction

In observational studies with mortality endpoints, one needs to consider how to account for subjects whose interventions appear to be part of ‘end-of-life’ care.

Objective

The objective of this study was to develop a diagnostic predictive model to identify those in end-of-life care at the time of a drug exposure.

Methods

We used data from four administrative claims datasets from 2000 to 2017. The index date was the date of the first prescription for the last new drug subjects received during their observation period. The outcome of end-of-life care was determined by the presence of one or more codes indicating terminal or hospice care. Models were developed using regularized logistic regression. Internal validation was through examination of the area under the receiver operating characteristic curve (AUC) and through model calibration in a 25% subset of the data held back from model training. External validation was through examination of the AUC after applying the model learned on one dataset to the three other datasets.

Results

The models showed excellent performance characteristics. Internal validation resulted in AUCs ranging from 0.918 (95% confidence interval [CI] 0.905–0.930) to 0.983 (95% CI 0.978–0.987) for the four different datasets. Calibration results were also very good, with slopes near unity. External validation also produced very good to excellent performance metrics, with AUCs ranging from 0.840 (95% CI 0.834–0.846) to 0.956 (95% CI 0.952–0.960).

Conclusion

These results show that developing diagnostic predictive models for determining subjects in end-of-life care at the time of a drug treatment is possible and may improve the validity of the risk profile for those treatments.

Electronic supplementary material

The online version of this article (10.1007/s40264-020-00906-7) contains supplementary material, which is available to authorized users.

Factors Affecting Racial Disparities in End-of-Life Care Costs Among Lung Cancer Patients: A SEER-Medicare-based Study

OBJECTIVES

Racial disparities exist in end-of-life lung cancer care, which could potentially lead to considerable racial differences in end-of-life care costs. This study for the first time estimates the racial differences in end-of-life care costs among lung cancer patients, and identifies and quantifies factors that contribute the most to these differences using a statistical decomposition method.

METHODS

This is a retrospective analysis of patients 66 years and older, diagnosed with stage I-IV lung cancer, who died on or before December 31, 2013, using the Surveillance Epidemiology and End Result-Medicare data from 1991 to 2013. Ordinary least square regression of logarithmically transformed cost was used to estimate racial differences in end-of-life care costs among lung cancer patients. Blinder-Oaxaca decomposition was used to identify and quantify factors that contributed the most to these differences.

RESULTS

Non-Hispanic blacks had 10% to 13% higher end-of-life care costs as compared with non-Hispanic whites. Geographic variations, baseline comorbidity indices and stage at diagnosis contributed the most to explaining the racial differences in costs, with geographic variation explaining most of the differences. However, the observed factors could only explain 25% to 32% of the racial differences in end-of-life care costs.

CONCLUSIONS

Geographic differences in access to timely and appropriate care, and provider practice patterns, should be examined to understand the reasons behind geographic variations in racial disparity. Provider-level educational interventions to reduce small area practice variations and differential management of patients by race, as well as racially sensitive patient-level educational and navigational interventions might be critical in improving quality of care and reducing costs during end-of-life.

Barriers to palliative and hospice care utilization in older adults with cancer: A systematic review

The number of older adults with cancer and the need for palliative care among this population is increasing in the United States. The objective of this systematic review was to synthesize the evidence on the barriers to palliative and hospice care utilization in older adults with cancer. A systematic literature search was conducted using PubMed, CINAHL, PsycINFO, Embase, and Cochrane Library databases (from inception to 2018) in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Research articles that examined palliative or hospice care utilization in older adults with cancer were included in this review. Fineout-Overholt's Level of Evidence was used for quality appraisal. A total of 19 studies were synthesized in this review. Barriers to palliative and hospice care utilization were categorized into socio-demographic barriers, provider-related barriers, and health insurance-related barriers. Findings revealed that male, racial minority, unmarried individuals, individuals with low socio-economic status or residing in rural areas, and fee-for-service enrollees were less likely to use palliative or hospice care. Lack of communication with care providers is also a barrier of using palliative or hospice care. The factors identified in this review provide guidance on identification of high-risk population and intervention development to facilitate the use of palliative and hospice care in older adults with cancer. Larger prospective studies on this topic are needed to address this critical issue.

Association between advanced cancer patient-caregiver agreement regarding prognosis and hospice enrollment

BACKGROUND

Patients with advanced, incurable cancer who understand their illness is incurable are more likely to prefer hospice care at the end of life compared with patients who believe their illness is curable. To the authors' knowledge, it is unclear whether patient-caregiver agreement regarding perceived prognosis is associated with hospice enrollment.

METHODS

The current study examined the prospective relationship between patient-caregiver agreement concerning perceived prognosis and hospice enrollment in the last 30 days of life. Data were collected during a cluster randomized controlled trial examining a communication intervention for oncologists and patients with advanced cancer and their caregivers. At the time of study entry, patients and caregivers (141 dyads) were categorized as endorsing a "good" prognosis if they: 1) reported a >50% chance of surviving ≥2 years; or if they 2) predicted that the patient's quality of life 3 months into the future would be ≥7 on an 11-point scale.

RESULTS

Approximately one-fifth of dyads agreed on a poor prognosis whereas approximately one-half disagreed regarding prognosis. In approximately one-third of dyads, patients and caregivers both believed the patient's future quality of life would be good (34%) and that the patient would live for ≥2 years (30%). Patients in these dyads were less likely to enroll in hospice compared with patients in dyads who disagreed and those who agreed on a shorter life expectancy and poor future quality of life.

CONCLUSIONS

Dyadic understanding of patients' projected life expectancy and future quality of life appears to be predictive of care received at the end of life. Improving rates of hospice enrollment may be best achieved with dyadic interventions.

Cohabitation Status Influenced Admittance to Specialized Palliative Care for Cancer Patients: A Nationwide Study from the Danish Palliative Care Database

BACKGROUND

The utilization of the health care system varies in relation to cohabitation status, but conflicting results have been found in studies investigating the association in relation to specialized palliative care (SPC).

OBJECTIVE

To investigate the association between cohabitation status and admittance to SPC; to establish whether this association differed between hospital-based palliative care team/units (mainly outpatient/home care) and hospice (mainly inpatient care).

DESIGN

A nationwide study based on the Danish Palliative Care Database, which is linked with additional registers.

MEASUREMENTS

The study population included all patients dying from cancer in Denmark between 2010 and 2012 (n = 44,480). The associations were investigated using logistic regression analysis adjusted for sex, age, diagnosis, and geography and standardized absolute prevalences.

RESULTS

Comparison with cohabiting patients showed that overall admittance to SPC was lowest among patients who were widows/widowers (odds ratio [OR] = 0.86; 95% confidence interval [CI]: 0.81-0.91) and those who had never married (OR = 0.74; 95% CI: 0.68-0.80). Patients living alone were more likely to be admitted to a hospice [e.g., divorced OR = 1.41 (95% CI: 1.31-1.52)] than to a hospital-based palliative care team/unit [e.g., never married OR = 0.64 (95% CI: 0.59-0.70)] compared with cohabiting patients. Standardized prevalences of overall admittance to SPC showed a similar pattern, for example, admittance was highest (41%) for patients cohabiting and lowest (30%) for patients who had never married.

CONCLUSION

Cohabiting individuals were favored in admittance to SPC. Compared with cohabiting patients it is unlikely that patients living alone have lower needs for SPC: results point toward inequity in admittance to specialist health care, a problem that should be addressed.

Social Inequalities in Palliative Care for Cancer Patients in the United States: A Structured Review

OBJECTIVES

To identify patterns of access to and use or provision of palliative care services in medically underserved and vulnerable groups diagnosed with cancer.

DATA SOURCES

Google Scholar, PubMed, MEDLINE, and Web of Science were searched to identify peer-reviewed studies that described palliative care in medically underserved or vulnerable populations diagnosed with cancer.

CONCLUSION

Disparities in both access and referral to palliative care are evident in many underserved groups. There is evidence that some groups received poorer quality of such care.

IMPLICATIONS FOR NURSING PRACTICE

Achieving health equity in access to and receipt of quality palliative care requires prioritization of this area in clinical practice and in research funding.

Variations in Hospice Utilization and Length of Stay for Medicare Patients With Melanoma

CONTEXT

Timely hospice referral is an indicator of high-quality end-of-life care for cancer patients. Variations in patient characteristics associated with hospice utilization and length of stay have been demonstrated in studies of other malignancies but not melanoma.

OBJECTIVES

We sought to understand hospice utilization and patient characteristics associated with variability in use for the older melanoma population.

METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify 13,393 melanoma patients aged 65+ years at time of diagnosis between 2000 and 2009, who died by 12/31/10. The primary outcome was enrollment in hospice with secondary outcome of hospice duration. Patient characteristics associated with variations in hospice enrollment were examined.

RESULTS

Among 13,393 patients who died with melanoma, 5298 (40%) received hospice care. Of these, 17% were enrolled in hospice for three days or less, while 13% had ≥90 days of hospice care. Despite improvements over time in the proportion of patients who received hospice and those who received at least 90 days of hospice care, late hospice enrollments did not change. Multivariable analysis revealed that patients of older age, with distant disease at time of diagnosis, and residing in rural areas or in census tracts with higher rates of high school completion were more likely to enroll in hospice.

CONCLUSION

Rates of hospice enrollment increased over time but remained under accepted quality benchmarks with variations evident in those who receive hospice services. Efforts to increase access to earlier hospice care for all patients dying with melanoma are essential.

Gender and geographic differences in Medicare service utilization during the last six months of life

End-of-life issues are important for senior women, particularly rural women, who are more likely than their urban counterparts to live alone. The role of residence as a factor for health-care utilization among Medicare beneficiaries during the last six months of life has yet to be investigated. The purpose of this study is to examine whether service utilization in the last six months of life differs across gender and rurality. The sample was restricted to fee-for-service Medicare beneficiaries who died between July 1, 2013, and December 31, 2013 (n = 39,508). The odds of rural beneficiaries using home health (aOR 0.87; 95% CI 0.81-0.93) and/or hospice (aOR 0.82; 95% CI 0.77-0.87) in the last six months of life were lower than urban beneficiaries. Female beneficiaries were more likely to use support services such as hospice (aOR 1.24; 95% CI 1.18-1.29) and/or home health services (aOR 1.07; 95% CI 1.02-1.13) than male beneficiaries. The odds of female beneficiaries using inpatient (aOR 1.14; 95% CI 1.08-1.20) and/or outpatient (aOR 1.06; 95% CI 1.01-1.12) were higher than male beneficiaries. This research is important as we examine the range of health services used during the last six months of life, by gender and rurality. Future research is needed to understand how access to health services, residential isolation, and age- and disease-related factors relate to women's observed greater use of inpatient, outpatient, hospice, and home health services in the last six months of life.

Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system

BACKGROUND

Hospice, a patient-centered care system for those with limited life expectancy, is important for enhancing quality of life and is understudied in integrated health care systems.

METHODS

This was a retrospective cohort study of 21,860 decedents with advanced-stage lung cancer diagnosed from January 2007 to June 2013 in the national US Veterans Affairs Health Care System. Trends over time, geographic regional variability, and patient and tumor characteristics associated with hospice use and the timing of enrollment were examined. Multivariable logistic regression and Cox proportional hazards modeling were used.

RESULTS

From 2007 to 2013, 70.3% of decedents with advanced-stage lung cancer were enrolled in hospice. Among patients in hospice, 52.9% were enrolled in the last month of life, and 14.7% were enrolled in the last 3 days of life. Hospice enrollment increased (adjusted odds ratio [AOR], 1.07; P < .001), whereas the mean time from the cancer diagnosis to hospice enrollment decreased by 65 days (relative decrease, 32%; adjusted hazard ratio, 1.04; P < .001). Relative decreases in late hospice enrollment were observed in the last month (7%; AOR, 0.98; P = .04) and last 3 days of life (26%; AOR, 0.95; P < .001). The Southeast region of the United States had both the highest rate of hospice enrollment and the lowest rate of late enrollment. Patient sociodemographic and lung cancer characteristics were associated with hospice enrollment.

CONCLUSIONS

Among patients with advanced-stage lung cancer in the Veterans Affairs Health Care System, overall and earlier hospice enrollment increased over time. Considerable regional variability in hospice enrollment and the persistence of late enrollment suggests opportunities for improvement in end-of-life care. Cancer 2018;124:426-33. © 2017 American Cancer Society.

Admittance to specialized palliative care (SPC) of patients with an assessed need: a study from the Danish palliative care database (DPD)

BACKGROUND

Admittance to specialized palliative care (SPC) has been discussed in the literature, but previous studies examined exclusively those admitted, not those with an assessed need for SPC but not admitted. The aim was to investigate whether admittance to SPC for referred adult patients with cancer was related to sex, age, diagnosis, geographic region or referral unit.

MATERIAL AND METHODS

A register-based study with data from the Danish Palliative Care Database (DPD). From DPD we identified all adult patients with cancer, who died in 2010-2012 and who were referred to and assessed to have a need for SPC (N = 21,597).The associations were investigated using logistic regression models, which also evaluated whether time from referral to death influenced the associations.

RESULTS

In the adjusted analysis, we found that admittance was higher for younger patients [e.g., 50-59 versus 80 + years: odds ratio (OR) = 2.03; 1.78-2.33]. There was lower odds of admittance for patients with hematological malignancies and patients from two regions: Capital Region of Denmark and Region of Southern Denmark. Lower admittance among men and patients referred from hospital departments was explained by later referral.

CONCLUSIONS

In this first nationwide study of admittance to SPC among patients with a SPC need, we found difference in admittance according to age, diagnosis and region. This indicates that prioritization of the limited resources means that certain subgroups with a documented need have reduced likelihood of admission to SPC.

Is admittance to specialised palliative care among cancer patients related to sex, age and cancer diagnosis? A nation-wide study from the Danish Palliative Care Database (DPD)

BACKGROUND

Specialised palliative care (SPC) takes place in specialised services for patients with complex symptoms and problems. Little is known about what determines the admission of patients to SPC and whether there are differences in relation to institution type. The aims of the study were to investigate whether cancer patients' admittance to SPC in Denmark varied in relation to sex, age and diagnosis, and whether the patterns differed by type of institution (hospital-based palliative care team/unit, hospice, or both).

METHODS

This was a register-based study of adult patients living in Denmark who died from cancer in 2010-2012. Data sources were the Danish Palliative Care Database, Danish Register of Causes of Death and Danish Cancer Registry. The associations between the explanatory variables (sex, age, diagnosis) and admittance to SPC were investigated using logistic regression.

RESULTS

In the study population (N = 44,548) the overall admittance proportion to SPC was 37%. Higher odds of overall admittance to SPC were found for women (OR = 1.23; 1.17-1.28), younger patients (<40 compared with 80+ years old) (OR = 6.44; 5.19-7.99) and patients with sarcoma, pancreatic and stomach cancers, whereas the lowest were for patients with haematological malignancies. The higher admission found for women was most pronounced for hospices compared to hospital-based palliative care teams/units, whereas higher admission of younger patients was more pronounced for hospital-based palliative care teams/units. Patients with brain cancer were more often admitted to hospices, whereas patients with prostate cancer were more often admitted to hospital-based palliative care teams/units.

CONCLUSION

It is unlikely that the variations in relation to sex, age and cancer diagnoses can be fully explained by differences in need. Future research should investigate whether the groups having the lowest admittance to SPC receive sufficient palliative care elsewhere.

Physician Characteristics Strongly Predict Patient Enrollment In Hospice

Individual physicians are widely believed to play a large role in patients' decisions about end-of-life care, but little empirical evidence supports this view. We developed a novel method for measuring the relationship between physician characteristics and hospice enrollment, in a nationally representative sample of Medicare patients. We focused on patients who died with a diagnosis of poor-prognosis cancer in the period 2006-11, for whom palliative treatment and hospice would be considered the standard of care. We found that the proportion of a physician's patients who were enrolled in hospice was a strong predictor of whether or not that physician's other patients would enroll in hospice. The magnitude of this association was larger than that of other known predictors of hospice enrollment that we examined, including patients' medical comorbidity, age, race, and sex. Patients cared for by medical oncologists and those cared for in not-for-profit hospitals were significantly more likely than other patients to enroll in hospice. These findings suggest that physician characteristics are among the strongest predictors of whether a patient receives hospice care-which mounting evidence indicates can improve care quality and reduce costs. Interventions geared toward physicians, both by specialty and by previous history of patients' hospice enrollment, may help optimize appropriate hospice use.

Geographic Variation in California Pediatric Hospice Care for Children and Adolescents: 2007-2010

OBJECTIVE

To map and describe the geographic distribution of pediatric hospice care need versus supply in California over a 4-year time period (2007-2010).

METHODS

Multiple databases were used for this descriptive longitudinal study. The sample consisted of 2036 children and adolescent decedents and 136 pediatric hospice providers. Geocoded data were used to create the primary variables of interest for this study-need and supply of pediatric hospice care. Geographic information systems were used to create heat maps for analysis.

RESULTS

Almost 90% of the children and adolescents had a potential need for hospice care, whereas more than 10% had a realized need. The highest density of potential need was found in the areas surrounding Los Angeles. The areas surrounding the metropolitan communities of Los Angeles and San Diego had the highest density of realized hospice care need. Sensitivity analysis revealed neighborhood-level differences in potential and realized need in the Los Angeles area. Over 30 pediatric hospice providers supplied care to the Los Angeles and San Diego areas.

CONCLUSION

There were distinctive geographic patterns of potential and realized need with high density of potential and realized need in Los Angeles and high density of realized need in the San Diego area. The supply of pediatric hospice care generally matched the needs of children and adolescents. Future research should continue to explore the needs of children and adolescents at end of life at the neighborhood level, especially in large metropolitan areas.

Are there Racial Differences in Attitudes Toward Hospice Care? A Study of Hospice-Eligible Patients at the Visiting Nurse Service of New York

Research on African American and white attitudes, perceptions, and knowledge of hospice care has focused predominantly on patients and providers in institutions and community-based care settings. Little is known about patients receiving home health services, despite growing trends toward noninstitutional care in the United States. This study of home health clients who are eligible for hospice, but not currently receiving it, found few differences between racial groups with regard to attitudes about end-of-life care. An alarming proportion of African American and white home health clients held erroneous ideas about hospice care and had not discussed this option with their providers. These findings suggest that increased referrals to home-based hospice care among home health clients depend on the availability and professional dissemination of accurate, spiritually sensitive information.

The Impact of Hospice Services in the Care of Patients with Advanced Stage Nonsmall Cell Lung Cancer

INTRODUCTION

Prior research has shown that advanced stage nonsmall cell lung cancer (NSCLC) patients enrolled in hospice care receive less aggressive treatment at the end of life (EOL) without compromising survival. Our purpose was to profile the continuum of care of these patients, exploring the connection between hospice enrollment and quality indicators for excellence in EOL cancer care.

METHODS

One hundred ninety-seven deceased stage IV NSCLC patients diagnosed between 2008 and 2010 at two separate tertiary care centers within the same county were identified. A retrospective review was conducted, collecting data from electronic medical records regarding antitumor treatment, postdiagnosis hospital visits and admissions, hospice referrals and enrollments, and circumstances surrounding the patient's death. Patients were grouped by their status of hospice enrollment, and the remainder of the measures compared accordingly.

RESULTS

There was no significant difference found in total number of postdiagnosis hospital admissions between the patients who were enrolled in hospice and those who were not. However, the group who received hospice services had a significantly lower number of hospitalizations (p < 0.001), emergency department visits (p < 0.01), and intensive care unit admissions in the last 30 days of life (p < 0.001). The number of lines of chemotherapy received did not differ significantly between the groups. Median survival, measured by the length of time between diagnosis and death, was significantly longer for hospice patients (p = 0.02).

CONCLUSIONS

This study demonstrates that, among patients with metastatic NSCLC, hospice enrollment was associated with optimized EOL oncological care and a significantly longer median survival.

Place of Death of Individuals with Terminal Cancer: New Insights from Medicare Hospice Place-of-Service Codes

OBJECTIVES

To use place-of-service (POS) codes in the Medicare hospice claims files to document where elderly hospice users with cancer die.

DESIGN

Retrospective cohort study.

SETTING

Surveillance, Epidemiology, and End Results (SEER) cancer registry areas.

PARTICIPANTS

Elderly Medicare beneficiaries who died of lung, breast, colorectal, or pancreatic cancer in 2007 and 2008 (N = 46,037).

MEASUREMENT

Use of hospice, place of service at death (home, nursing home, hospital, inpatient hospice, other), length of stay in hospice.

RESULTS

Two-thirds of the beneficiaries used hospice. Younger, male, black, Asian, and unmarried beneficiaries and those enrolled in fee-for-service Medicare or from areas with lower income were less likely to use hospice. Hospice enrollment also varied significantly according to SEER registry. Thirty percent of the hospice users were not receiving home-based care at the time of death, and 17% were enrolled for less than 3 days. Factors associated with hospice death in the home mirrored those associated with hospice use. Individuals dying in hospitals (odds ratio (OR) = 5.13, 95% confidence interval (CI) = 4.63-5.69), inpatient hospice (OR = 1.86, 95% CI = 1.70-2.02), and nursing homes (OR = 1.19, 95% CI = 1.10-1.28) had greater odds of a short hospice stay (≤7 days) than those dying at home, after controlling for all other measured factors, whereas those dying in nursing homes had greater odds of long stays (>180 days) (OR = 1.46, 95% CI = 1.28-1.67).

CONCLUSION

New hospice POS codes are useful for understanding place of death for hospice users. Hospice deaths cannot be assumed to happen at home.

Utilization of surgery, chemotherapy, radiation therapy, and hospice at the end of life for patients diagnosed with metastatic melanoma

OBJECTIVES

To examine the patterns of utilization of radiation therapy, chemotherapy, surgery, and hospice at the end-of-life care for patients diagnosed with metastatic melanoma.

METHODS

We identified 816 Medicare beneficiaries toward who were 65 years of age or older, with pathologically confirmed metastatic malignant melanoma between January 1, 2000, and December 31, 2007. We evaluated trends and associations between sociodemographic and health service characteristics and the use of hospice care, chemotherapy, surgery, and radiation therapy.

RESULTS

We found increasing use of surgery for patients with metastatic melanoma from 13% in 2000 to 30% in 2007 (P=0.03 for trend), and no significant fluctuation in the use of chemotherapy (P=0.43) or radiation therapy (P=0.46). Older patients were less likely to receive radiation therapy or chemotherapy. The use of hospice care increased from 61% in 2000 to 79% in 2007 (P=0.07 for trend). Enrollment in short-term (1 to 3 d) hospice care use increased, whereas long-term hospice care (≥4 d) remained stable. Patients living in the SEER (Surveillance, Epidemiology and End Results) northeast and south regions were less likely to undergo surgery. Patients enrolled in long-term hospice care used significantly less chemotherapy, surgery, and radiation therapy.

CONCLUSIONS

Surgery and hospice care use increased over the years of this study, whereas the use of chemotherapy and radiation therapy remained consistent for patients diagnosed with metastatic melanoma.

Factors Affecting Willingness to Use Hospice in Racially/Ethnically Diverse Older Men and Women

Racial/ethnic minorities tend to underutilize hospice services. Guided by Andersen behavioral health model, the purpose of this study was to explore the predictors of the willingness to use hospice services in racially/ethnically diverse older men and women. Data were drawn from the Survey of Older Floridians: 504 non-Hispanic whites, 360 African Americans, 328 Cuban Americans, and 241 non-Cuban Hispanics. In each group, logistic regression models of the willingness to use hospice were estimated. A greater likelihood of willingness was observed among younger non-Hispanic whites and among African Americans with fewer functional disabilities. In non-Cuban Hispanics, English proficiency increased the willingness by 3.1 times. Findings of the study identified group-specific factors contributing to the willingness to use hospice services and hold implications for tailored intervention programs.

Determinants of access to pediatric hospice care: A conceptual model

One of the many difficult moments for families of children with life-limiting illnesses is to make the decision to access pediatric hospice care. Although determinants that influence families' decisions to access pediatric hospice care have been recently identified, the relationship between these determinants and access to pediatric hospice care have not been explicated or grounded in accepted healthcare theories or models. Using the Andersen Behavioral Healthcare Utilization Model, this article presents a conceptual model describing the determinants of hospice access. Predisposing (demographic; social support; and knowledge, beliefs, and values), enabling (family and community resources) and need (perceived and evaluated needs) factors were identified through the use of hospice literature. The relationships among these factors are described and implications of the model for future study and practice are discussed.

Provider-based research networks demonstrate greater hospice use for minority patients with lung cancer

PURPOSE

The Community Clinical Oncology Program (CCOP) and Minority-Based Community Clinical Oncology Program (MBCCOP) are provider-based research networks (PBRN) that improve minority enrollment in cancer-focused clinical trials. We hypothesized that affiliation with a PBRN may also mitigate racial differences in hospice enrollment for patients with lung cancer.

METHODS

We used the SEER-Medicare data, linked to the National Cancer Institute's CCOP program data, to identify all patients (≥ age 65 years) with lung cancer, diagnosed from 2001 to 2007. We defined clinical treatment settings as CCOP, MBCCOP, academic, or community-affiliated and used multivariable logistic regression analysis to determine factors associated with hospice enrollment.

RESULTS

Forty-one thousand eight hundred eighty-five (55.1%) patients with lung cancer enrolled in hospice before death. Approximately 55% of CCOP, 57% of MBCCOP, 57% of academic, and 52% of community patients enrolled. Patients who were more likely to enroll were female (odds ratio [OR], 1.36; 95% CI, 1.31 to 1.40); ≥ age 79 years (OR, 1.11; 95%CI, 1.06 to 1.16); white; lived in more educated areas; had minimal comorbidities; and had distant disease. Asian and black patients in academic (41.1% and 50.4%, respectively) and community practices (35.2% and 43.4%, respectively) were less likely to enroll in hospice compared with white patients (academic, 58.8%; community, 53.1%). However, hospice enrollment was equivalent for black and white patients in MBCCOP (59.5% v 57.2%) and CCOP (52.2% v 56.3%) practices.

CONCLUSION

Minority patients with lung cancer receiving treatment in cancer-focused PBRN- affiliated practices have greater hospice enrollment than those treated in academic and community practices.

Factors Associated With Utilization of an Inpatient Palliative Care Consultation Service in an Urban Public Hospital

Rationale: To evaluate factors associated with palliative care consultation (PCC) in an urban public hospital. Methods: A retrospective chart review of patients who died on inpatient medical services. Results: Patients with a PCC were more likely to have a “do not resuscitate” (DNR) order at the time of death (p<0.001) and had a decreased likelihood of death in the ICU (p<0.001). Factors associated with PCC in a multivariate analysis included: cancer diagnosis (p=0.01), at least a high school education (p=0.04), older age (p=.003), and birth outside the US (p=0.03). Conclusion: The increased PCC utilization for immigrants is in contrast to previously reported literature. This increased use may be because access to services in a municipal hospital is not driven by demographic and socioeconomic factors.

Access to palliative care among patients treated at a comprehensive cancer center

BACKGROUND

Palliative care (PC) is a critical component of comprehensive cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually receive PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center and the predictors of PC referral.

METHODS

We reviewed the charts of consecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center who died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death.

RESULTS

In total, 366 of 816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range, 0.5-4.2 months) and the median number of medical team encounters before PC was 20 (interquartile range, 6-45). On multivariate analysis, older age, being married, and specific cancer types (gynecologic, lung, and head and neck) were significantly associated with a PC referral. Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between an advanced cancer diagnosis and PC consultation (median, 16 months), the shortest interval between PC consultation and death (median, 0.4 months), and one of the largest numbers of medical team encounters (median, 38) before PC.

CONCLUSIONS

We found that a majority of cancer patients at our cancer center did not access PC before they died. PC referral occurs late in the disease process with many missed opportunities for referral.

Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer

PURPOSE

To measure intensity of end-of-life (EOL) care for Medicare cancer patients and variations in care by age, gender, and race.

PATIENTS AND METHODS

This retrospective cohort analysis of Medicare claims (20% sample) examined 235,821 Medicare Parts A and B fee-for-service patients dying with poor-prognosis cancers between 2003 and 2007. Logistic regression models quantified associations between care intensity and age, gender, and race. Measures included hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions, in-hospital deaths, late-life chemotherapy administration, overall and late hospice enrollment within six months of death.

RESULTS

Within 30 days of death, 61.3% of patients were hospitalized, 10.2% were hospitalized more than once, 10.2% visited an ED more than once, 23.7% had ICU admissions, and 28.8% died in-hospital. Within two weeks of death, 6% received chemotherapy. In their final six months, 55.2% accessed hospice, 15.1% within three days of death. Older age (≥75 versus <75) was associated with lower odds ratios (ORs) of 0.49 to 0.89 for aggressive care, and an OR of 0.92 (95% CI 0.89-0.95) for late hospice enrollment. Female gender was associated with lower ORs (0.82 to 0.86) for aggressive care, and an OR of 0.84 (95% CI 0.81-0.86) for late hospice enrollment. Black (versus nonblack) race was associated with higher ORs (1.08 to 1.38) for aggressive acute care, lower ORs for late chemotherapy, OR 0.76 (95% CI 0.71-0.81), and late hospice enrollment, OR 0.81 (95% CI 0.76-0.86).

CONCLUSIONS

Seniors dying with poor-prognosis cancer experience high-intensity care with rates varying by age, gender, and race.

The role of race and ethnicity in predicting length of hospice care among older adults

BACKGROUND

The purpose of the study was to examine both direct and interactive roles of race/ethnicity with patients' characteristics (age, gender, relationship with caregiver, diagnosis, referral source, and payment type) in predicting length of hospice care.

METHOD

This study included a total of 16,323 patients 65 years of age and older (M(age)=81.4, SD=8.3) who were served by a hospice in central Florida during a four-year period, 2002-2006. Survival analyses were conducted using the Cox proportional hazards model to predict the length of hospice care and test the interaction effects of race/ethnicity.

RESULTS

The majority of subjects (83.5%) were white, 7.6% were African-American, and 8.9% were Hispanic. During the study period, 58.5% died. All patient characteristics were significantly associated with the length of hospice care (p < .05). Overall, Hispanics had the longest hospice stay (M=98.84 days), followed by African-Americans (M=90.29) and whites (M=88.20). With the exception of African-American women who were no more likely to stay longer under hospice care than African-American men, the women in this study stayed longer under hospice care than men did. Patients referred from long-term care (LTC) settings had shorter stays in hospice care compared to those referred by physicians in other settings. Additionally, African-Americans and Hispanics referred from LTC had significantly shorter hospice stays than those referred by primary physicians.

CONCLUSION

In this limited sample of hospice patients, length of stay was longer for minority patients than white patients.

Racial disparities in length of stay in hospice care by tumor stage in a large elderly cohort with non-small cell lung cancer

This study examined whether there are racial disparities for length of stay in hospice for patients with non-small cell lung cancer (NSCLC).We studied 53,626 deceased patients aged ≥66 years diagnosed with American Joint Committee on Cancer stages I-IV NSCLC identified from the Surveillance, Epidemiology, and End Results-Medicare linked data who used hospice services in the last six months before death, and died between 1 January 1991 and 31 December 2005. Median time (days) and percent length of stay in hospice, and multivariate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) using zero-truncated negative binomial regression described relationships. In 2000-2005, most patients (64.1%) had <30 days, including those (30.2%) with <7 days length of stay in hospice care. After adjusting for confounders, the IRR for length of stay in hospice compared to whites was 38% increased for blacks (IRR = 1.38; 95% CI: 1.01-1.89), and almost three-fold increased for Hispanics (IRR = 2.91;95% CI: 1.15-7.37) at stages I-II. However, blacks at stages III-IV had slightly decreased use of hospice services (IRR = 0.91; 95% CI: 0.85-0.97). Length of stay decreased slightly among blacks diagnosed with late stage (III-IV) NSCLC in 2000-2005.The gap in disparity for length of stay in hospice has narrowed for ethnic minorities compared to whites, while some ethnic minorities had greater length of stay at early disease stage.

Hospice care and resource utilization in Medicare beneficiaries with heart failure

BACKGROUND

Although hospice use may be increasing among heart failure patients, its association with both cost and intensity of care in this population has not been well examined.

OBJECTIVE

To assess the association of hospice care with resource utilization among a national sample of Medicare beneficiaries with heart failure during the last 6 months of life.

METHODS

We performed a cross-sectional analysis of the 5% sample of Medicare claims data. Negative binomial regression models were used to compare expenditures, hospitalization rates, and intensive care unit (ICU) days between hospice and nonhospice beneficiaries. We used Poisson regression models to compare utilization of certain procedures between hospice and nonhospice beneficiaries.

RESULTS

Among 16613 Medicare beneficiaries who died with heart failure in 2007, 6436 (38.7%) received hospice care during the last 6 months of life. The mean total medical expenditures were $31,793 (SD 25,691) among decedents with hospice care, in comparison to $34,067 (SD 40,561) among decedents without hospice care. However, after adjustments for covariates, hospice care was associated with 4% higher expenditures (cost ratio, 1.04; 95% confidence interval, CI: 1.01-1.07). Hospice use was associated with reduced hospitalizations (adjusted incidence rate ratio, 0.87, 95% CI: 0.84-0.89), ICU days (adjusted incidence rate ratio, 0.68, 95% CI: 0.63-0.73), and procedures, including cardiac catheterization, noninvasive ventilation, and mechanical ventilation.

CONCLUSIONS

Despite lower rates of hospitalization, ICU days, and invasive procedures, hospice care was not associated with reduced expenditures in heart failure. Financial savings related to reduced intensive medical care seems to be offset by the expenditures related to hospice care itself.

Prostate cancer survivorship: lessons from caring for the uninsured

Since 2001, UCLA has operated

IMPACT

Improving Access, Counseling, and Treatment for Californians with Prostate Cancer (CaP). Funded by the California Department of Public Health, with a cumulative budget of over $80 million, the program provides comprehensive care for low-income, uninsured Californian men with biopsy-proven CaP. Health services research conducted with program enrollees, through the UCLA Men's Health Study, yields an opportunity to perform qualitative and quantitative assessments of patient-reported outcomes in these men, all members of historically underserved, primarily minority populations. This review summarizes data from several studies in which validated instruments were administered longitudinally in 727 participants, prospectively measuring health-related quality of life (HRQOL), self-efficacy in interactions with physician interactions, social and emotional health, symptom distress, satisfaction with care, and other patient-reported outcomes.

Disparity in hospice utilization by African American patients with cancer

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

Hospice care and survival among elderly patients with lung cancer

BACKGROUND

Recently observed trends toward increasingly aggressive end-of-life care may reflect providers' concerns that hospice may hasten death.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 7879 patients aged 65 years or older who died of advanced non-small-cell lung cancer from 1991 through 1999 after surviving for at least 3 months from their cancer diagnoses. Length of hospice admission post-cancer diagnosis and indicators of aggressive end-of-life care were ascertained based on claims data. We evaluated overall survival and care near death after controlling for baseline characteristics by using propensity score (PS) and instrumental variable analyses (IVA).

RESULTS

Hospice patients were older, more likely to be non-Hispanic white and female, more likely to reside in urban areas with high hospice availability and higher socioeconomic status, more likely to be treated in a teaching hospital, and received less aggressive end-of-life care compared to nonhospice patients. Among hospice patients, those experiencing short-term hospice admissions within 3 days of death were more likely to be male, reside in urban areas, be treated in a teaching hospital, and receive more aggressive end-of-life care. PS analysis found that survival favored hospice patients slightly relative to nonhospice patients by 5.0 percentage points (25.7% versus 20.7%) at 1 year and 1.4 percentage points (6.9% versus 5.5%) at 2 years postdiagnosis (p < 0.001), while there was no significant difference between those with short- and longer duration hospice stays (p = 1.00). IVA confirmed these findings.

CONCLUSIONS

Hospice enrollment did not compromise length of survival following advanced lung cancer diagnosis.

End-of-life care in Medicare beneficiaries dying with pancreatic cancer

BACKGROUND

The authors' goal was to characterize hospice enrollment and aggressiveness of care for pancreatic cancer patients at the end of life.

METHODS

Surveillance, Epidemiology, and End Results and linked Medicare claims data (1992-2006) were used to identify patients with pancreatic cancer who had died (n = 22,818). The authors evaluated hospice use, hospice enrollment ≥ 4 weeks before death, and aggressiveness of care as measured by receipt of chemotherapy, acute care hospitalization, and intensive care unit (ICU) admission in the last month of life.

RESULTS

Overall, 56.9% of patients enrolled in hospice, and 35.9% of hospice users enrolled for 4 weeks or more. Hospice use increased from 36.2% in 1992-1994 to 67.2% in 2004-2006 (P < .0001). Admission to the ICU and receipt of chemotherapy in the last month of life increased from 15.5% to 19.6% (P < .0001) and from 8.1% to 16.4% (P < .0001), respectively. Among patients with locoregional disease, those who underwent resection were less likely to enroll in hospice before death and much less likely to enroll early. They were also more likely to receive chemotherapy (14% vs 9%, P < .0001), be admitted to an acute care hospital (61% vs 53%, P < .0001), and be admitted to an ICU (27% vs 15%, P < .0001) in the last month of life.

CONCLUSIONS

Although hospice use increased over time, there was a simultaneous decrease in early enrollment and increase in aggressive care at the end of life for patients with pancreatic cancer.

A population-based study on the determinants of hospice utilization in the last year of life for Taiwanese cancer decedents, 2001-2006

BACKGROUND

No population-based studies conducted outside Western countries have identified determinants of hospice utilization for all ages and cancer groups.

OBJECTIVE

To evaluate associations between hospice utilization in the last year of life and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of healthcare resources at the hospital and regional levels in Taiwan.

METHODS

Retrospective cohort study using administrative data among 204, 850 Taiwanese cancer decedents, 2001-2006.

RESULTS

Rates of hospice utilization increased significantly (12.99-17.24%) over the study period. Hospice utilization was more likely for cancer patients who were female; over 65 years old; currently or formerly married; with ≤1 concurrent disease; diagnosed with breast cancer or cancer having a poorer prognosis; with distant metastasis, and longer illness duration (>2 months since diagnosis); receiving care in a teaching hospital or hospital with an inpatient-hospice unit; and receiving care in a region with greater density of inpatient-hospice beds. However, patients with hematological malignancies and esophageal cancer were less likely to use hospice care.

CONCLUSIONS

Despite the 1.33 times increase in hospice utilization among cancer patients who died from 2001 to 2006, only one in six Taiwanese cancer decedents used hospice care in their last year of life. Our findings regarding determinants of hospice utilization should be used by healthcare professionals and policy makers to guide the development of policies and interventions that facilitate prognosis disclosure and EOL care discussions between physicians and patients, especially younger patients, to help the transition from curative to palliative care.

Hospice use in Alabama, 2002-2005

CONTEXT

The literature predominately describes hospice utilization among Medicare recipients, with a limited number of reports describing use among all age groups.

OBJECTIVES

This study aimed to describe and compare patterns of hospice use among decedents of all ages in Alabama using a population-based approach.

METHODS

We obtained death certificates for Alabama residents who died from January 1, 2002 to December 31, 2005 (n=178,420). To ascertain hospice use, we linked death certificates to the hospice administering care using state-mandated listings of deaths reported by hospices. Additionally, each decedent's residence at death was geocoded and area-level socioeconomic status (SES) measures were added.

RESULTS

From 2002 to 2005, a total of 43,638 Alabamians died while under hospice care, representing a quarter (24.5%) of all deaths in the state. During this four-year span, the rate of hospice use increased by nearly 15% (22.2%-25.6%). As expected, rates of hospice use increased with age at death. For the SES indicators for poverty, education, and income, rates of hospice use increased as SES improved. However, this pattern was found to vary by race and metro/nonmetro status.

CONCLUSIONS

In addition to revealing racial, geographic, and other disparities in hospice care across Alabama, our results indicate usage rates in Alabama trail behind those observed nationally. We also identified previously unreported interactions between race, urbanization level, and poverty classification. Future studies should explore whether such relationships exist elsewhere and the rationale for their occurrence.

Geographic access to hospice in the United States

BACKGROUND

Despite a 41% increase in the number of hospices since 2000, more than 60% of Americans die without hospice care. Given that hospice care is predominantly home based, proximity to a hospice is important in ensuring access to hospice services. We estimated the proportion of the population living in communities within 30 and 60 minutes driving time of a hospice.

METHODS

We conducted a cross-sectional study of geographic access to U.S. hospices using the 2008 Medicare Provider of Services data, U.S. Census data, and ArcGIS software. We used multivariate logistic regression to identify gaps in hospice availability by community characteristics.

RESULTS

As of 2008, 88% of the population lived in communities within 30 minutes and 98% lived in communities within 60 minutes of a hospice. Mean time to the nearest hospice was 15 minutes and the range was 0 to 403 minutes. Community characteristics independently associated with greater geographic access to hospice included higher population density, higher median income, higher educational attainment, higher percentage of black residents, and the state not having a Certificate of Need policy. The percentage of each state's population living in communities more than 30 minutes from a hospice ranged from 0% to 48%.

CONCLUSIONS

Recent growth in the hospice industry has resulted in widespread geographic access to hospice care in the United States, although state and community level variation exists. Future research regarding variation and disparities in hospice use should focus on barriers other than geographic proximity to a hospice.

Hospice use and high-intensity care in men dying of prostate cancer

BACKGROUND

Hospice programs improve the quality of life and quality of death for men dying of cancer. We sought to characterize hospice use by men dying of prostate cancer and to compare the use of high-intensity care between those who did or did not enroll in hospice.

METHODS

We used linked Surveillance, Epidemiology, and End Results-Medicare data to identify a cohort of Medicare beneficiaries who died of prostate cancer between 1992 and 2005. We created 2 multivariable logistic regression models, one to identify factors associated with hospice use and one to determine the association of hospice use with the receipt of diagnostic and interventional procedures and physician visits at the end of life.

RESULTS

Of 14,521 men dying of prostate cancer, 7646 (53%) used hospice for a median of 24 days. Multivariable modeling demonstrated that African American ethnicity (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.68-0.88) and higher Charlson comorbidity index (OR, 0.49; 95% CI, 0.44-0.55) were associated with lower odds of hospice use, while having a partner (OR, 1.23; 95% CI, 1.14-1.32) and more recent year of death (OR, 1.12; 95% CI, 1.11-1.14) were associated with higher odds of hospice use. Men dying of prostate cancer who enrolled in hospice were less likely (OR, 0.82; 95% CI, 0.74-0.91) to receive high-intensity care, including intensive care unit admissions, inpatient stays, and multiple emergency department visits.

CONCLUSIONS

The proportion of individuals using hospice is increasing, but the timing of hospice referral remains poor. Those who enroll in hospice are less likely to receive high-intensity end-of-life care.

Quality of end-of-life care in low-income, uninsured men dying of prostate cancer

BACKGROUND

The quality of end-of-life care was assessed in disadvantaged men prospectively enrolled in a public assistance program. That end-of-life care would be aggressive, more so than recommended by quality-of-care guidelines, was hypothesized.

METHODS

Included in the study were all 60 low-income, uninsured men in a state-funded public assistance program who had died since its inception in 2001. To measure quality of end-of-life care, information was collected regarding timing of the institution of new chemotherapeutic regimens, time from administration of last chemotherapy dose to death, the number of inpatient admissions and intensive care unit stays made in the 3 months preceding death, and the number of emergency room visits made in the 12 months before dying. Also noted were hospice use and the timing of hospice referrals.

RESULTS

Eighteen men (30%) enrolled in hospice before death and the average hospice stay lasted 45 days (standard deviation, 32; range, 2-143 days; median, 41 days). Two patients (11%) were enrolled for fewer than 7 days, and none were enrolled for more than 180 days. The average time from administration of the last dose of chemotherapy to death was 104 days. Chemotherapy was never initiated within 3 months of death, and in only 2 instances (6%) was the final chemotherapeutic regimen administered within 2 weeks of dying. Use of hospital resources (emergency room visits, inpatient admissions, and intensive care unit stays) was uniformly low (mean, 1.0 +/- 1.0, 0.65 +/- 0.82, and 0.03 +/- 0.18, respectively).

CONCLUSIONS

End-of-life care in disadvantaged men dying of prostate cancer, who enroll in a comprehensive statewide assistance program, is high-quality.

Factors that influence the presence of a hospice in a rural community

PURPOSE

The purpose of this study was to identify socioeconomic, physician-related, and rural-urban factors that may influence the presence of a Medicare-certified hospice in three rural-urban areas.

DESIGN

This was secondary analysis of selected socioeconomic, physician-related, and rural-urban data from 3,140 counties using the 2005 Area Resource File, a county-level database. The county was the unit of analysis.

METHODS

Descriptive statistics were calculated for selected socioeconomic, physician, and rural-urban variables for the data set of 3,140 counties. Logistic regression was used to identify variables that influenced the presence of a Medicare-certified hospice across three rural-urban areas.

FINDINGS

As the rural-urban classification progressed from metropolitan (least rural) to rural-nonadjacent (most rural), the physician rate, racial-ethnic diversity, and number of counties with at least one Medicare-certified hospice decreased. However, in all three rural-urban areas only the physician rate was consistently significantly associated with the presence of a Medicare-certified hospice.

CONCLUSIONS

Given the increasing numbers of patients and families who will be facing end-of-life care issues across the globe, access to hospice care is a significant end-of-life outcome. The most rural communities are least likely to have a Medicare-certified hospice. The higher the physician rate, the more likely a county is to have a Medicare-certified hospice. The Medicare Hospice Benefit's regulations requiring a physician's certification of terminal illness may be creating a barrier to hospice care, especially in rural communities. In this study, racial-ethnic diversity decreased as the rural-urban classification progressed from metropolitan (least rural) to rural-adjacent to metro to rural-nonadjacent (the most rural). The availability of Medicare-certified hospices in the metro and rural nonadjacent counties was influenced by the minority composition of the county. More research is needed on how the interaction of rurality, race-ethnicity, and physician access may affect access to hospice in rural communities.

CLINICAL RELEVANCE

Increasing numbers of patients and their families across the globe will be facing end-of-life care. One of the most common barriers to end-of-life care in rural communities all over the world is physician availability. People living in rural communities with few physicians may experience less access to the comprehensive services of hospice than people living in metropolitan communities and therefore not realize important end-of-life outcomes such as symptom management, improved quality of life, financial support, and bereavement support.

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

Background

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

Methods

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

Results

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

Conclusion

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

Impact of caregivers' unmet needs for supportive care on quality of terminal cancer care delivered and caregiver's workforce performance

GOALS OF WORK

Family caregivers play an important role in caring for cancer patients, but the impact of caregivers' unmet needs on the quality of end-of-life (EOL) care they deliver and on their workplace performance are less understood.

PATIENTS AND METHODS

We identified 1,662 family caregivers of cancer patients who had died at any of 17 hospitals in Korea during 2004. The caregivers answered a telephone questionnaire about needs that were not met when they delivered terminal cancer care and how those unmet their needs affected their workplace performance; they also answered the Quality Care Questionnaire-End of Life (QCQ-EOL).

RESULTS

Compared with caregivers who did not have unmet needs, caregivers who had unmet needs for symptom management, financial support, or community support showed poorer QCQ-EOL scores (P < 0.01). Caregivers who had unmet needs for financial support (adjusted odds ratio (aOR) = 7.55; 95% confidential interval (CI) 3.80-15.00), psychosocial support (aOR = 6.24; 95% CI 2.95-13.05), symptom management (aOR = 3.21; 95% CI 2.26-4.54), community support (aOR = 3.82; 95% CI 2.38-6.11), or religious support (aOR = 4.55; 95% CI 1.84-11.26) were more likely to experience work limitations. Caregivers of patients receiving conventional hospital care were more likely to have unmet needs for symptom management (aOR = 1.21; 95% CI 1.00-1.47), psychosocial support (aOR = 1.99; 95% CI 1.37-2.88), and religious support (aOR = 1.73; 95% CI 1.08-2.78) than those of patients receiving palliative hospice care.

CONCLUSIONS

Caregivers' unmet needs negatively affected both the quality of EOL care they delivered and their workplace performance. More investment in caregiver support and public policies that meet caregiver needs are needed, and hospice use should be encouraged.

Discussions with physicians about hospice among patients with metastatic lung cancer

BACKGROUND

Many terminally ill patients enroll in hospice only in the final days before death or not at all. Discussing hospice with a health care provider could increase awareness of hospice and possibly result in earlier use.

METHODS

We used data on 1517 patients diagnosed as having stage IV lung cancer from a multiregional study. We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health care provider before an interview 4 to 7 months after diagnosis as reported by either the patient or surrogate or documented in the medical record.

RESULTS

Half (53%) of the patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy were less likely to have discussed hospice. Only 53% of individuals who died within 2 months after the interview had discussed hospice, and rates were lower among those who lived longer. Patients who reported that they expected to live less than 2 years had much higher rates of discussion than those expecting to live longer. Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms. A third of patients who reported discussing do-not-resuscitate preferences with a physician had also discussed hospice.

CONCLUSIONS

Many patients diagnosed as having metastatic lung cancer had not discussed hospice with a provider within 4 to 7 months after diagnosis. Increased communication with physicians could address patients' lack of awareness about hospice and misunderstandings about prognosis.

Patterns of access to community palliative care services: a literature review

Policies state that access to palliative care should be provided according to principles of equity. Such principles would include the absence of disparities in access to health care that are systematically associated with social advantage. A review of the literature a decade ago identified that patients with different characteristics used community palliative care services in variable ways that appeared inequitable. The objective of this literature review was to review recent literature to identify whether such variability remains. Searching included the use of electronic databases, scrutinizing bibliographies, and hand searching journals. Articles were included if they were published after 1997 (the date of the previous review) up to the beginning of 2008, and if they reported any data that investigated the characteristics of adult patients in relation to their relative utilization of community palliative care services, with reference to a comparator population. Forty-eight studies met the inclusion criteria. Patients still access community palliative care services in variable ways. Those who are older, male, from ethnic minority populations, not married, without a home carer, are socioeconomically disadvantaged, and who do not have cancer are all less likely to access community palliative care services. These studies do not identify the reasons for such variable access, or whether such variability is warranted with reference to clinical need or other factors. Studies tend to focus on access to specialist palliative care services without looking at the complexities of service use. Studies need to move beyond description of utilization patterns, and examine whether such patterns are inequitable, and what is happening in the referral or other processes that may result in such patterns.

A population-based study of age inequalities in access to palliative care among cancer patients

BACKGROUND

Inequalities in access to palliative care programs (PCP) by age have been shown to exist in Canada and elsewhere. Few studies have been able to provide greater insight by simultaneously adjusting for multiple demographic, health service, and socio-cultural indicators.

OBJECTIVE

To re-examine the relationship between age and registration to specialized community-based PCP programs among cancer patients and identify the multiple indicators contributing to these inequalities.

METHODS

This retrospective, population-based study was a secondary data analysis of linked individual level information extracted from 6 administrative health databases and contextual (neighborhood level) data from provincial and census information. Subjects included all adults who died due to cancer between 1998 and 2003 living within 2 District Health Authorities in the province of Nova Scotia, Canada. The relationship between registration in a PCP and age was examined using hierarchical nonlinear regression modeling techniques. Identification of potential patient and ecologic contributing indicators was guided by Andersen's conceptual model of health service utilization.

RESULTS

Overall, 66% of 7511 subjects were registered with a PCP. Older subjects were significantly less likely than those <65 years of age to be registered with a PCP, in particular those aged 85 years and older (adjusted odds ratio: 0.4; 95% confidence interval: 0.3-0.5). Distance to the closest cancer center had a major impact on registration.

CONCLUSIONS

Age continues to be a significant predictor of PCP registration in Nova Scotia even after controlling for the confounding effects of many new demographic, health service, and ecologic indicators.

Growth in the care of older patients by hospitalists in the United States

BACKGROUND

National and population-based information on the increase in patient care by hospitalists in the United States is lacking.

METHODS

Using a 5% sample of Medicare beneficiaries in 1995, 1997, 1999, and the period from 2001 through 2006, we identified 120,226 physicians in general internal medicine who were providing care to older patients in 5800 U.S. hospitals. We defined hospitalists as general internists who derived 90% or more of their Medicare claims for evaluation-and-management services from the care of hospitalized patients. We then calculated the percentage of all inpatient Medicare services provided by hospitalists and identified patient and hospital characteristics associated with the receipt of hospitalist services.

RESULTS

The percentage of physicians in general internal medicine who were identified as hospitalists increased from 5.9% in 1995 to 19.0% in 2006, and the percentage of all claims for inpatient evaluation-and-management services by general internists that were attributed to hospitalists increased from 9.1% to 37.1% during this same period. Accompanying the increase in care by hospitalists was an increase in the percentage of all hospitalized Medicare patients who were treated by general internists (both hospitalists and traditional, non-hospital-based general internists), from 46.4% in 1995 to 61.0% in 2006. In a multilevel, multivariable analysis controlling for patient and hospital characteristics, the odds of receiving care from a hospitalist increased by 29.2% per year from 1997 through 2006. In 2006, there was marked geographic variation in the rates of care provided by hospitalists, with rates of more than 70% in some hospital-referral regions.

CONCLUSIONS

These analyses of data from Medicare claims showed a substantial increase in the care of hospitalized patients by hospitalist physicians from 1995 to 2006.