1
|
Lenko RA, Hoffman GJ, Robinson-Lane SG, Silveira MJ, Voepel-Lewis T. Achieving goal-concordant care: Formal and informal advance care planning for White, Black, and Hispanic older adults. J Am Geriatr Soc 2024; 72:2412-2422. [PMID: 38760957 PMCID: PMC11323214 DOI: 10.1111/jgs.18971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Advance care planning (ACP) aims to ensure that patients receive goal-concordant care (GCC), which is especially important for racially or ethnically minoritized populations at greater risk of poor end-of-life outcomes. However, few studies have evaluated the impact of advance directives (i.e., formal ACP) or goals-of-care conversations (i.e., informal ACP) on such care. This study aimed to examine the relationship between each of formal and informal ACP and goal-concordant end-of-life care among older Americans and to determine whether their impact differed between individuals identified as White, Black, or Hispanic. METHODS We conducted a retrospective cohort study using 2012-2018 data from the biennial Health and Retirement Study. We examined the relationships of interest using two, separate multivariable logistic regression models. Model 1 regressed a proxy report of GCC on formal and informal ACP and sociodemographic and health-related covariates. Model 2 added interaction terms between race/ethnicity and the two types of ACP. RESULTS Our sample included 2048 older adults. There were differences in the proportions of White, Black, and Hispanic decedents who received GCC (83.1%, 75.3%, and 71.3%, respectively, p < 0.001) and in the use of each type of ACP by racial/ethnic group. In model 1, informal compared with no informal ACP was associated with higher odds of GCC (adjusted odds ratio = 1.38 [95% confidence interval, 1.05-1.82]). In model 2, Black decedents who had formal ACP were more likely to receive GCC than those who did not, but there were no statistically significant differences between decedents of different racial/ethnic groups who had no ACP, informal ACP only, or both types of ACP. CONCLUSIONS Our results build on previous work by indicating the importance of incorporating goals-of-care conversations into routine healthcare for older adults and encouraging ACP usage among racially and ethnically minoritized populations who use ACP tools at lower rates.
Collapse
Affiliation(s)
- Rachel A Lenko
- Department of Nursing, Calvin University School of Health, Grand Rapids, Michigan, USA
| | - Geoffrey J Hoffman
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Sheria G Robinson-Lane
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Maria J Silveira
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Terri Voepel-Lewis
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| |
Collapse
|
2
|
Kim H(D, Duberstein PR, Lin H, Wu B, Zafar A, Jarrín OF. Home Health Care and Hospice Use Among Medicare Beneficiaries With and Without a Diagnosis of Dementia. J Palliat Med 2024; 27:776-783. [PMID: 38359388 PMCID: PMC11310562 DOI: 10.1089/jpm.2023.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Background: Home health care is a core benefit of Medicare and Medicaid insurance programs and includes services to improve health, maintain health, or slow health decline. Objective: To examine the relationship between home health care use during the last three years of life and hospice use in the last six months of life among Medicare beneficiaries with and without dementia. Design: Nationally representative retrospective cohort study. Setting/Subjects: Medicare beneficiaries with at least three years of continuous enrollment who died in 2019 in the United States (n = 2,169,422). Measurements: The primary outcome was hospice use, and the secondary outcome was hospice duration. The independent variable was a composite of the presence and timing of home health care initiation during the last three years of life. Results: Home health care was used by 46.4% of Medicare beneficiaries and hospice care was used by 53.1% of beneficiaries, with 28.3% using both. Compared with beneficiaries who did not use home health care, those who started home health care before the last year of life (odds ratio [OR] = 1.57, 95% confidence interval [CI] = 1.56-1.58) or during the last year of life (OR = 1.75, 95% CI = 1.74-1.77) were more likely to use hospice. The effects were stronger in those without a diagnosis of dementia (OR = 1.92, 95% CI = 1.90-1.94) compared with those without a dementia diagnosis (OR = 1.34, 95% CI = 1.32-1.35) who started home health in the final year of life. Conclusions: Receiving home health care in the final years of life is associated with increased hospice use at the end-of-life in Medicare beneficiaries with and without a dementia diagnosis.
Collapse
Affiliation(s)
| | - Paul R. Duberstein
- School of Public Health, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Haiqun Lin
- School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Bei Wu
- Rory Meyers College of Nursing, New York, New York, USA
- NYU Aging Incubator, New York University, New York, New York, USA
| | - Anum Zafar
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Olga F. Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| |
Collapse
|
3
|
Hooker ER, Chapa J, Vranas KC, Niederhausen M, Goodlin SJ, Slatore CG, Sullivan DR. Intersection of Palliative Care and Hospice Use Among Patients With Advanced Lung Cancer. J Palliat Med 2023; 26:1474-1481. [PMID: 37262128 PMCID: PMC10658737 DOI: 10.1089/jpm.2023.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
Background: Hospice and palliative care (PC) are important components of lung cancer care and independently provide benefits to patients and their families. Objective: To better understand the relationship between hospice and PC and factors that influence this relationship. Methods: A retrospective cohort study of patients diagnosed with advanced lung cancer (stage IIIB/IV) within the U.S. Veterans Health Administration (VA) from 2007 to 2013 with follow-up through 2017 (n = 22,907). Mixed logistic regression models with a random effect for site, adjustment for patient variables, and propensity score weighting were used to examine whether the association between PC and hospice use varied by U.S. region and PC team characteristics. Results: Overall, 57% of patients with lung cancer received PC, 69% received hospice, and 16% received neither. Of those who received hospice, 60% were already enrolled in PC. Patients who received PC had higher odds of hospice enrollment than patients who did not receive PC (adjusted odds ratio = 3.25, 95% confidence interval: 2.43-4.36). There were regional differences among patients who received PC; the predicted probability of hospice enrollment was 85% and 73% in the Southeast and Northeast, respectively. PC team and facility characteristics influenced hospice use in addition to PC; teams with the shortest duration of existence, with formal team training, and at lower hospital complexity were more likely to use hospice (all p < 0.05). Conclusions: Among patients with advanced lung cancer, PC was associated with hospice enrollment. However, this relationship varied by geographic region, and PC team and facility characteristics. Our findings suggest that regional PC resource availability may contribute to substitution effects between PC and hospice for end-of-life care.
Collapse
Affiliation(s)
- Elizabeth R. Hooker
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
| | - Joaquin Chapa
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Portland Veterans Affairs Medical Center, Divisions of Pulmonary Critical Care Medicine, Portland, Oregon, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health and Science University—Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Sarah J. Goodlin
- Geriatrics Section, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Donald R. Sullivan
- Center to Improve Veteran Involvement in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
4
|
Ankuda CK, Ornstein KA, Leff B, Rajagopalan S, Kinosian B, Brody AA, Ritchie CS. Defining a taxonomy of Medicare-funded home-based clinical care using claims data. BMC Health Serv Res 2023; 23:120. [PMID: 36747175 PMCID: PMC9900204 DOI: 10.1186/s12913-023-09081-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND As more Americans age in place, it is critical to understand care delivery in the home. However, data on the range of home-based services provided by Medicare is limited. We define a taxonomy of clinical care in the home funded through fee-for-service Medicare and methods to identify receipt of those services. METHODS We analyzed Fee-for-service (FFS) Medicare claims data from a nationally-representative cohort of older adults, the National Health and Aging Trends Study (NHATS), to identify home-based clinical care. We included 6,664 NHATS enrollees age ≥ 70 and living in the community, observed an average of 3 times each on claims-linked NHATS surveys. We examined provider and service type of home-based clinical care to identify a taxonomy of 5 types: home-based medical care (physician, physician assistant, or nurse practitioner visits), home-based podiatry, skilled home health care (SHHC), hospice, and other fee-for-service (FFS) home-based care. We further characterized home-based clinical care by detailed care setting and visit types. RESULTS From 2011-2016, 17.8%-20.8% of FFS Medicare beneficiaries age ≥ 70 received Medicare-funded home-based clinical care. SHHC was the most common service (12.8%-16.1%), followed by other FFS home-based care (5.5%-6.5%), home-based medical care (3.2%-3.9%), and hospice (2.6%-3.0%). Examination of the other-FFS home-based care revealed imaging/diagnostics and laboratory testing to be the most common service. CONCLUSIONS We define a taxonomy of clinical care provided in the home, serving 1 in 5 FFS Medicare beneficiaries. This approach can be used to identify and address research and clinical care gaps in home-based clinical care delivery.
Collapse
Affiliation(s)
- Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Subashini Rajagopalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce Kinosian
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA
- NYU Grossman School of Medicine, New York, NY, USA
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, USA.
| |
Collapse
|
5
|
Ankuda CK, Moreno J, Teno JM, Aldridge MD. Transitions from Home Health to Hospice: The Role of Agency Affiliation. J Palliat Med 2022; 25:873-879. [PMID: 34964665 PMCID: PMC9360178 DOI: 10.1089/jpm.2021.0390] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 01/31/2023] Open
Abstract
Background: Home health agencies (HHAs) are often affiliated with hospice agencies and commonly care for patients with serious illness within the Medicare program. HHAs may therefore provide a potential opportunity to facilitate timely referral to hospice when appropriate. Objectives: To determine if patients cared for by HHAs affiliated with hospice agencies experience differential hospice use and care patterns. Design: Nationally representative cohort study. Setting/Subjects: 1431 decedents in the 2002 to 2017 Medicare Current Beneficiary Survey who received home health in the last year of life in the United States. Measurements: Primary independent variable was HHA hospice affiliation. Primary dependent variable was hospice enrollment; secondary dependent variables were hospice live discharge and length of stay. Results: The 27.3% of decedents cared for by a HHA affiliated with a hospice had greater education levels and wealth and were more likely to live in the Midwest and Northeast. In adjusted models, HHA-hospice affiliated decedents had greater odds of enrolling in hospice compared to those cared for by HHAs not affiliated with a hospice, corresponding to a hospice enrollment rate of 51.0% for those cared for by HHAs affiliated with hospices versus 39.7% for HHAs not affiliated (p = 0.004). There were no differences in hospice length of stay or live discharge rate by hospice affiliation. Conclusion: Medicare beneficiaries cared for by HHAs affiliated with hospices are more likely to enroll in hospice at the end of life. This has implications for improving hospice access through home health incentives and models of care.
Collapse
Affiliation(s)
- Claire K. Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Melissa D. Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters Bronx Veterans Affairs Medical Center, Bronx, New York, USA
| |
Collapse
|
6
|
Presley CJ, Kaur K, Han L, Soulos PR, Zhu W, Corneau E, O'Leary JR, Chao H, Shamas T, Rose MG, Lorenz KA, Levy CR, Mor V, Gross CP. Aggressive End-of-Life Care in the Veterans Health Administration versus Fee-for-Service Medicare among Patients with Advanced Lung Cancer. J Palliat Med 2022; 25:932-939. [PMID: 35363053 PMCID: PMC9360181 DOI: 10.1089/jpm.2021.0436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice. Methods: We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries. Results: Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare (p < 0.001). Hospice use significantly increased within both cohorts (VHA 28%-41%; SM 60%-73%, p < 0.001). Veterans receiving care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive aggressive care at end of life (adjusted odds ratio: 0.13, 95% confidence interval: 0.08-0.23, p < 0.001). Conclusions: Patients receiving lung cancer care in the VHA had a greater decline in aggressive care at end of life, perhaps due to increasing concurrent care availability.
Collapse
Affiliation(s)
- Carolyn J. Presley
- Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
- Address correspondence to: Carolyn J. Presley, MD, Division of Medical Oncology, The Ohio State University, 1800 Cannon Drive, 13th Floor, Columbus, OH 43210, USA
| | - Kiranveer Kaur
- Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Ling Han
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Pamela R. Soulos
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Weiwei Zhu
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Emily Corneau
- Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island, USA
| | - John R. O'Leary
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Herta Chao
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Tracy Shamas
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Michal G. Rose
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Connecticut Veterans Health Administration, West Haven, Connecticut, USA
| | - Karl A. Lorenz
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
- School of Medicine, Stanford University, Stanford, California, USA
| | - Cari R. Levy
- Eastern Colorado VA Healthcare System, Aurora, Colorado, USA
| | - Vincent Mor
- Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cary P. Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
7
|
Nursing Leadership and Palliative Care in Long-Term Care for Residents with Advanced Dementia. Nurs Clin North Am 2022; 57:259-271. [DOI: 10.1016/j.cnur.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
8
|
Mun S, Wang R, Ma X, Ananth P. Sociodemographic and hospital-based predictors of intense end-of-life care among children, adolescents, and young adults with hematologic malignancies. Cancer 2021; 127:3817-3824. [PMID: 34185881 PMCID: PMC8478813 DOI: 10.1002/cncr.33764] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/07/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Children, adolescents, and young adults with hematologic malignancies tend to receive high-intensity end-of-life care (HI-EOLC), but sociodemographic and hospital-based predictors of HI-EOLC remain unclear. METHODS The authors conducted a population-based, retrospective cohort study with the Premier Healthcare Database. They identified individuals with hematologic malignancies who were 0 to 39 years old at death and died between 2010 and 2017. HI-EOLC was defined as experiencing 2 or more of the following: cardiopulmonary resuscitation, intravenous chemotherapy, hemodialysis, mechanical ventilation, tracheostomy placement, or an emergency department visit within the last 30 days of life and death in the intensive care unit. Multivariable logistic regression models were constructed to identify patient sociodemographic and hospital characteristics associated with HI-EOLC. RESULTS Among 1454 decedents, more than half (55%) experienced HI-EOLC. In multivariable models, patients treated in medium (adjusted odds ratio [aOR], 1.63; 95% confidence interval [CI], 1.07-2.50) or large hospitals (aOR, 2.21; 95% CI, 1.45-3.39), insured by Medicaid (aOR, 1.40 ; 95% CI, 1.09-2.06), or receiving cancer-directed treatment in the Northeast (aOR, 1.50; 95% CI, 1.05-2.15) were more likely to receive HI-EOLC. CONCLUSIONS A majority of children, adolescents, and young adults with hematologic malignancies experienced HI-EOLC, and the likelihood of HI-EOLC was influenced by the hospital size, type of insurance, and geographic region. Further research is needed to determine how to mitigate these risks.
Collapse
Affiliation(s)
- Sophia Mun
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
| | - Rong Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of
Public Health, New Haven, CT
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of
Public Health, New Haven, CT
| | - Prasanna Ananth
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Pediatrics, Yale School of Medicine, New
Haven, CT
| |
Collapse
|
9
|
Lam MB, Riley KE, Zheng J, Orav EJ, Jha AK, Burke LG. Healthy days at home: A population-based quality measure for cancer patients at the end of life. Cancer 2021; 127:4249-4257. [PMID: 34374429 DOI: 10.1002/cncr.33817] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/01/2021] [Accepted: 06/30/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Healthy Days at Home (HDAH) is a novel population-based outcome measure. In this study, its use as a potential measure for cancer patients at the end of life (EOL) was explored. METHODS Patient demographics and health care use among Medicare beneficiaries with cancer who died over the years 2014 to 2017 were identified. The HDAH was calculated by subtracting the following components from 180 days: number of days spent in inpatient and outpatient hospital observation, the emergency room, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation, long-term hospitals, and inpatient hospice. How HDAH and its components varied by beneficiary demographics and health care market were evaluated. A patient-level linear regression model with HDAH as the outcome, hospital referral region (HRR) random effects, and market fixed effects were specified, as well as beneficiary age, sex, and comorbidities as covariates. RESULTS The 294,751 beneficiaries at the EOL showed a mean number of 154.0 HDAH (out of 180 days). Inpatient (10.7 days) and SNF (9.7 days) resulted in the most substantial reductions in HDAH. Males had fewer adjusted HDAH (153.1 vs 155.7, P < .001) than females; Medicaid-eligible patients had fewer HDAH compared with non-Medicaid-eligible patients (152.0 vs 154.9; P < .001). Those with hematologic malignancies had the fewest number of HDAH (148.9). Across HRRs, HDAH ranged from 10.8 fewer to 10.9 more days than the national mean. At the HRR-level, home hospice was associated with greater HDAH, whereas home health was associated with fewer HDAH. CONCLUSIONS HDAH may be a useful measure to understand, quantify, and improve patient-centered outcomes for cancer patients at EOL.
Collapse
Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kristen E Riley
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - E John Orav
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ashish K Jha
- Brown School of Public Health, Providence, Rhode Island
| | - Laura G Burke
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Emergency Medicine, Beth Israel Deaconess Hospital, Boston, Massachusetts
| |
Collapse
|
10
|
Weissman JS, Reich AJ, Prigerson HG, Gazarian P, Tjia J, Kim D, Rodgers P, Manful A. Association of Advance Care Planning Visits With Intensity of Health Care for Medicare Beneficiaries With Serious Illness at the End of Life. JAMA HEALTH FORUM 2021; 2:e211829. [PMID: 35977213 PMCID: PMC8796875 DOI: 10.1001/jamahealthforum.2021.1829] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/04/2021] [Indexed: 12/31/2022] Open
Abstract
Question What is the association of a billed advance care planning (ACP) visit with intensive use of health care services at the end of life (EOL) for Medicare beneficiaries with serious illness? Findings In this cohort study of claims data of 955 777 Medicare beneficiaries with serious illness who died in 2017 and 2018, billed ACP visits that occurred during the decedents’ EOL course but before the last month of life were relatively uncommon. However, their occurrence was associated with less intensive use of EOL health care services. Meaning The findings of this cohort study suggest that ACP is associated with less intensive use of EOL health care services. Importance Advance care planning (ACP) is intended to maximize the concordance of preferences with end-of-life (EOL) care and is assumed to lead to less intensive use of health care services. The Centers for Medicare & Medicaid Services began reimbursing clinicians for ACP discussions with patients in 2016. Objective To determine whether billed ACP visits are associated with intensive use of health care services at EOL. Design, Setting, and Participants This prospective patient-level cohort analysis of seriously ill patients included Medicare fee-for-service beneficiaries who met criteria for serious illness from January 1 to December 31, 2016, and died from January 1, 2017, to December 31, 2018. Analyses were completed from November 1, 2020, to March 31, 2021. Main Outcomes and Measures Five measures of EOL health care services used (inpatient admission, emergency department visit, and/or intensive care unit stay within 30 days of death; in-hospital death; and timing of first hospice bill) and a measure of EOL expenditures. Analyses were adjusted for age, race and ethnicity, sex, Charlson Comorbidity Index, Medicare-Medicaid dual eligibility, and expenditure by hospital referral region (high, medium, or low). The primary exposure was receipt of a billed ACP service classified as none, timely (>1 month before death), or late (first ACP visit ≤1 month before death). Results Of the 955 777 Medicare beneficiaries who met criteria for serious illness in 2016 and died in 2017 or 2018, 522 737 (54.7%) were women, 764 666 (80.0%) were 75 years or older, and 822 684 (86.1%) were non-Hispanic White individuals. Among the study population, 81 131 (8.5%) had a timely ACP visit, and an additional 22 804 (2.4%) had a late ACP visit. After multivariable adjustment, compared with patients without any billed ACP visit, patients with a timely ACP visit experienced significantly less intensive EOL care on 4 of 5 measures, including in-hospital death (adjusted odds ratio [aOR], 0.85; 95% CI, 0.84-0.87), hospital admission (aOR, 0.84; 95% CI, 0.83-0.85), intensive care unit admission (aOR, 0.87; 95% CI, 0.85-0.88), and emergency department visit (OR, 0.83; 95% CI, 0.82-0.84). Only small or insignificant differences in late hospice use or mean total EOL expenditures were noted. Compared with patients without ACP, patients with late ACP experienced more intensive EOL care, including in-hospital death (aOR, 1.22; 95% CI, 1.19-1.26), hospital admission (aOR, 5.28; 95% CI, 5.07-5.50), intensive care unit admission (aOR, 1.57; 95% CI, 1.53-1.62), and emergency department visit (aOR, 3.87; 95% CI, 3.72-4.02). Conclusions and Relevance In this cohort study of US Medicare beneficiaries, billed ACP services during the EOL course of patients with serious illness were relatively uncommon, but if they occurred before the last month of life, they were associated with less intensive use of EOL services. Further research on the variables affecting hospice use and expenditures in the EOL period and the differential effect of late ACP is recommended to understand the relative role of ACP in achieving goal-concordant care.
Collapse
Affiliation(s)
- Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Amanda J. Reich
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Holly G. Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
| | - Priscilla Gazarian
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer Tjia
- Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Dae Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Phil Rodgers
- Department of Family Medicine, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Adoma Manful
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
11
|
de Avila V, Paik JM, de Avila L, Henry L, Mohess D, Roche-Green A, Younossi ZM. Hospice care utilisation among elderly patients who died with hepatocellular carcinoma in the United States. JHEP Rep 2021; 3:100236. [PMID: 33748729 PMCID: PMC7970151 DOI: 10.1016/j.jhepr.2021.100236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/08/2020] [Accepted: 12/28/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND & AIMS The benefits of hospice care in Medicare recipients with hepatocellular carcinoma (HCC) have not been fully evaluated, which we aimed to study. METHODS We used nationally representative samples of the Medicare beneficiaries in the USA (2011-2016) to assess the impact of hospice care on the outcomes of patients with HCC. Hospice care benefits on the survival time, length of stay (LOS), 30-day readmissions, and daily charges during the last year and month of life were assessed by logistic regression and generalised linear regression. RESULTS Among 2,230 Medicare beneficiaries with HCC (mean age, 74.9 years; non-Hispanic White 79.1%; male 66.6%), median survival from HCC diagnosis was 68 days; 556 (24.9%) received hospice services; median hospice LOS was 12 days (4-35 days). Hospice users increased from 20.1% to 31.1% over time, driven by enrolment ≤15 days (45.1-59.2%, respectively). In the last year of life, hospice users (vs. no hospice care) had longer median survival time (76.5 vs. 66 days), lower in-hospital mortality (1.1% vs. 25.5%) and lower median daily charges ($951 vs. $1,004) despite more inpatient admissions and higher comorbid diseases. Hospice enrolment was associated with 48.6% reduction in daily charges (95% CI: -54.9% to -41.5%). Longer hospice LOS was associated with lower rates of healthcare utilisation. Patients with chronic liver disease were less likely to enrol in hospice care (odds ratio = 0.18, 95% CI: 0.14-0.24). CONCLUSIONS Although hospice provides a significant decrease in healthcare utilisation and some benefit in survival, most care is given in the last 2 weeks of life. Efforts to encourage earlier use of hospice services must continue. LAY SUMMARY The purpose of hospice care is to provide comfort and lessen suffering at the end of life. Hospice care allows one to die outside the hospital environment which is the wish of most people. However, we found that among persons aged 65 years and older who were diagnosed with liver cancer (which has a poor prognosis), only 25% were enrolled in hospice care and the majority used a hospice only in the last weeks of life. This is a disheartening finding as liver cancer patients with longer hospice enrolment had lower costs and improved survival. We suggest that healthcare practitioners consider discussion of palliative and hospice care routinely with patients suffering from liver cancer.
Collapse
Affiliation(s)
- Victor de Avila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - James M. Paik
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
- Center for Liver Disease and Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Leyla de Avila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Linda Henry
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Denise Mohess
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Alva Roche-Green
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Zobair M. Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
- Center for Liver Disease and Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
- Inova Medicine, Inova Health Systems, Falls Church, VA, USA
| |
Collapse
|
12
|
Gupta A, Jin G, Reich A, Prigerson HG, Ladin K, Kim D, Ashana DC, Cooper Z, Halpern SD, Weissman JS. Association of Billed Advance Care Planning with End-of-Life Care Intensity for 2017 Medicare Decedents. J Am Geriatr Soc 2020; 68:1947-1953. [PMID: 32853429 DOI: 10.1111/jgs.16683] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 04/21/2020] [Accepted: 05/19/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND/OBJECTIVE The Centers for Medicare & Medicaid Services (CMS) reimburses clinicians for advance care planning (ACP) discussions with Medicare patients. The objective of the study was to examine the association of CMS-billed ACP visits with end-of-life (EOL) healthcare utilization. DESIGN Patient-level analyses of claims for the random 20% Medicare fee-for-service (FFS) sample of decedents in 2017. To account for multiple comparisons, Bonferroni adjusted P value <.008 was considered statistically significant. SETTING Nationally representative sample of Medicare FFS beneficiaries. PARTICIPANTS A total of 237,989 Medicare FFS beneficiaries who died in 2017 and included those with and without a billed ACP visit during 2016-17. INTERVENTION The key exposure variable was receipt of first billed ACP (none, >1 month before death). MEASUREMENTS Six measures of EOL healthcare utilization or intensity (inpatient admission, emergency department [ED] visit, intensive care unit [ICU] stay, and expenditures within 30 days of death, in-hospital death, and first hospice within 3 days of death). Analyses was adjusted for age, race, sex, Charlson Comorbidity Index, expenditure by Dartmouth hospital referral region (high, medium, or low), and dual eligibility. RESULTS Overall, 6.3% (14,986) of the sample had at least one billed ACP visit. After multivariable adjustment, patients with an ACP visit experienced significantly less intensive EOL care on four of six measures: hospitalization (odds ratio [OR] = .77; 95% confidence interval [CI] = .74-.79), ED visit (OR = .77; 95% CI = .75-.80), or ICU stay (OR = .78; 95% CI = .74-.81) within a month of death; and they were less likely to die in the hospital (OR = .79; 95% CI = .76-.82). There were no differences in the rate of late hospice enrollment (OR = .97; 95% CI = .92-1.01; P = .119) or mean expenditures ($242.50; 95% CI = -$103.63 to $588.61; P = .169). CONCLUSION Billed ACP visits were relatively uncommon among Medicare FFS decedents, but their occurrence was associated with less intensive EOL utilization. Further research on the variables affecting hospice use and expenditures in the EOL period is recommended to understand the relative role of ACP.
Collapse
Affiliation(s)
- Avni Gupta
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, USA
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amanda Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Holly G Prigerson
- Cornell Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, USA
| | - Keren Ladin
- Department of Occupational Therapy and Community Health, Tufts University, Boston, Massachusetts, USA.,Research on Ethics, Aging, and Community Health (REACH), Tufts University, Boston, Massachusetts, USA
| | - Dae Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Deepshikha Charan Ashana
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Khaki AR, Xu Y, Cheung WY, Li L, Fedorenko C, Grivas P, Ramsey S, Shankaran V. Comparison of Health Care Utilization at the End of Life Among Patients With Cancer in Alberta, Canada, Versus Washington State. JCO Oncol Pract 2020; 16:e1543-e1552. [PMID: 32804586 DOI: 10.1200/op.20.00217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Aggressive care at the end of life (EOL) can lead to unnecessary suffering and health care costs for patients with cancer. Despite geographic proximity and cultural similarities, we hypothesize that EOL care is more intense in the United States multipayer system versus the Canadian single-payer system. We compared health care utilization at EOL among patients with cancer in Alberta, Canada, with those in Washington state in the United States. METHODS Adult patients with American Joint Committee on Cancer stage II to IV solid tumors who died between 2014 and 2016 in Alberta and between 2015 and 2017 in Washington were identified from regional population-based cancer registries linked to treatment and hospitalization records (Alberta) and health claims from major regional insurance plans (Washington). The proportion of patients receiving chemotherapy and having multiple emergency department (ED) visits, or intensive care unit (ICU) admissions in the last 30, 60, and 90 days of life (DOL) in Alberta and Washington were determined and compared using two-sample z-test and multivariable logistic regression (α = .006 after Bonferroni correction). RESULTS Of patients, 11,177 in Alberta and 12,807 in Washington were included. Patients were similar in age (median, 71 v 72 year), with more patients in Washington with no comorbidities. More patients in Washington were treated with chemotherapy (12.6% v 6.6%; adjusted OR [aOR], 2.74), had multiple ED visits (16.2% v 12.1%; aOR, 1.40), and ICU admissions (23.7% v 3.9%; aOR, 14.27) in the last 30 DOL. Utilization was also higher in Washington in the last 60 and 90 DOL and among those with stage IV disease and those age 65 years and older. CONCLUSION Utilization of chemotherapy, ED visits, and ICU admissions near EOL was higher in Washington versus Alberta. Future studies to characterize drivers of aggressive EOL care may help improve cancer care for patients in the United States and Canada.
Collapse
Affiliation(s)
- Ali Raza Khaki
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA.,Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yuan Xu
- Department of Community health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Winson Y Cheung
- Department of Community health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Li Li
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Catherine Fedorenko
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Petros Grivas
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Scott Ramsey
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA.,Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Veena Shankaran
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA.,Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| |
Collapse
|
14
|
|
15
|
Nguyen C, Downer B, Chou LN, Kuo YF, Raji M. End-of-Life Healthcare Utilization of Older Mexican Americans With and Without a Diagnosis of Alzheimer's Disease and Related Dementias. J Gerontol A Biol Sci Med Sci 2020; 75:326-332. [PMID: 30855070 PMCID: PMC7176060 DOI: 10.1093/gerona/glz065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 02/28/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Little is known about the patterns of end-of-life health care for older Mexican Americans with or without a diagnosis of Alzheimer's disease and related dementias (ADRD). Our objective was to investigate the frequency of acute hospital admissions, intensive care unit use, and ventilator use during the last 30 days of life for deceased older Mexican American Medicare beneficiaries with and without an ADRD diagnosis. METHODS We used Medicare claims data linked with survey information from 1,090 participants (mean age of death 85.1 years) of the Hispanic Established Populations for the Epidemiologic Studies of the Elderly. Multivariable logistic regression models were used to estimate the odds for hospitalization, intensive care unit use, and ventilator use in the last 30 days of life for decedents with ADRD than those without ADRD. Generalized linear models were used to estimate the risk ratio (RR) for length of stay in hospital. RESULTS Within the last 30 days of life, 64.5% decedents had an acute hospitalization (59.1% ADRD, 68.3% no ADRD), 33.9% had an intensive care unit stay (31.3% ADRD, 35.8% no ADRD), and 17.2% used a ventilator (14.9% ADRD, 18.8% no ADRD). ADRD was associated with significantly lower hospitalizations (odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.50-0.89) and shorter length of stay in hospital (RR = 0.77, 95% CI = 0.65-0.90). CONCLUSION Hospitalization, intensive care unit stay, and ventilator use are common at the end of life for older Mexican Americans. The lower hospitalization and shorter length of stay in hospital of decedents with ADRD indicate a modest reduction in acute care use. Future research should investigate the impact of end-of-life planning on acute-care use and quality of life in terminally ill Mexican American older adults.
Collapse
Affiliation(s)
| | - Brian Downer
- Division of Rehabilitation Sciences, School of Health Professions
| | - Lin-Na Chou
- Office of Biostatistics, Preventive Medicine and Community Health
| | - Yong-Fang Kuo
- Office of Biostatistics, Preventive Medicine and Community Health
| | - Mukaila Raji
- Division of Geriatrics, Internal Medicine, The University of Texas Medical Branch at Galveston
| |
Collapse
|
16
|
Dieudonné-Rahm N, Burkhardt S, Pautex S. In-hospital care prior to assisted and unassisted suicide in swiss older people: a state-level retrospective study. BMC Geriatr 2019; 19:300. [PMID: 31694557 PMCID: PMC6833264 DOI: 10.1186/s12877-019-1325-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 10/18/2019] [Indexed: 11/25/2022] Open
|
17
|
Robbins SG, Hackstadt AJ, Martin S, Shinall MC. Implications of Palliative Care Consultation Timing among a Cohort of Hospice Decedents. J Palliat Med 2019; 22:1129-1132. [PMID: 30864893 PMCID: PMC7364302 DOI: 10.1089/jpm.2018.0514] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Earlier palliative care consultation is associated with less intensive medical care and improved quality outcomes for patients with cancer. However, there are limited data about how the timing of palliative care affects utilization among noncancer patients exposed to palliative care consultation. Objective: Comparison of health care utilization for hospice decedents who received early versus late palliative care. Design: A retrospective cohort study utilizing hospital and hospice administrative databases. Setting/Subjects: Patients with cancer and noncancer diagnoses who received specialty palliative care consultation before dying at a local hospice. Measurements: Comparing early (>90 days before death) versus late (<90 days before death) palliative care, outcome measures included intensive care unit (ICU) utilization and hospice length of stay (LOS). Results: Of 233 hospice decedents in 2014 who had palliative care referrals, 36 (15.4%) had early and 197 (84.5%) had late referrals. Nearly half of the patients had a noncancer hospice diagnosis. Only 6% of the early group used the ICU in the last month of life, whereas 56% of the late group did. Patients receiving early palliative care had a longer median hospice LOS than those with late palliative care (138 days vs. 8 days). Conclusions: Early palliative care appears to reduce intensive medical care and increase hospice LOS for patients with a variety of end-stage diseases.
Collapse
Affiliation(s)
- Samuel G. Robbins
- Section of Palliative Care, Vanderbilt University Medical Center, Nashville, Tennessee.,Address correspondence to: Samuel G. Robbins, DNP, Section of Palliative Care, Vanderbilt University Medical Center, Nashville, TN 37232
| | - Amber J. Hackstadt
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara Martin
- Section of Palliative Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Myrick C. Shinall
- Section of Palliative Care, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
18
|
Bone AE, Evans CJ, Etkind SN, Sleeman KE, Gomes B, Aldridge M, Keep J, Verne J, Higginson IJ. Factors associated with older people's emergency department attendance towards the end of life: a systematic review. Eur J Public Health 2019; 29:67-74. [PMID: 30481305 PMCID: PMC6345149 DOI: 10.1093/eurpub/cky241] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Emergency department (ED) attendance for older people towards the end of life is common and increasing, despite most preferring home-based care. We aimed to review the factors associated with older people’s ED attendance towards the end of life. Methods Systematic review using Medline, Embase, PsychINFO, CINAHL and Web of Science from inception to March 2017. Included studies quantitatively examined factors associated with ED attendance for people aged ≥65 years within the last year of life. We assessed study quality using the QualSyst tool and determined evidence strength based on quality, quantity and consistency. We narratively synthesized the quantitative findings. Results Of 3824 publications identified, 21 were included, combining data from 1 565 187 participants. 17/21 studies were from the USA and 19/21 used routinely collected data. We identified 47 factors and 21 were included in the final model. We found high strength evidence for associations between ED attendance and palliative/hospice care (adjusted effect estimate range: 0.1–0.94); non-white ethnicity (1.03–2.16); male gender (1.04–1.83, except 0.70 in one sub-sample) and rural areas (0.98–1.79). The final model included socio-demographic, illness and service factors, with largest effect sizes for service factors. Conclusions In this synthesis, receiving palliative care was associated with lower ED attendance in the last year of life for older adults. This has implications for service models for older people nearing the end of life. However, there is limited evidence from European countries and none from low or middle-income countries, which warrants further research.
Collapse
Affiliation(s)
- Anna E Bone
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
| | - Simon N Etkind
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Barbara Gomes
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai, Department of Geriatrics and Palliative Medicine, New York, USA
| | - Jeff Keep
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| |
Collapse
|
19
|
Keating NL, Huskamp HA, Kouri E, Schrag D, Hornbrook MC, Haggstrom DA, Landrum MB. Factors Contributing To Geographic Variation In End-Of-Life Expenditures For Cancer Patients. Health Aff (Millwood) 2019; 37:1136-1143. [PMID: 29985699 DOI: 10.1377/hlthaff.2018.0015] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health care spending in the months before death varies across geographic areas but is not associated with outcomes. Using data from the prospective multiregional Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, we assessed the extent to which such variation is explained by differences in patients' sociodemographic factors, clinical factors, and beliefs; physicians' beliefs; and the availability of services. Among 1,132 patients ages sixty-five and older who were diagnosed with lung or colorectal cancer in 2003-05, had advanced-stage cancer, died before 2013, and were enrolled in fee-for-service Medicare, mean expenditures in the last month of life were $13,663. Physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared to those in lower-spending areas. Higher-spending areas also had more physicians and fewer primary care providers and hospices in proportion to their total population than lower-spending areas did. Availability of services and physicians' beliefs, but not patients' beliefs, were important in explaining geographic variations in end-of-life spending. Enhanced training to better equip physicians to care for patients at the end of life and strategic resource allocation may have potential for decreasing unwarranted variation in care.
Collapse
Affiliation(s)
- Nancy L Keating
- Nancy L. Keating ( ) is a professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School and the Division of General Internal Medicine at Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Haiden A Huskamp
- Haiden A. Huskamp is the 30th Anniversary Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School
| | - Elena Kouri
- Elena Kouri is project director in the Department of Health Care Policy at Harvard Medical School
| | - Deborah Schrag
- Deborah Schrag is a professor of medicine at Harvard Medical School and a research scientist in medical oncology and population sciences at the Dana-Farber Cancer Institute, in Boston
| | - Mark C Hornbrook
- Mark C. Hornbrook is a senior investigator emeritus in the Center for Health Research, Kaiser Permanente Northwest, in Portland, Oregon
| | - David A Haggstrom
- David A. Haggstrom is an associate professor of medicine at Indiana University School of Medicine and core investigator at the Indianapolis Veterans Affairs Medical Center, in Indianapolis
| | - Mary Beth Landrum
- Mary Beth Landrum is a professor of health care policy in the Department of Health Care Policy, Harvard Medical School
| |
Collapse
|
20
|
Wang SE, Liu ILA, Lee JS, Khang P, Rosen R, Reinke LF, Mularski RA, Nguyen HQ. End-of-Life Care in Patients Exposed to Home-Based Palliative Care vs Hospice Only. J Am Geriatr Soc 2019; 67:1226-1233. [PMID: 30830695 DOI: 10.1111/jgs.15844] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The current evidence base regarding the effectiveness of home-based palliative care (HomePal) on outcomes of importance to multiple stakeholders remains limited. The purpose of this study was to compare end-of-life care in decedents who received HomePal with two cohorts that either received hospice only (HO) or did not receive HomePal or hospice (No HomePal-HO). DESIGN Retrospective cohorts from an ongoing study of care transition from hospital to home. Data were collected from 2011 to 2016. SETTING Kaiser Permanente Southern California. PARTICIPANTS Decedents 65 and older who received HomePal (n = 7177) after a hospitalization and two comparison cohorts (HO only = 25 102; No HomePal-HO = 22 472). MEASUREMENTS Utilization data were extracted from administrative, clinical, and claims databases, and death data were obtained from state and national indices. Days at home was calculated as days not spent in the hospital or in a skilled nursing facility (SNF). RESULTS Patients who received HomePal were enrolled for a median of 43 days and had comparable length of stay on hospice as patients who enrolled only in hospice (median days = 13 vs 12). Deaths at home were comparable between HomePal and HO (59% vs 60%) and were higher compared with No HomePal-HO (16%). For patients who survived at least 6 months after HomePal admission (n = 2289), the mean number of days at home in the last 6 months of life was 163 ± 30 vs 161 ± 30 (HO) vs 149 ± 40 (No HomePal-HO). Similar trends were also noted for the last 30 days of life, 25 ± 8 (HomePal, n = 5516), 24 ± 8 (HO), and 18 ± 11 (No HomePal-HO); HomePal patients had a significantly lower risk of hospitalizations (relative risk [RR] = .58-.87) and SNF stays (RR = .32-.77) compared with both HO and No HomePal-HO patients. CONCLUSION Earlier comprehensive palliative care in patients' home in place of or preceding hospice is associated with fewer hospitalizations and SNF stays and more time at home in the final 6 months of life. J Am Geriatr Soc, 2019.
Collapse
Affiliation(s)
- Susan E Wang
- West Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CA
| | - In-Lu Amy Liu
- Pasadena Regional Office, Kaiser Permanente Southern California, Pasadena, CA
| | - Janet S Lee
- Pasadena Regional Office, Kaiser Permanente Southern California, Pasadena, CA
| | - Peter Khang
- Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, CA
| | - Romina Rosen
- Panorama City Medical Center, Kaiser Permanente Southern California, Panorama City, CA
| | | | | | - Huong Q Nguyen
- Pasadena Regional Office, Kaiser Permanente Southern California, Pasadena, CA
| |
Collapse
|
21
|
Nipp RD, Tramontano AC, Kong CY, Hur C. Patterns and predictors of end-of-life care in older patients with pancreatic cancer. Cancer Med 2018; 7:6401-6410. [PMID: 30426697 PMCID: PMC6308041 DOI: 10.1002/cam4.1861] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Little is known about end-of-life care among patients with pancreatic adenocarcinoma (PDAC). We used the Surveillance, Epidemiology, and End Results-Medicare linked database to analyze patterns of hospice use and end-of-life treatment in patients with PDAC. METHODS We included patients diagnosed with PDAC between 2000-2011 and who had died by December 31, 2012. We assessed patterns of hospice use, chemotherapy receipt, and intensive care unit (ICU) admissions at end-of-life. We used multivariable logistic regression to investigate predictors of end-of-life care. RESULTS In our cohort of 16 309 patients, 70.5% enrolled in hospice, of which 29.1% enrolled in the last 7 days of life. Use of hospice increased over time, from 61.6% in 2000 to 77.5% in 2012 (P-value for trend <0.0001). Among the entire cohort, 6.4% received chemotherapy within the last 14 days of life and 13.1% were admitted to the ICU within the last 30 days of life. Late ICU admissions increased over time, while chemotherapy receipt at the end-of-life decreased. Patients who were older, female, with higher SES, or from the South or Midwest were more likely to enroll in hospice. Those who were younger or male were more likely to receive chemotherapy or have an ICU admission at the end-of-life. CONCLUSION Although hospice enrollment has increased among patients with PDAC, late enrollment still occurs in a substantial proportion of patients. While chemotherapy at the end-of-life has decreased slightly, ICU admissions at the end-of-life have continued to increase. Further research is needed to determine effective ways of enhancing end-of-life care for patients with PDAC.
Collapse
Affiliation(s)
- Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chung Yin Kong
- Harvard Medical School, Boston, Massachusetts.,Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chin Hur
- Harvard Medical School, Boston, Massachusetts.,Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
22
|
Schuler MS, Joyce NR, Huskamp HA, Lamont EB, Hatfield LA. Medicare Beneficiaries With Advanced Lung Cancer Experience Diverse Patterns Of Care From Diagnosis To Death. Health Aff (Millwood) 2018; 36:1193-1200. [PMID: 28679805 DOI: 10.1377/hlthaff.2017.0448] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Characterizations of average end-of-life care for people with cancer can obscure important differences in patients' experiences. Using Medicare claims data for 14,257 patients diagnosed with extensive-stage small-cell lung cancer in the period 1995-2009, we used latent class analysis to identify classes of people with different care patterns. We characterized care trajectories from diagnosis to death using time spent in five care settings-home, hospital inpatient unit (acute), hospital intensive care unit (ICU), postacute skilled nursing facility, and hospice-and transitions across these settings. We identified four classes of patients: 66 percent spent the time primarily at home, 11 percent were primarily in hospice, 17 percent were largely in an acute setting, and 6 percent were largely in an ICU. Patients in these classes differed significantly in terms of baseline clinical characteristics, survival length, time spent in hospice, site of death, and spending. The findings show substantial heterogeneity in patterns of care for patients with advanced cancer, which should be accounted for in efforts to improve end-of-life care.
Collapse
Affiliation(s)
- Megan S Schuler
- Megan S. Schuler is a health policy researcher at the RAND Corporation, in Boston, Massachusetts
| | - Nina R Joyce
- Nina R. Joyce is a National Institute of Mental Health Postdoctoral Fellow in the Department of Health Care Policy, Harvard Medical School, in Boston
| | - Haiden A Huskamp
- Haiden A. Huskamp is a professor in the Department of Health Care Policy, Harvard Medical School
| | - Elizabeth B Lamont
- Elizabeth B. Lamont is a Biomedical Informatics Research Training (BIRT) Fellow in the Division of General Medicine, Brigham and Women's Hospital, in Boston, and an associate professor of medicine at the Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School
| | - Laura A Hatfield
- Laura A. Hatfield is an associate professor in the Department of Health Care Policy, Harvard Medical School
| |
Collapse
|
23
|
Haliko S, Downs J, Mohan D, Arnold R, Barnato AE. Hospital-Based Physicians' Intubation Decisions and Associated Mental Models when Managing a Critically and Terminally Ill Older Patient. Med Decis Making 2017; 38:344-354. [PMID: 29166565 DOI: 10.1177/0272989x17738958] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Variation in the intensity of acute care treatment at the end of life is influenced more strongly by hospital and provider characteristics than patient preferences. OBJECTIVE We sought to describe physicians' mental models (i.e., thought processes) when encountering a simulated critically and terminally ill older patient, and to compare those models based on whether their treatment plan was patient preference-concordant or preference-discordant. METHODS Seventy-three hospital-based physicians from 3 academic medical centers engaged in a simulated patient encounter and completed a mental model interview while watching the video recording of their encounter. We used an "expert" model to code the interviews. We then used Kruskal-Wallis tests to compare the weighted mental model themes of physicians who provided preference-concordant treatment with those who provided preference-discordant treatment. RESULTS Sixty-six (90%) physicians provided preference-concordant treatment and 7 (10%) provided preference-discordant treatment (i.e., they intubated the patient). Physicians who intubated the patient were more likely to emphasize the reversible and emergent nature of the patient situation (z = -2.111, P = 0.035), their own comfort (z = -2.764, P = 0.006), and rarely focused on explicit patient preferences (z = 2.380, P = 0.017). LIMITATIONS Post-decisional interviewing with audio/video prompting may induce hindsight bias. The expert model has not yet been validated and may not be exhaustive. The small sample size limits generalizability and power. CONCLUSIONS Hospital-based physicians providing preference-discordant used a different mental model for decision making for a critically and terminally ill simulated case. These differences may offer targets for future interventions to promote preference-concordant care for seriously ill patients.
Collapse
Affiliation(s)
- Shannon Haliko
- Department of Critical Care Medicine, Hoag Hospital, Newport Beach, CA, USA
| | - Julie Downs
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Deepika Mohan
- Department of Critical Care Medicine and Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Arnold
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amber E Barnato
- Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| |
Collapse
|
24
|
Sullivan DR, Ganzini L, Lapidus JA, Hansen L, Carney PA, Osborne ML, Fromme EK, Izumi S, Slatore CG. Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system. Cancer 2017; 124:426-433. [PMID: 29023648 DOI: 10.1002/cncr.31047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/12/2017] [Accepted: 09/05/2017] [Indexed: 11/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon.,Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Linda Ganzini
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon.,Division of Geriatric Psychiatry, Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Jodi A Lapidus
- Biostatistics, School of Public Health, Oregon Health and Science University, Portland, Oregon
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Molly L Osborne
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Palliative Care Service, Oregon Health and Science University, Portland, Oregon
| | - Erik K Fromme
- Palliative Care Service, Oregon Health and Science University, Portland, Oregon.,Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Seiko Izumi
- School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Christopher G Slatore
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon.,Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.,Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon
| |
Collapse
|
25
|
Aldridge MD, Bradley EH. Epidemiology And Patterns Of Care At The End Of Life: Rising Complexity, Shifts In Care Patterns And Sites Of Death. Health Aff (Millwood) 2017; 36:1175-1183. [DOI: 10.1377/hlthaff.2017.0182] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Melissa D. Aldridge
- Melissa D. Aldridge ( ) is an associate professor in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, in New York City
| | - Elizabeth H. Bradley
- Elizabeth H. Bradley is president of and a professor of political science and science, technology, and society at Vassar College, in Poughkeepsie, New York
| |
Collapse
|