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Wladkowski SP, Enguídanos S. Alzheimer's Disease and Related Dementias: Caregiver Perspectives on Hospice Re-Enrollment Following a Hospice Live Discharge. J Palliat Med 2023; 26:1374-1379. [PMID: 37155702 DOI: 10.1089/jpm.2023.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: The number of individuals dying of Alzheimer's disease and related dementias (ADRDs) is steadily increasing and they represent the largest group of hospice enrollees. In 2020, 15.4% of hospice patients across the United States were discharged alive from hospice care, with 5.6% decertified due to being "no longer terminally ill." A live discharge from hospice care can disrupt care continuity, increase hospitalizations and emergency room visits, and reduce the quality of life for patients and families. Furthermore, this discontinuity may impede re-enrollment into hospice services and receipt of community bereavement services. Objectives: The aim of this study is to explore the perspectives of caregivers of adults with ADRDs around hospice re-enrollment following a live discharge from hospice. Design: We conducted semistructured interviews of caregivers of adults with ADRDs who experienced a live discharge from hospice (n = 24). Thematic analysis was used to analyze data. Results: Three-quarters of participants (n = 16) would consider re-enrolling their loved one in hospice. However, some believed they would have to wait for a medical crisis (n = 6) to re-enroll, while others (n = 10) questioned the appropriateness of hospice for patients with ADRDs if they cannot remain in hospice care until death. Conclusions: A live discharge for ADRD patients impacts caregivers' decisions on whether they will choose to re-enroll a patient who has been discharged alive from hospice. Further research and support of caregivers through the discharge process are necessary to ensure that patients and their caregivers remain connected to hospice agencies postdischarge.
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Affiliation(s)
| | - Susan Enguídanos
- USC Leonard Davis School of Gerontology, Los Angeles, California, USA
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Hunt LJ, Gan S, Smith AK, Aldridge MD, Boscardin WJ, Harrison KL, James JE, Lee AK, Yaffe K. Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia. J Palliat Med 2023; 26:1100-1108. [PMID: 37010377 PMCID: PMC10440673 DOI: 10.1089/jpm.2023.0011] [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: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Alexander K. Smith
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Krista L. Harrison
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer E. James
- Institute for Health and Aging, University of California, San Francisco, San Francisco, California, USA
| | - Alexandra K. Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
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Zhang Y, Shao H, Zhang M, Li J. Healthcare Utilization and Mortality After Hospice Live Discharge Among Medicare Patients With and Without Alzheimer's Disease and Related Dementias. J Gen Intern Med 2023; 38:2272-2278. [PMID: 36650330 PMCID: PMC10406979 DOI: 10.1007/s11606-023-08031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Little is known about post-discharge outcomes among patients who were discharged alive from hospice. OBJECTIVE To compare healthcare utilization and mortality after hospice live discharge among Medicare patients with and without Alzheimer's disease and related dementias (ADRD). DESIGN Retrospective cohort study using Medicare claims data of a 20% random sample of Medicare fee-for-service (FFS) patients. PARTICIPANTS A total of 153,696 Medicare FFS patients experienced live discharge from hospice between 2014 and 2019. MEASURES Two types of burdensome transition (type 1: live discharge from hospice followed by hospitalization and subsequent hospice readmission; type 2: live discharge from hospice followed by hospitalization with the patient deceased in the hospital), acute care utilization, hospice readmission, and mortality in the 30 and 180 days after live discharge and between live discharge and death. RESULTS Compared with non-ADRD patients, ADRD patients were less likely to experience burdensome transitions (type 1: adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.90-0.98; type 2: aOR, 0.70; 95% CI, 0.65-0.75), more likely to have ED visits (aOR, 1.05; 95% CI, 1.01-1.09), less likely to die (aOR, 0.71; 95% CI, 0.69-0.73), and less likely to be readmitted to hospice (aOR, 0.86; 95% CI, 0.84-0.89) 30 days after live discharge. Results of 180-day post-discharge outcomes were largely consistent with results of 30-day outcomes. Among patients who died as of December 31, 2019, ADRD patients were less likely to be hospitalized (aOR, 0.88; 95% CI, 0.85-0.92) and more likely to be readmitted to hospice (aOR, 1.12; 95% CI, 1.08-1.16) between live discharge and death. Significant racial/ethnicity disparities in acute care utilization and mortality after live discharge existed in both ADRD and non-ADRD groups. CONCLUSION ADRD patients had lower mortality, a longer survival time, a lower rate of hospitalization, and an initially lower but gradually increasing rate of hospice readmission than non-ADRD patients after hospice live discharge. These different trajectories warrant further investigation of the eligibility of their initial hospice enrollment. Black patients had significantly worse outcomes after hospice live discharge compared with White patients.
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Affiliation(s)
- Yongkang Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, 402 East 67th Street, New York, NY, 10065, USA.
| | - Hui Shao
- Center for Drug Evaluation and Safety, Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Manyao Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, 402 East 67th Street, New York, NY, 10065, USA
| | - Jing Li
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
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4
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Mullins MA, Ruterbusch J, Cote ML, Uppal S, Wallner LP. Trends in hospice referral timing and location among individuals dying of ovarian cancer: persistence of missed opportunities. Int J Gynecol Cancer 2023; 33:1099-1105. [PMID: 37208020 PMCID: PMC10577799 DOI: 10.1136/ijgc-2023-004405] [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: 05/21/2023] Open
Abstract
OBJECTIVE To evaluate trends, racial disparities, and opportunities to improve the timing and location of hospice referral for women dying of ovarian cancer. METHODS This retrospective claims analysis included 4258 Medicare beneficiaries over age 66 diagnosed with ovarian cancer who survived at least 6 months after diagnosis, died between 2007 and 2016, and enrolled in a hospice. We examined trends in timing and clinical location (outpatient, inpatient hospital, nursing/long-term care, other) of hospice referrals and associations with patient race and ethnicity using multivariable multinomial logistic regression. RESULTS In this sample, 56% of hospice enrollees were referred to a hospice within a month of death, and referral timing did not vary by patient race. Referrals were most commonly inpatient hospital (1731 (41%) inpatient, 703 (17%) outpatient, 299 (7%) nursing/long-term care, 1525 (36%) other), with a median of 6 inpatient days prior to hospice enrollment. Only 17% of hospice referrals were made in an outpatient clinic, but participants had a median of 1.7 outpatient visits per month in the 6 months prior to hospice referral. Referral location varied by patient race, with non-Hispanic black people experiencing the most inpatient referrals (60%). Hospice referral timing and location trends did not change between 2007 and 2016. Compared with individuals referred to a hospice in an outpatient setting, individuals referred from an inpatient hospital setting had more than six times the odds of a referral in the last 3 days of life (OR=6.5, 95% CI 4.4 to 9.8) versus a referral more than 90 days before death. CONCLUSION Timeliness of hospice referral is not improving over time despite opportunities for earlier referral across multiple clinical settings. Future work delineating how to capitalize on these opportunities is essential for improving the timeliness of hospice care.
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Affiliation(s)
- Megan A Mullins
- Peter O'Donnell Jr. School of Public Health, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Julie Ruterbusch
- Karmanos Cancer Insitute, Wayne State University, Detroit, Michigan, USA
| | - Michele L Cote
- Simon Comprehensive Cancer Center, Indiana University, Indianapolis, Indiana, USA
- Richard M. Fairbanks School of Public Health, Indiana University Purdue University Indianapolis (IUPUI), Indianapolis, Indiana, USA
| | - Shitanshu Uppal
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Hunt LJ, Gan S, Boscardin WJ, Yaffe K, Ritchie CS, Aldridge MD, Smith AK. A national study of disenrollment from hospice among people with dementia. J Am Geriatr Soc 2022; 70:2858-2870. [PMID: 35670444 PMCID: PMC9588572 DOI: 10.1111/jgs.17912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with dementia (PWD) are at high risk for hospice disenrollment, yet little is known about patterns of disenrollment among the growing number of hospice enrollees with dementia. DESIGN Retrospective, observational cohort study of 100% Medicare beneficiaries with dementia aged 65 and older enrolled in the Medicare Hospice Benefit between July 2012 and December 2017. Outcome measures included hospice-initiated disenrollment for patients whose rate of decline ceased to meet the Medicare hospice eligibility guideline of "expected death within 6 months" (extended prognosis) and patient-initiated disenrollment (revocation). Hospice, regional, and patient risk factors and variation were assessed with multilevel mixed-effects logistic regression models. RESULTS Among 867,695 hospice enrollees with dementia, 70,945 (8.2%) were disenrolled due to extended prognosis and 43,133 (5.0%) revoked within 1-year of their index admission. There was substantial variation in hospice provider disenrollment due to extended prognosis (10th-90th percentile 4.5%-14.6%, adjusted median odds ratio (MOR) 1.86, 95% confidence interval (CI) 1.82, 1.91) and revocation (10th-90th percentile 2.5%-10.1%, MOR 2.09, 95% CI 2.03, 2.14). Among hospital referral regions (HRR), there was more variation in revocation (10th-90th percentile 3.5%-7.6%, MOR 1.4, 95% CI 1.34, 1.47) than extended prognosis (10th-90th percentile 7.0%-9.5%, MOR 1.23, 95% CI 1.18, 1.27), with much higher revocation rates noted in HRRs located in the Southeast and Southern California. A number of patient and hospice characteristics were associated with higher odds of both types of disenrollment (younger age, female sex, minoritized race and ethnicity, Medicaid dual eligibility, Medicare Part C enrollment), while some were associated with revocation only (more comorbidities, newer, smaller, and for-profit hospices). CONCLUSIONS In this nationally representative study of hospice enrollees with dementia, hospice disenrollment varied by type of hospice, geographic region, and patient characteristics including age, sex, race, and ethnicity. These findings raise important questions about whether and how the Medicare Hospice Benefit could be adapted to reduce disparities and better support PWD.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco
- Global Brain Health Institute, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, CA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kristine Yaffe
- Department of Psychiatry, University of California, San Francisco
- Department of Neurology, University of California, San Francisco
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, MA
- Mongan Institute for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
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6
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Di Nitto M, Artico M, Piredda M, De Maria M, Magnani C, Marchetti A, Mastroianni C, Latina R, De Marinis MG, D’Angelo D. Factors influencing place of death and disenrollment among patients receiving specialist palliative care. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022189. [PMID: 35545986 PMCID: PMC9534221 DOI: 10.23750/abm.v93is2.12637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/04/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIM OF THE WORK Place of death and disenrollment from specialized palliative care services (SPCSs) are two aspects that determine service utilization. These aspects should be determined by patient needs and preferences, but they are often associated to patient sociodemographic or contextual characteristics. The aim of this study was to describe which factors are associated with utilizing SPCSs in terms of place of death and disenrollment. METHODS Retrospective cohort study. Patients (>18 years) who died or were disenrolled during SPCSs utilization. Two hierarchical regression models were performed, and variables were categorized in predisposing, enabling, and need factors according to the Andersen behavioral model of health services use. RESULTS We included 35,869 patients (52,5% male, mean age 74,6 ± 12,3 SD), where 17,225 patients died in hospice and 16,953 at home, while 1,691 patients were disenrolled. Dying at home was associated with older age, oncological diagnosis, painful symptoms and longer survival time. Instead, service disenrollment was associated with less education, longer wait time and longer length of stay. CONCLUSIONS SPCS utilization was not influenced only by patient need, but also by other factors, such as social and contextual factors. These factors need to be considered by health care providers and efforts are needed for 1) identifying barriers and implementing effective interventions to support patients and caregivers in their preferred place of care and death and 2) for avoiding SPCS disenrollment with an increased probability of aggressive treatments and worse quality of life for patients.
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Affiliation(s)
- Marco Di Nitto
- Department of biomedicine and prevention, University of Rome “Tor Vergata”, Rome, Italy
| | - Marco Artico
- Department of Palliative Care and Pain Therapy Unit, Azienda ULSS n.4 Veneto Orientale, San Donà di Piave, Italy
| | - Michela Piredda
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy
| | - Maddalena De Maria
- Department of biomedicine and prevention, University of Rome “Tor Vergata”, Rome, Italy
| | | | - Anna Marchetti
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy
| | | | - Roberto Latina
- Deptment of Health Promotion Sciences, Maternal & Infant Care, Internal Medicine & Excellence Specialists University of Palermo, Palermo, Italy
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End-of-life care quality outcomes among Medicare beneficiaries with hematologic malignancies. Blood Adv 2021; 4:3606-3614. [PMID: 32766855 DOI: 10.1182/bloodadvances.2020001767] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/22/2020] [Indexed: 01/12/2023] Open
Abstract
Patients with hematologic malignancies are thought to receive more aggressive end-of-life (EOL) care and have suboptimal hospice use compared with patients with solid tumors, but descriptions of EOL outcomes from comprehensive cohorts have been lacking. We used the population-based Surveillance, Epidemiology, and End Results-Medicare dataset to describe hospice use and indicators of aggressive EOL care among Medicare beneficiaries who died of hematologic malignancies in 2008-2015. Overall, 56.5% of decedents used hospice services for median 9 days (interquartile range, 3-27), 33.0% died in an acute hospital setting, 36.8% had an intensive care unit (ICU) admission in the last 30 days of life, and 13.3% received chemotherapy within the last 14 days of life. Hospice use was associated with 96% lower probability of inpatient death (adjusted risk ratio [aRR], 0.038; 95% confidence interval [CI], 0.035-0.042), 44% lower probability of an ICU stay in the last 30 days of life (aRR, 0.56; 95% CI, 0.54-0.57), and 62% decrease in chemotherapy use in the last 14 days of life (aRR, 0.38; 95% CI, 0.35-0.41). Hospice enrollees spent on average 41% fewer days as inpatient during the last month of life (adjusted means ratio, 0.59; 95% CI, 0.57-0.60) and had 38% lower mean Medicare spending in the last month of life (adjusted means ratio, 0.62; 95% CI, 0.61-0.64). These associations were consistent across histologic subgroups. In conclusion, EOL care quality outcomes and hospice enrollment were suboptimal among older decedents with hematologic cancers, but hospice use was associated with a consistent decrease in aggressive care at EOL.
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8
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Abstract
BACKGROUND Hospice performance is an overlooked area in the health care field due to the difficulty of measuring quality of care and the infrequent quality inspection. Based on the daily reimbursement mechanism for different levels of hospice care, inpatient services provision could influence both hospice-level length of stay (LOS) and financial performance. PURPOSE The objective of this study was to explore the relationship between hospice inpatient services provision and hospice utilization and financial performance. METHODOLOGY/APPROACH A longitudinal secondary data set (2009-2013) was merged from three sources: (a) Hospice Cost Reports from the Centers for Medicare & Medicaid Services, (b) the Provider of Services files, and (c) the Area Health Resources Files. The dependent variable in this study was hospice average LOS and financial performance measured by total operating margin (TOM) and return on assets. The independent variable was hospice inpatient services' offering. Mixed-effects regression models were used in the multivariate regression analyses. RESULTS When comparing to hospices not providing inpatient services, offering inpatient services by staff was negatively related to average LOS (b = -0.063, p < .05) and TOM (b = -0.022, p < .05). The combination method with providing inpatient services by staff and under arrangement was negatively associated with return on assets (b = -0.073, p < .05). CONCLUSION Hospice inpatient services provision was associated with average LOS and financial performance. PRACTICE IMPLICATIONS Offering the inpatient services to patients by staff decreased average LOS and TOM. Hospice agencies may seek strategies to maintain their financial sustainability through outsourcing.
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9
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Frasca M, Galvin A, Raherison C, Soubeyran P, Burucoa B, Bellera C, Mathoulin-Pelissier S. Palliative versus hospice care in patients with cancer: a systematic review. BMJ Support Palliat Care 2020; 11:188-199. [PMID: 32680891 DOI: 10.1136/bmjspcare-2020-002195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Guidelines recommend an early access to specialised palliative medicine services for patients with cancer, but studies have reported a continued underuse. Palliative care facilities deliver early care, alongside antineoplastic treatments, whereas hospice care structures intervene lately, when cancer-modifying treatments stop. AIM This review identified factors associated with early and late interventions of specialised services, by considering the type of structures studied (palliative vs hospice care). DESIGN We performed a systematic review, prospectively registered on PROSPERO (ID: CRD42018110063). DATA SOURCES We searched Medline and Scopus databases for population-based studies. Two independent reviewers extracted the data and assessed the study quality using Joanna Briggs Institute critical appraisal checklists. RESULTS The 51 included articles performed 67 analyses. Most were based on retrospective cohorts and US populations. The median quality scores were 19/22 for cohorts and 15/16 for cross-sectional studies. Most analyses focused on hospice care (n=37). Older patients, men, people with haematological cancer or treated in small centres had less specialised interventions. Palliative and hospice facilities addressed different populations. Older patients received less palliative care but more hospice care. Patients with high-stage tumours had more palliative care while women and patients with a low comorbidity burden received more hospice care. CONCLUSION Main disparities concerned older patients, men and people with haematological cancer. We highlighted the challenges of early interventions for older patients and of late deliveries for men and highly comorbid patients. Additional data on non-American populations, outpatients and factors related to quality of life and socioeconomic status are needed.
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Affiliation(s)
- Matthieu Frasca
- Department of Palliative Medicine, CHU of Bordeaux, Bordeaux, Aquitaine, France .,Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Angeline Galvin
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Chantal Raherison
- Department of Pneumology, CHU of Bordeaux, Bordeaux, Aquitaine, France
| | - Pierre Soubeyran
- CIC1401, Bergonie institute, Comprehensive Cancer Center, Bordeaux, Aquitaine, France.,UMR 1218, ACTION, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Benoît Burucoa
- Department of Palliative Medicine, CHU of Bordeaux, Bordeaux, Aquitaine, France
| | - Carine Bellera
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France.,CIC1401, Bergonie institute, Comprehensive Cancer Center, Bordeaux, Aquitaine, France
| | - Simone Mathoulin-Pelissier
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France.,UMR 1218, ACTION, University of Bordeaux, Bordeaux, Aquitaine, France
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10
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Kaufman BG, Klemish D, Olson A, Kassner CT, Reiter JP, Harker M, Sheble L, Goldstein BA, Taylor DH, Bhavsar NA. Use of Hospital Referral Regions in Evaluating End-of-Life Care. J Palliat Med 2019; 23:90-96. [PMID: 31424316 DOI: 10.1089/jpm.2019.0056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Hospital referral regions (HRRs) are often used to characterize inpatient referral patterns, but it is unknown how well these geographic regions are aligned with variation in Medicare-financed hospice care, which is largely provided at home. Objective: Our objective was to characterize the variability in hospice use rates among elderly Medicare decedents by HRR and county. Methods: Using 2014 Master Beneficiary File for decedents 65 and older from North and South Carolina, we applied Bayesian mixed models to quantify variation in hospice use rates explained by HRR fixed effects, county random effects, and residual error among Medicare decedents. Results: We found HRRs and county indicators are significant predictors of hospice use in NC and SC; however, the relative variation within HRRs and associated residual variation is substantial. On average, HRR fixed effects explained more variation in hospice use rates than county indicators with a standard deviation (SD) of 10.0 versus 5.1 percentage points. The SD of the residual error is 5.7 percentage points. On average, variation within HRRs is about half the variation between regions (52%). Conclusions: The magnitude of unexplained residual variation in hospice use for NC and SC suggests that novel, end-of-life-specific service areas should be developed and tested to better capture geographic differences and inform research, health systems, and policy.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - David Klemish
- Department of Statistical Sciences, Duke University, Durham, North Carolina
| | - Andrew Olson
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | | | - Jerome P Reiter
- Department of Statistical Sciences, Duke University, Durham, North Carolina
| | - Matthew Harker
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Laura Sheble
- School of Information Sciences, Wayne State University, Detroit, Michigan.,Duke Network Analysis Center, Social Science Research Institute, Duke University, Durham, North Carolina
| | | | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Nrupen A Bhavsar
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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11
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Wilk AS, Hirth RA, Messana JM. Paying for Frequent Dialysis. Am J Kidney Dis 2019; 74:248-255. [PMID: 30922595 PMCID: PMC7758184 DOI: 10.1053/j.ajkd.2019.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/29/2019] [Indexed: 11/11/2022]
Abstract
In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis treatments in excess of 3 weekly to exceptional acute-care circumstances. Frequent hemodialysis is performed more frequently than the traditional thrice-weekly pattern, and many stakeholders-patients, providers, dialysis machine manufacturers, and others-have expressed concern that these payment rules will inhibit the growth of this treatment modality's use among US dialysis patients. In this Perspective, we explain the role of these contractors in the context of Medicare's in-center hemodialysis-centric dialysis payment system and assess how well this system accommodates the higher treatment frequencies of both peritoneal dialysis and frequent hemodialysis. Then, given the available evidence concerning the relative effectiveness of these modalities versus thrice-weekly in-center hemodialysis and trends in their use, we discuss options for modifying Medicare's payment system to support frequent dialysis.
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Affiliation(s)
- Adam S Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Richard A Hirth
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Joseph M Messana
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
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Systematic review of the hospice performance literature. Health Care Manage Rev 2019; 45:E23-E34. [PMID: 31233425 DOI: 10.1097/hmr.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospice is the key provider of end-of-life care to patients. As the number of U.S. hospice agencies has rapidly increased, the performance has been scrutinized more deeply. PURPOSE To foster understanding of how hospice performance is measured and what factors are associated with performance, we conducted a systematic review of empirical research on hospice performance in the United States. METHODS Both structure-process-outcome and structure-conduct-performance frameworks were applied to categorize and summarize the hospice performance literature. A total of 36 studies were included in the systematic review. RESULTS Hospice agencies adopted different strategies (e.g., service provision strategy and staffing strategy) to improve performance. Two strategic approaches (innovation and volunteer usage) were associated with better outcomes. Hospice organizational factors, market environment, and patient characteristics were related to hospice strategic conduct and performance. Majority of hospice performance studies have examined the relationship between hospice structure and strategic conduct/process, with fewer studies focusing on structure performance and even fewer concentrating on strategy performance. PRACTICE IMPLICATIONS Patient, organizational, and market factors are associated with hospice strategic conduct and performance. The majority of the literature considered the impact of hospice organizational characteristics, whereas only a few studies included patient and market factors. The summarization of factors that may influence hospice performance provides insight to different stakeholders.
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Anhang Price R, Stucky B, Parast L, Elliott MN, Haas A, Bradley M, Teno JM. Development of Valid and Reliable Measures of Patient and Family Experiences of Hospice Care for Public Reporting. J Palliat Med 2018; 21:924-932. [DOI: 10.1089/jpm.2017.0594] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Brian Stucky
- Los Alamos National Laboratory, Santa Fe, New Mexico
| | | | | | - Ann Haas
- RAND Corporation, Pittsburgh, Pennsylvania
| | | | - Joan M. Teno
- Oregon Health & Science University, Portland, Oregon
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Dolin R, Holmes GM, Stearns SC, Kirk DA, Hanson LC, Taylor DH, Silberman P. A Positive Association Between Hospice Profit Margin And The Rate At Which Patients Are Discharged Before Death. Health Aff (Millwood) 2018; 36:1291-1298. [PMID: 28679817 DOI: 10.1377/hlthaff.2017.0113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death-a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program.
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Affiliation(s)
- Rachel Dolin
- Rachel Dolin is a fellow at the David A. Winston Health Policy Fellowship, in Washington, D.C. Previously, she was a National Science Foundation Graduate Research Fellow in the Department of Health Policy and Management, Gillings School of Global Public Health, at the University of North Carolina at Chapel Hill (UNC)
| | - G Mark Holmes
- G. Mark Holmes is an associate professor in the Department of Health Policy and Management, Gillings School of Global Public Health, and director of the Cecil G. Sheps Center for Health Services Research, both at UNC
| | - Sally C Stearns
- Sally C. Stearns is a professor in the Department of Health Policy and Management, Gillings School of Global Public Health, UNC
| | - Denise A Kirk
- Denise A. Kirk is an applications analyst in the North Carolina Rural Health Research Program at the Cecil G. Sheps Center for Health Services Research, UNC
| | - Laura C Hanson
- Laura C. Hanson is a professor of medicine in the Division of Geriatric Medicine, associate director of the Geriatric Fellowship Program, and director of the Palliative Care Program, all at UNC
| | - Donald H Taylor
- Donald H. Taylor Jr. is a professor in the Sanford School of Public Policy, Duke University, in Durham, North Carolina
| | - Pam Silberman
- Pam Silberman is a professor of the practice and director of the Executive Doctoral Program in Health Leadership, Department of Health Policy and Management, Gillings School of Global Public Health, and associate director for policy analysis at the Cecil G. Sheps Center for Health Services Research, all at UNC
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Unroe KT, Stump TE, Effler S, Tu W, Callahan CM. Quality of Hospice Care at Home Versus in an Assisted Living Facility or Nursing Home. J Am Geriatr Soc 2018; 66:687-692. [PMID: 29427519 PMCID: PMC6034702 DOI: 10.1111/jgs.15260] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe differences in perceived quality of hospice care for individuals living at home or in a nursing home (NH) or assisted living facility (ALF) through analysis of after-death surveys of family members. DESIGN Retrospective cohort study using hospice medical record data and Family Evaluation of Hospice Care (FEHC) survey data. SETTING Large, national hospice provider. PARTICIPANTS Individuals who died while receiving routine hospice care and family caregivers who completed after-death quality-of-care surveys. MEASUREMENTS Survey results for 7,510 individuals were analyzed using analysis of variance and chi-square tests. Logistic regression was used to assess relationship between location of care and overall service quality. RESULTS The overall survey response rate was 27%; 34.5% of families of individuals in ALFs in hospice, 27.4% of those at home, and 22.9% of those in NHs returned the survey (P < .001). Differences in return rate according to primary diagnosis were significant, although differences were not large. Most (84.3%) respondents reported that hospice referral had occurred at the right time, and 63.4% rated service quality as excellent. Hospice care in the NH was less likely to be perceived as excellent. CONCLUSION There were significant differences in characteristics of individuals whose family members did and did not return surveys, which has implications for use of after-death surveys to evaluate hospice quality. Lower perceived quality of hospice care in NHs may be related to general dissatisfaction with receiving care in this setting. Survey results have the potential to set priorities for quality improvement, choice of provider, and potentially reimbursement. Underlying causes of differences of perceived quality in different settings of care should be examined.
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Affiliation(s)
- Kathleen T. Unroe
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy E. Stump
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shannon Effler
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Wanzhu Tu
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christopher M. Callahan
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Dolin R, Silberman P, Kirk DA, Stearns SC, Hanson LC, Taylor DH, Holmes GM. Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps? J Pain Symptom Manage 2018; 55:775-784. [PMID: 29180057 DOI: 10.1016/j.jpainsymman.2017.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/15/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year. OBJECTIVE The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases. METHODS We analyzed monthly hospice outcomes using 2012-2013 Medicare claims. RESULTS Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges. CONCLUSION Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care.
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Affiliation(s)
| | - Pam Silberman
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Denise A Kirk
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Laura C Hanson
- Palliative Care Program, Division of Geriatric Medicine, Center for Aging and Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - G Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Parast L, Elliott MN, Hambarsoomian K, Teno J, Anhang Price R. Effects of Survey Mode on Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey Scores. J Am Geriatr Soc 2018; 66:546-552. [DOI: 10.1111/jgs.15265] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Joan Teno
- Department of Health Services Policy and Practice; University of Washington; Seattle Washington
- Center for Gerontology and Health Care Research; Division of Gerontology and Geriatric Medicine; Department of Medicine; University of Washington; Seattle Washington
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Rizzuto J, Aldridge MD. Racial Disparities in Hospice Outcomes: A Race or Hospice-Level Effect? J Am Geriatr Soc 2017; 66:407-413. [PMID: 29250770 DOI: 10.1111/jgs.15228] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To determine whether there is racial variation in hospice enrollees in rates of hospitalization and hospice disenrollment and, if so, whether systematic differences in hospice provider patterns explain the variation. DESIGN Longitudinal cohort study. SETTING Hospice. PARTICIPANTS Medicare beneficiaries (N = 145,038) enrolled in a national random sample of hospices (N = 577) from the National Hospice Survey and followed until death (2009-10). MEASUREMENTS We used Medicare claims data to identify hospital admissions, emergency department (ED) visits, and hospice disenrollment after hospice enrollment. We used a series of hierarchical models including hospice-level random effects to compare outcomes of blacks and whites. RESULTS In unadjusted models, black hospice enrollees were significantly more likely than white enrollees to be admitted to the hospital (14.9% vs 8.7%, odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.74-1.95), visit the ED (19.8% vs 13.5%, OR = 1.58, 95% CI = 1.50-1.66), and disenroll from hospice (18.1% vs 13.0%, OR = 1.48, 95% CI = 1.40-1.56). These results were largely unchanged after accounting for participant clinical and demographic covariates and hospice-level random effects. In adjusted models, blacks were at higher risk of hospital admission (OR = 1.75, 95% CI = 1.64-1.86), ED visits (OR = 1.61, 95% CI = 1.52-1.70), and hospice disenrollment (OR = 1.54, 95% CI = 1.45-1.63). CONCLUSION Racial differences in intensity of care at the end of life are not attributable to hospice-level variation in intensity of care. Differences in patterns of care between black and white hospice enrollees persist within the same hospice.
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De Vleminck A, Morrison RS, Meier DE, Aldridge MD. Hospice Care for Patients With Dementia in the United States: A Longitudinal Cohort Study. J Am Med Dir Assoc 2017; 19:633-638. [PMID: 29153752 DOI: 10.1016/j.jamda.2017.10.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/02/2017] [Accepted: 10/05/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients with dementia form an increasing proportion of those entering hospice care. Little is known about the types of hospices serving patients with dementia and the patterns of hospice use, including timing of hospice disenrollment between patients with and without dementia. OBJECTIVES To characterize the hospices that serve patients with dementia, to compare patterns of hospice disenrollment for patients with dementia and without dementia, and to evaluate patient-level and hospice-level characteristics associated with hospice disenrollment. METHODS We used data from a longitudinal cohort study (2008-2011) of Medicare beneficiaries (n = 149,814) newly enrolled in a national random sample of hospices (n = 577) from the National Hospice Survey and followed until death (84% response rate). RESULTS A total of 7328 patients (4.9%) had a primary diagnosis of dementia. Hospices caring for patients with dementia were more likely to be for-profit, larger sized, provide care for more than 5 years, and serve a large (>30%) percentage of nursing home patients. Patients with dementia were less likely to disenroll from hospice in conjunction with an acute hospitalization or emergency department visit and more likely to disenroll from hospice after long enrollment periods (more than 165 days) as compared with patients without dementia. No significant difference was found between patients with and without dementia for disenrollment after shorter enrollment periods (less than 165 days). In the multivariable analyses, patients were more likely to be disenrolled after 165 days if they were served by smaller hospices and hospices that served a small percentage of nursing home patients. CONCLUSION Patients with dementia are significantly more likely to be disenrolled from hospice following a long enrollment period compared with patients without dementia. As the number of individuals with dementia choosing hospice care continues to grow, it is critical to address potential barriers to the provision of quality palliative care for this population near the end of life.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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Accordino MK, Wright JD, Vasan S, Neugut AI, Gross T, Hillyer GC, Hershman DL. Association between survival time with metastatic breast cancer and aggressive end-of-life care. Breast Cancer Res Treat 2017; 166:549-558. [PMID: 28752188 PMCID: PMC5695862 DOI: 10.1007/s10549-017-4420-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/24/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE For women with stage IV breast cancer (BC), the association between survival time (ST) and use of aggressive end-of-life (EOL) care is unknown. METHODS We used the SEER-Medicare database to identify women with stage IV BC diagnosed 2002-2011 who died by 12/31/2012. Aggressive EOL care was defined as receipt in the last month of life: >1 ED visit, >1 hospitalization, ICU admission, life-extending procedures, hospice admission within 3 days of death, IV chemotherapy within 14 days of death, and/or ≥10 unique physician encounters in the last 6 months of life. Receipt of aggressive EOL care and hospice in the last month of life were determined using claims, and multivariable analysis was used to identify factors associated with receipt. Costs of care were also evaluated. RESULTS We identified 4521 eligible patients. Of these, 2748 (60.8%) received aggressive EOL care. Factors associated with aggressive EOL care were race (OR 1.45, 95% CI 1.19-1.81 for blacks compared to whites) and more frequent oncology office visits (OR 1.56, 95% CI 1.28-1.90). Patients who lived >12 months after diagnosis were less likely to receive aggressive EOL care (OR 0.44, 95% CI 0.38-0.52), and more likely to utilize hospice (OR 1.43, 95% CI 1.21-1.69) compared to patients who lived ≤6 months. Patients with a shorter ST had significantly higher costs of care per-month-alive compared to patients with longer ST. CONCLUSION Patients with a shorter ST were more likely to receive aggressive EOL care and had higher costs of care compared to patients who lived longer.
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Affiliation(s)
- Melissa K Accordino
- Department of Medicine, Columbia University College of Physicians and Surgeons, 161 Ft Washington Ave, Room 9-962, New York, NY, 10032, USA.
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - Jason D Wright
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Sowmya Vasan
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Alfred I Neugut
- Department of Medicine, Columbia University College of Physicians and Surgeons, 161 Ft Washington Ave, Room 9-962, New York, NY, 10032, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Tal Gross
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Grace C Hillyer
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dawn L Hershman
- Department of Medicine, Columbia University College of Physicians and Surgeons, 161 Ft Washington Ave, Room 9-962, New York, NY, 10032, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Associations of Hospice Disenrollment and Hospitalization With Continuous Home Care Provision. Med Care 2017; 55:848-855. [PMID: 28692573 DOI: 10.1097/mlr.0000000000000776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine rates of hospice disenrollment and posthospice hospitalization among patients who are enrolled in hospices that provide continuous home care (CHC) (CHC hospices) compared with patients who are enrolled in hospices that do not offer CHC (non-CHC hospices). METHODS We performed a retrospective cohort study among Medicare fee-for-service decedents between July and December 2011, who were 66 years and older and had used hospice in their last 6 months of life. We used propensity score matching to account for potential confounding characteristics of hospices. Generalized estimating equation models were applied to estimate between CHC hospices and non-CHC hospices the associations of hospice disenrollment/hospitalization, adjusted for patient characteristics. We also conducted subgroup analyses to examine how the association might have differed by hospice size, and by the percentage of enrollees who received CHC. RESULTS After matching, we identified 936 pairs of CHC and non-CHC hospices, well balanced in terms of organizational characteristics. In fully adjusted models, compared with non-CHC hospices, CHC hospices had significantly lower disenrollment rates (adjusted rate ratio, 0.73; 95% confidence interval, 0.60-0.87), and lower hospitalization rates (adjusted rate ratio, 0.79; 95% confidence interval, 0.66-0.95). These associations were significantly more pronounced among larger hospices (those with >175 enrollees during study period), and among hospices in which at least 7.3% of enrollees used CHC. CONCLUSIONS CHC hospices had significantly lower rates of hospice disenrollment and posthospice hospitalization, suggesting CHC service available may enable higher quality of end-of-life care.
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Yim CK, Barrón Y, Moore S, Murtaugh C, Lala A, Aldridge M, Goldstein N, Gelfman LP. Hospice Enrollment in Patients With Advanced Heart Failure Decreases Acute Medical Service Utilization. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003335. [PMID: 28292824 DOI: 10.1161/circheartfailure.116.003335] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with advanced heart failure (HF) enroll in hospice at low rates, and data on their acute medical service utilization after hospice enrollment is limited. METHODS AND RESULTS We performed a descriptive analysis of Medicare fee-for-service beneficiaries, with at least one home health claim between July 1, 2009, and June 30, 2010, and at least 2 HF hospitalizations between July 1, 2009, and December 31, 2009, who subsequently enrolled in hospice between July 1, 2009, and December 31, 2009. We estimated panel-negative binomial models on a subset of beneficiaries to compare their acute medical service utilization before and after enrollment. Our sample size included 5073 beneficiaries: 55% were female, 45% were ≥85 years of age, 13% were non-white, and the mean comorbidity count was 2.38 (standard deviation 1.22). The median number of days between the second HF hospital discharge and hospice enrollment was 45. The median number of days enrolled in hospice was 15, and 39% of the beneficiaries died within 7 days of enrollment. During the study period, 11% of the beneficiaries disenrolled from hospice at least once. The adjusted mean number of hospital, intensive care unit, and emergency room admissions decreased from 2.56, 0.87, and 1.17 before hospice enrollment to 0.53, 0.19, and 0.76 after hospice enrollment. CONCLUSIONS Home health care Medicare beneficiaries with advanced HF who enrolled in hospice had lower acute medical service utilization after their enrollment. Their pattern of hospice use suggests that earlier referral and improved retention may benefit this population. Further research is necessary to understand hospice referral and palliative care needs of advanced HF patients.
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Affiliation(s)
- Cindi K Yim
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Yolanda Barrón
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Stanley Moore
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Chris Murtaugh
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Anuradha Lala
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Melissa Aldridge
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Nathan Goldstein
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Laura P Gelfman
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA.
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Dolin R, Hanson LC, Rosenblum SF, Stearns SC, Holmes GM, Silberman P. Factors Driving Live Discharge From Hospice: Provider Perspectives. J Pain Symptom Manage 2017; 53:1050-1056. [PMID: 28323079 DOI: 10.1016/j.jpainsymman.2017.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients. OBJECTIVE The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program. METHODS We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach. RESULTS Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices. CONCLUSION This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate.
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Affiliation(s)
- Rachel Dolin
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA.
| | - Laura C Hanson
- Division of Geriatric Medicine, Center for Aging and Health, Palliative Care Program, The University of North Carolina at Chapel Hill, North Carolina, USA
| | | | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - George M Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - Pam Silberman
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
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Taylor JS, Rajan SS, Zhang N, Meyer LA, Ramondetta LM, Bodurka DC, Lairson DR, Giordano SH. End-of-Life Racial and Ethnic Disparities Among Patients With Ovarian Cancer. J Clin Oncol 2017; 35:1829-1835. [PMID: 28388292 DOI: 10.1200/jco.2016.70.2894] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To assess disparities in end-of-life care among patients with ovarian cancer. Patients and Methods Using Texas Cancer Registry-Medicare data, we assessed patients with ovarian cancer deceased in 2000 to 2012 with at least 13 months of continuous Medicare coverage before death. Descriptive statistics and multivariate logistic regressions were conducted to evaluate end-of-life care, including chemotherapy in the final 14 days of life, intensive care unit (ICU) admission in the final 30 days of life, more than one emergency room (ER) or hospital admission in the final 30 days of life, invasive or life-extending procedures in the final 30 days of life, enrollment in hospice, enrollment in hospice during the final 3 days of life, and enrollment in hospice while not hospitalized. Results A total of 3,666 patients were assessed: 2,819 (77%) were white, 553 (15%) Hispanic, 256 (7%) black, and 38 (1%) other. A total of 2,642 (72%) enrolled in hospice before death, but only 2,344 (64%) died while enrolled. The median hospice enrollment duration was 20 days. In the final 30 days of life, 381 (10%) had more than one ER visit, 505 (14%) more than one hospital admission, 593 (16%) ICU admission, 848 (23%) invasive care, and 418 (11%) life-extending care. In the final 14 days of life, 357 (10%) received chemotherapy. Several outcomes differed for minorities compared with white patients. Hispanic and black patients were less likely to enroll and die in hospice (black odds ratio [OR], 0.66; 95% CI, 0.50 to 0.88; P = .004; Hispanic OR, 0.76; 95% CI, 0.61 to 0.94; P = .01). Hispanic patients were more likely to be admitted to an ICU (OR, 1.37; 95% CI, 1.05 to 1.78; P = .02), and black patients were more likely to have more than one ER visit (OR, 2.20; 95% CI, 1.53 to 3.16; P < .001) and receive a life-extending procedure (OR, 2.13; 95% CI, 1.49 to 3.04; P < .001). Conclusion We found being a minority was associated with receiving intensive and invasive end-of-life care among patients with ovarian cancer.
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Affiliation(s)
- Jolyn S Taylor
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Suja S Rajan
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Ning Zhang
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Larissa A Meyer
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Lois M Ramondetta
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Diane C Bodurka
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - David R Lairson
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
| | - Sharon H Giordano
- Jolyn S. Taylor, Ning Zhang, Larissa A. Meyer, Lois M. Ramondetta, Diane C. Bodurka, and Sharon H. Giordano, The University of Texas MD Anderson Cancer Center; and Suja S. Rajan and David R. Lairson, The University of Texas School of Public Health, Houston, TX
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25
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Wilk AS, Hirth RA, Zhang W, Wheeler JRC, Turenne MN, Nahra TA, Sleeman KK, Messana JM. Persistent Variation in Medicare Payment Authorization for Home Hemodialysis Treatments. Health Serv Res 2017; 53:649-670. [PMID: 28105639 DOI: 10.1111/1475-6773.12650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy. DATA SOURCES/STUDY SETTING Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD). STUDY DESIGN We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities. DATA COLLECTION We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims. PRINCIPAL FINDINGS MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts. CONCLUSIONS Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity.
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Affiliation(s)
- Adam S Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Richard A Hirth
- Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Wei Zhang
- Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI
| | - John R C Wheeler
- Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Tammie A Nahra
- Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Kathryn K Sleeman
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Joseph M Messana
- Division of Nephrology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
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Stevenson DG, Dalton JB, Grabowski DC, Huskamp HA. Nearly half of all Medicare hospice enrollees received care from agencies owned by regional or national chains. Health Aff (Millwood) 2017; 34:30-8. [PMID: 25561641 DOI: 10.1377/hlthaff.2014.0599] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Analyses of ownership in the US hospice sector have focused on the growth of for-profit hospice care and on aggregate differences in patient populations and service use patterns between for-profit and not-for-profit agencies. Such comparisons, although useful, do not offer insights about the types of organizations within the hospice sector, including the emergence of multiagency chains. Using Medicare cost report data for the period 2000-11, we tracked the evolution of the US hospice industry. We not only describe the market's composition by profit status but also provide new information about the roles of regional and national chains. Almost half of all Medicare hospice enrollees in 2011 received hospice services from a multiagency chain. A handful of companies play a prominent role, although the presence of smaller for-profit and not-for-profit hospice chains also has grown in recent years. By focusing on the role of the diverse organizations that provide hospice care, our analyses can help inform efforts to monitor and assure quality of care, to assess payment adequacy and options for reform, and to facilitate greater transparency and accountability within the hospice marketplace.
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Affiliation(s)
- David G Stevenson
- David G. Stevenson is an associate professor in the Department of Health Policy at Vanderbilt University, in Nashville, Tennessee
| | - Jesse B Dalton
- Jesse B. Dalton is a research analyst in the Department of Health Care Policy at Harvard Medical School, in Boston, Massachusetts
| | - David C Grabowski
- David C. Grabowski is a professor of health care policy at Harvard Medical School
| | - Haiden A Huskamp
- Haiden A. Huskamp is a professor of health care policy at Harvard Medical School
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Jarosek SL, Shippee TP, Virnig BA. Place of Death of Individuals with Terminal Cancer: New Insights from Medicare Hospice Place-of-Service Codes. J Am Geriatr Soc 2016; 64:1815-22. [PMID: 27534517 DOI: 10.1111/jgs.14269] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Stephanie L Jarosek
- Department of Urology, Medical School, University of Minnesota, Minneapolis, Minnesota.
| | - Tetyana P Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Beth A Virnig
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
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28
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Aldridge MD, Epstein AJ, Brody AA, Lee EJ, Cherlin E, Bradley EH. The Impact of Reported Hospice Preferred Practices on Hospital Utilization at the End of Life. Med Care 2016; 54:657-63. [PMID: 27299952 PMCID: PMC5266506 DOI: 10.1097/mlr.0000000000000534] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Affordable Care Act requires hospices to report quality measures across a range of processes and practices. Yet uncertainties exist regarding the impact of hospice preferred practices on patient outcomes. OBJECTIVE Assess the impact of 6 hospice preferred practices and hospice organizational characteristics on hospital utilization and death using the first national data on hospice preferred practices. DESIGN Longitudinal cohort study (2008-2011) of Medicare beneficiaries (N=149,814) newly enrolled in a national random sample of hospices (N=577) from the National Hospice Survey (84% response rate) and followed until death. OUTCOME MEASURES The proportion of patients at each hospice admitted to the hospital, emergency department (ED), and intensive care unit (ICU), and who died in the hospital after hospice enrollment. RESULTS Hospices that reported assessing patient preferences for site of death at admission had lower odds of being in the highest quartile for hospital death (AOR=0.36; 95% CI, 0.14-0.93) and ED visits (AOR=0.27; 95% CI, 0.10-0.76). Hospices that reported more frequently monitoring symptoms had lower odds of being in the highest quartile for ICU stays (AOR=0.48; 95% CI, 0.24-0.94). In adjusted analyses, a higher proportion of patients at for-profit compared with nonprofit hospices experienced a hospital admission (15.3% vs. 10.9%, P<0.001), ED visit (21.8% vs. 15.6%, P<0.001), and ICU stay (5.1% vs. 3.0%, P<0.001). CONCLUSIONS Hospitalization of patients following hospice enrollment varies substantially across hospices. Two of the 6 preferred practices examined were associated with hospitalization rates and for-profit hospices had persistently high hospitalization rates regardless of preferred practice implementation.
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Affiliation(s)
- Melissa D Aldridge
- *Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York †Geriatrics Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY ‡Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA §New York University College of Nursing, New York, NY ∥Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, CT
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29
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Stevenson DG, Grabowski DC, Keating NL, Huskamp HA. Effect of Ownership on Hospice Service Use: 2005-2011. J Am Geriatr Soc 2016; 64:1024-31. [PMID: 27131344 DOI: 10.1111/jgs.14093] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess differences in populations and service use according to hospice ownership, chain status, and agency size. DESIGN Retrospective cohort study. SETTING United States. PARTICIPANTS Medicare beneficiaries aged 65 and older enrolled in hospice during 2005 to 2011 N = 5,405,526). MEASUREMENTS Hospice use according to ownership category (for-profit nonchain and chain, not-for-profit nonchain and chain, government) and agency size (0-50, 51-200, 201-400, ≥401 individuals discharged each year). Mean length of use, stays of 3 days or fewer, stays ending with live discharge, and decedents receiving no general inpatient care (GIP)- or continuous home care (CHC)-level hospice in the last 7 days of life. RESULTS After adjusting for individual and geographic differences, for-profit nonchain and chain agencies had longer mean length of use (84.5 and 91.2 days, respectively) than other agency types (66.3-72.5 days), higher rates of live discharge (21.0% and 20.2% vs 14.6-15.9%), and lower proportions of stays of 3 days or fewer (13.9% and 14.7% vs 16.6-17.5%) (all P < .001). The proportion of decedents not receiving GIP- or CHC-level care before death was highest in for-profit chains (75.9%) and lowest in not-for-profit nonchains (63.2%). Smaller agencies had longer mean length of use, higher live discharge rates, lower rates of stays of 3 days or fewer, and higher rates of individuals receiving no GIP- or CHC-level care. There were considerable differences in patient traits and unadjusted service use between the nation's largest chains. CONCLUSION In addition to for-profit and not-for-profit hospice agencies differing according to important dimensions, there is substantial heterogeneity within these ownership categories, highlighting the need to consider factors such as agency size and chain affiliation in understanding variations in Medicare beneficiaries' hospice care.
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Affiliation(s)
- David G Stevenson
- Department of Health Policy, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Brigham and Women's Hospital, Boston, Massachusetts
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Johnson KS, Payne R, Kuchibhatla MN, Tulsky JA. Are Hospice Admission Practices Associated With Hospice Enrollment for Older African Americans and Whites? J Pain Symptom Manage 2016; 51:697-705. [PMID: 26654945 PMCID: PMC4833599 DOI: 10.1016/j.jpainsymman.2015.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 11/09/2015] [Accepted: 11/13/2015] [Indexed: 11/30/2022]
Abstract
CONTEXT Hospices that enroll patients receiving expensive palliative therapies may serve more African Americans because of their greater preferences for aggressive end-of-life care. OBJECTIVES Examine the association between hospices' admission practices and enrollment of African Americans and whites. METHODS This was a cross-sectional study of 61 North and South Carolina hospices. We developed a hospice admission practices scale; higher scores indicate less restrictive practices, that is, greater frequency with which hospices admitted those receiving chemotherapy, inotropes, and so forth. In separate multivariate analyses for each racial group, we examined the relationship between the proportion of decedents (age ≥ 65) served by a hospice in their service area (2008 Medicare Data) and admission practices while controlling for health care resources (e.g., hospital beds) and market concentration in the area, ownership, and budget. RESULTS Nonprofit hospices and those with larger budgets reported less restrictive admission practices. In bivariate analyses, hospices with less restrictive admission practices served a larger proportion of patients in both racial groups (P < 0.001). However, in the multivariate models, nonprofit ownership and larger budgets but not admission practices predicted the outcome. CONCLUSION Hospices with larger budgets served a greater proportion of African Americans and whites in their service area. Although larger hospices reported less restrictive admission practices, they also may have provided other services that may be important to patients regardless of race, such as more in-home support or assistance with nonmedical expenses, and participated in more outreach activities increasing their visibility and referral base. Future research should explore factors that influence decisions about hospice enrollment among racially diverse older adults.
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Affiliation(s)
- Kimberly S Johnson
- Department of Medicine, Duke University, Durham, North Carolina, USA; Division of Geriatrics, Duke University, Durham, North Carolina, USA; Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA; Duke Palliative Care, Duke University, Durham, North Carolina, USA; Geriatrics Research, Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina, USA.
| | - Richard Payne
- Department of Medicine, Duke University, Durham, North Carolina, USA; Division of Geriatrics, Duke University, Durham, North Carolina, USA; Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA; Duke Divinity School, Duke University, Durham, North Carolina, USA
| | - Maragatha N Kuchibhatla
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - James A Tulsky
- Department of Medicine, Duke University, Durham, North Carolina, USA; Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA; Duke Palliative Care, Duke University, Durham, North Carolina, USA; Division of General Internal Medicine, Duke University, Durham, North Carolina, USA; Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina, USA
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Wang SY, Aldridge MD, Gross CP, Canavan M, Cherlin E, Johnson-Hurzeler R, Bradley E. Transitions Between Healthcare Settings of Hospice Enrollees at the End of Life. J Am Geriatr Soc 2016; 64:314-22. [PMID: 26889841 PMCID: PMC4762182 DOI: 10.1111/jgs.13939] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To characterize the number and types of care transitions in the last 6 months of life of individuals who used hospice and to examine factors associated with having multiple transitions in care. DESIGN Retrospective cohort study. SETTING One hundred percent fee-for-service Medicare decedent claims data. PARTICIPANTS Medicare beneficiaries aged 66 and older who died between July 1, 2011, and December 31, 2011, and were enrolled in hospice at some time during the last 6 months of life. MEASUREMENTS Hierarchical generalized linear modeling was used to identify individual, hospice, and regional factors associated with transitions. The sequence of transitions across healthcare settings was described. Healthcare transitions after hospice enrollment included from and to the hospital, skilled nursing facility, home health agency program, hospice, or home without receiving any service in these four healthcare settings. RESULTS Of 311,090 hospice decedents, 31,675 (10.2%) had at least one transition after hospice enrollment, and this varied substantially across the United States; 6.6% of all decedents had more than one transition in care after hospice enrollment (range 2-19 transitions). Of hospice users with transitions, 53.4% were admitted to hospitals, 17.7% were admitted to skilled nursing facilities, 9.6% used home health agencies, and 25.8% had transitions to home without receiving the services from the healthcare settings examined. In adjusted analyses, decedents who were younger, nonwhite, enrolled in a for-profit or small hospice program, or had less access to hospital-based palliative care had significantly higher odds of having at least one transition. CONCLUSION A notable proportion of hospice users experience at least one transition in care in the last 6 months of life, suggesting that further research on the effect of transitions on users and families is warranted.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York and James J. Peters VA Medical Center, Bronx, NY
| | - Cary P. Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Maureen Canavan
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT
| | - Emily Cherlin
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT
| | - Rosemary Johnson-Hurzeler
- John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, Connecticut, CT
| | - Elizabeth Bradley
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT
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32
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Ornstein KA, Meier DE. Beyond Enrollment: Providing the Highest-Quality Care within Hospice. J Am Geriatr Soc 2016; 64:330-1. [PMID: 26889842 PMCID: PMC5417357 DOI: 10.1111/jgs.13945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Katherine A. Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn
School of Medicine at Mount Sinai, New York, New York
| | - Diane E. Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn
School of Medicine at Mount Sinai, New York, New York
- Center to Advance Palliative Care, New York, New York
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33
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Teno JM, Bowman J, Plotzke M, Gozalo PL, Christian T, Miller SC, Williams C, Mor V. Characteristics of Hospice Programs With Problematic Live Discharges. J Pain Symptom Manage 2015; 50:548-52. [PMID: 26004403 DOI: 10.1016/j.jpainsymman.2015.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 05/03/2015] [Accepted: 05/13/2015] [Indexed: 11/24/2022]
Abstract
CONTEXT Little is known about how hospice live discharges vary by hospice providers' tax status and chain affiliation. OBJECTIVES To characterize hospices with high rates of problematic patterns of live discharges. METHODS Three hospice-level patterns of live discharges were defined as problematic when the facility rate was at the 90th percentile or higher. A hospice with a high rate of patients discharged, hospitalized, and readmitted to hospice was considered to have a problematic live discharge pattern, which we have referred to as burdensome transition. The two other problematic live discharge patterns examined were live discharge in the first seven days of a hospice stay and live discharge after 180 days in hospice. A multivariate logistic model examined variation in the hospice-level rate of each discharge pattern by the hospice's chain affiliation and profit status. This model also adjusted for facility rates of medical diagnoses, nonwhite patients, average age, and the state in which the hospice program is located. RESULTS In 2010, 3028 hospice programs had 996,208 discharges, with 18.0% being alive. Each proposed problematic pattern of live discharge varied by chain affiliation. For-profit providers without a chain affiliation had a higher rate of burdensome transitions than did for-profit providers in national chains (18.2% vs. 12.1%, P < 0.001), whereas not-for-profit providers had the lowest rate of burdensome transitions (1.4%). About one in three (33.8%) for-profit providers exhibited one or more of these discharge patterns compared with 9.0% of not-for-profit providers. CONCLUSION Problematic patterns of live discharges are higher among for-profit providers, especially those not affiliated with a hospice chain.
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Affiliation(s)
- Joan M Teno
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA.
| | - Jason Bowman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | | | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | | | - Susan C Miller
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cindy Williams
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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Stevenson DG. The Role of Ownership in Hospice Care: Commentary on Teno et al. J Pain Symptom Manage 2015; 50:435. [PMID: 26315544 PMCID: PMC4592838 DOI: 10.1016/j.jpainsymman.2015.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 08/19/2015] [Indexed: 11/22/2022]
Affiliation(s)
- David G Stevenson
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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Dain AS, Bradley EH, Hurzeler R, Aldridge MD. Massage, Music, and Art Therapy in Hospice: Results of a National Survey. J Pain Symptom Manage 2015; 49:1035-41. [PMID: 25555445 PMCID: PMC4480160 DOI: 10.1016/j.jpainsymman.2014.11.295] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 11/19/2014] [Accepted: 11/22/2014] [Indexed: 10/24/2022]
Abstract
CONTEXT Complementary and alternative medicine (CAM) provides clinical benefits to hospice patients, including decreased pain and improved quality of life. Yet little is known about the extent to which U.S. hospices employ CAM therapists. OBJECTIVES To report the most recent national data regarding the inclusion of art, massage, and music therapists on hospice interdisciplinary teams and how CAM therapist staffing varies by hospice characteristics. METHODS A national cross-sectional survey of a random sample of hospices (n = 591; 84% response rate) from September 2008 to November 2009. RESULTS Twenty-nine percent of hospices (169 of 591) reported employing an art, massage, or music therapist. Of those hospices, 74% employed a massage therapist, 53% a music therapist, and 22% an art therapist, and 42% expected the therapist to attend interdisciplinary staff meetings, indicating a significant role for these therapists on the patient's care team. In adjusted analyses, larger hospices compared with smaller hospices had significantly higher odds of employing a CAM therapist (adjusted odds ratio 6.38; 95% CI 3.40, 11.99) and for-profit hospices had lower odds of employing a CAM therapist compared with nonprofit hospices (adjusted odds ratio 0.52; 95% CI 0.32, 0.85). Forty-four percent of hospices in the Mountain/Pacific region reported employing a CAM therapist vs. 17% in the South Central region. CONCLUSION Less than one-third of U.S. hospices employ art, massage, or music therapists despite the benefits these services may provide to patients and families. A higher proportion of large hospices, nonprofit hospices, and hospices in the Mountain/Pacific region employ CAM therapists, indicating differential access to these important services.
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Affiliation(s)
- Aleksandra S Dain
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J. Peters VA, Bronx, New York, USA
| | - Elizabeth H Bradley
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Rosemary Hurzeler
- The John D. Thompson Hospice Institute for Education, Training, and Research, Inc., Branford, Connecticut, USA
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Abstract
BACKGROUND Hospice use has increased substantially during the past decade by an increasingly diverse patient population; however, little is known about patterns of hospice use and how these patterns have changed during the past decade. OBJECTIVE To characterize Medicare hospice users in 2000 and 2010 and estimate the prevalence of (1) very short (≤1 wk) hospice enrollment; (2) very long (>6 mo) hospice enrollment; and (3) hospice disenrollment and how these utilization patterns have varied over time and by patient and hospice characteristics. RESEARCH DESIGN Cross-sectional analysis of Medicare hospice claims data from 2000 and 2010. SUBJECTS All US Medicare Hospice Benefit enrollees in 2000 (N=529,573) and 2010 (N=1,150,194). RESULTS As of 2010, more than half (53.4%) of all Medicare decedents who used hospice had either very short (≤1 wk, 32.4%) or very long (>6 mo, 13.9%) hospice enrollment or disenrolled from hospice before death (10.6%). This represents an increase of 4.9 percentage points from 2000. In multivariable analysis, patients with noncancer diagnoses, the fastest growing group of hospice users, were approximately twice as likely as those with cancer to have very short or long enrollment periods and to disenroll from hospice. CONCLUSION The substantial proportion of hospice users with very short or long enrollment, or enrollments that end before death, underscores the potential for interventions to improve the timing and appropriateness of hospice referral so that the full benefits of hospice are received by patients and families.
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Affiliation(s)
- Melissa D Aldridge
- *Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York †James J. Peters VA Medical Center, Bronx, NY ‡Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
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Wright AA, Hatfield LA, Earle CC, Keating NL. End-of-life care for older patients with ovarian cancer is intensive despite high rates of hospice use. J Clin Oncol 2014; 32:3534-9. [PMID: 25287831 DOI: 10.1200/jco.2014.55.5383] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To date, few studies have examined end-of-life care for patients with ovarian cancer. One study documented increased hospice use among older patients with ovarian cancer from 2000 to 2005. We sought to determine whether increased hospice use was associated with less-intensive end-of-life medical care. PATIENTS AND METHODS We identified 6,956 individuals age ≥ 66 years living in SEER areas who were enrolled in fee-for-service Medicare, diagnosed with epithelial ovarian cancer between 1997 and 2007, and died as a result of ovarian cancer by December 2007. We examined changes in medical care during patients' last month of life over time. RESULTS Between 1997 and 2007, hospice use increased significantly, and terminal hospitalizations decreased (both P < .001). However, during this time, we also observed statistically significant increases in intensive care unit admissions, hospitalizations, repeated emergency department visits, and health care transitions (all P ≤ .01). In addition, the proportion of patients referred to hospice from inpatient settings rose over time (P = .001). Inpatients referred to hospice were more likely to enroll in hospice within 3 days of death than outpatients (adjusted odds ratio, 1.36; 95% CI, 1.12 to 1.66). CONCLUSION Older women with ovarian cancer were more likely to receive hospice services near death and less likely to die in a hospital in 2007 compared with earlier years. Despite this, use of hospital-based services increased over time, and patients underwent more transitions among health care settings near death, suggesting that the increasing use of hospice did not offset intensive end-of-life care.
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Affiliation(s)
- Alexi A Wright
- Alexi A. Wright, Dana-Farber Cancer Institute; Alexi A. Wright, Laura A. Hatfield, and Nancy L. Keating, Harvard Medical School; Nancy L. Keating, Brigham and Women's Hospital, Boston, MA; and Craig C. Earle, Cancer Care Ontario and Ontario Institute for Cancer Research, Toronto, Ontario, Canada.
| | - Laura A Hatfield
- Alexi A. Wright, Dana-Farber Cancer Institute; Alexi A. Wright, Laura A. Hatfield, and Nancy L. Keating, Harvard Medical School; Nancy L. Keating, Brigham and Women's Hospital, Boston, MA; and Craig C. Earle, Cancer Care Ontario and Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Craig C Earle
- Alexi A. Wright, Dana-Farber Cancer Institute; Alexi A. Wright, Laura A. Hatfield, and Nancy L. Keating, Harvard Medical School; Nancy L. Keating, Brigham and Women's Hospital, Boston, MA; and Craig C. Earle, Cancer Care Ontario and Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Nancy L Keating
- Alexi A. Wright, Dana-Farber Cancer Institute; Alexi A. Wright, Laura A. Hatfield, and Nancy L. Keating, Harvard Medical School; Nancy L. Keating, Brigham and Women's Hospital, Boston, MA; and Craig C. Earle, Cancer Care Ontario and Ontario Institute for Cancer Research, Toronto, Ontario, Canada
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Teno JM, Plotzke M, Gozalo P, Mor V. A national study of live discharges from hospice. J Palliat Med 2014; 17:1121-7. [PMID: 25101752 DOI: 10.1089/jpm.2013.0595] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Live discharges from hospice can occur because patients decide to resume curative care, their condition improves, or hospices may inappropriately use live discharge to avoid costly hospitalizations. OBJECTIVE Describe the variation, outcomes, and organizational characteristics associated with live discharges. DESIGN Retrospective cohort study. SETTING/SUBJECTS Medicare fee-for-service hospice beneficiaries. MEASUREMENT Overall rate, timing, and health care transitions of live discharges. RESULTS In 2010, 182,172 of 1,003,958 (18.2%) hospice discharges were alive. Hospice rate of live discharges varied by hospice program with interquartile range of 9.5% to 26.4% and by geographic regions with the lowest rate in Connecticut (12.8%) and the highest in Mississippi (40.5%). Approximately 1 in 4 (n=43,889; 24.1%) beneficiaries discharged alive were hospitalized within 30 days. Nearly 8% (n=13,770) had a pattern of hospice discharge, hospitalization, and hospice readmission. These latter cases account for $126 million in Medicare reimbursement. Not-for-profit hospice programs had a lower rate of live discharges compared to for-profit programs (14.6% versus 22.4%; adjusted odds ratio [AOR] 0.84, 95% confidence interval [CI] 0.77-0.91). More mature hospice programs (over 21 years in operation) had lower rates of live discharge compared to programs in operation for 5 years or less (14.2% versus 26.7%; AOR 0.71, 95% CI 0.65-0.77). Small for-profits in operation 5 years or less had a higher live discharge rate than older, for-profit programs (31.5% versus 14.3%, p<0.001). CONCLUSIONS Approximately 1 in 5 hospice patients are discharged alive with variation by geographic regions and hospice programs. Not-for-profit hospices and older hospices have lower rates of live discharge.
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Affiliation(s)
- Joan M Teno
- 1 School of Public Health, Center for Gerontology and Healthcare Research, Brown University , Providence, Rhode Island
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Aldridge MD, Schlesinger M, Barry CL, Morrison RS, McCorkle R, Hürzeler R, Bradley EH. National hospice survey results: for-profit status, community engagement, and service. JAMA Intern Med 2014; 174:500-6. [PMID: 24567076 PMCID: PMC4315613 DOI: 10.1001/jamainternmed.2014.3] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery. OBJECTIVE To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States. EXPOSURES For-profit or nonprofit hospice ownership. MAIN OUTCOMES AND MEASURES Provision of community benefits; setting and timing of the hospice population served; and community outreach. RESULTS A total of 591 hospices completed our survey (84% response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55% vs 82%; adjusted relative risk [ARR], 0.67 [95% CI, 0.59-0.76]), conducting research (18% vs 23%; ARR, 0.67 [95% CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95% CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare's aggregate annual cap (22% vs 4%; ARR, 3.66 [95% CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P < .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61% vs 46%; ARR, 1.23 [95% CI, 1.05-1.44]) and minority communities (59% vs 48%; ARR, 1.18 [95% CI, 1.02-1.38]) and less likely to partner with oncology centers (25% vs 33%; ARR, 0.59 [95% CI, 0.44-0.80]). CONCLUSIONS AND RELEVANCE Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare's aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase.
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Affiliation(s)
- Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York
| | - Mark Schlesinger
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
| | - Colleen L Barry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York4Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
| | - Ruth McCorkle
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
| | - Rosemary Hürzeler
- John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, Connecticut
| | - Elizabeth H Bradley
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
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Aldridge Carlson MD, Barry CL, Cherlin EJ, McCorkle R, Bradley EH. Hospices' enrollment policies may contribute to underuse of hospice care in the United States. Health Aff (Millwood) 2013; 31:2690-8. [PMID: 23213153 DOI: 10.1377/hlthaff.2012.0286] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hospice use in the United States is growing, but little is known about barriers that terminally ill patients may face when trying to access hospice care. This article reports the results of the first national survey of the enrollment policies of 591 US hospices. The survey revealed that 78 percent of hospices had at least one enrollment policy that may restrict access to care for patients with potentially high-cost medical care needs, such as chemotherapy or total parenteral nutrition. Smaller hospices, for-profit hospices, and hospices in certain regions of the country consistently reported more limited enrollment policies. We observe that hospice providers' own enrollment decisions may be an important contributor to previously observed underuse of hospice by patients and families. Policy changes that should be considered include increasing the Medicare hospice per diem rate for patients with complex needs, which could enable more hospices to expand enrollment.
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Barry CL, Carlson MDA, Thompson JW, Schlesinger M, McCorkle R, Kasl S, Bradley EH. Caring for grieving family members: results from a national hospice survey. Med Care 2012; 50:578-84. [PMID: 22310561 PMCID: PMC3374048 DOI: 10.1097/mlr.0b013e318248661d] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A founding principle of hospice is that the patient and family is the unit of care; however, we lack national information on services to family members. Although Medicare certification requires bereavement services be provided, reimbursement rates are not tied to the level or quality of care; therefore, limited financial incentives exist for hospice to provide more than a minimal benefit. OBJECTIVES To assess the scope and intensity of services provided to family members by hospice. RESEARCH DESIGN We fielded a national survey of hospices between September 2008 and November 2009. PARTICIPANTS A national sample of US hospices with an 84% response rate (N=591). MEASURES Bereavement services to the family, bereavement services to the community, labor-intensive family services, and comprehensive family services. RESULTS Most hospices provided bereavement services to the family (78%) and to the community (76%), but only a minority of hospices provided labor-intensive (23%) or comprehensive (27%) services to grieving family members. Larger hospice size was positively and significantly associated with each of the 4 measures of family services. We found no significant difference in provision of bereavement services to the family, labor-intensive services, or comprehensive services by ownership type; however, nonprofit hospices were more likely than for-profit hospices to provide bereavement services to the community. CONCLUSIONS Our results show substantial diversity in the scope and intensity of services provided to families of patients with terminal illnesses, suggesting a need for clearer guidance on what hospices should provide to exemplify best practices. Consensus within the field on more precise guidelines in this area is essential.
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Affiliation(s)
- Colleen L. Barry
- Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health 624 N. Broadway, Room 403 Baltimore, MD 21205
| | - Melissa D. A. Carlson
- Geriatrics and Palliative Medicine Mount Sinai School of Medicine Annenberg Building Floor 10 1468 Madison Avenue New York, NY 10029
| | | | - Mark Schlesinger
- Yale School of Public Health 60 College Street New Haven CT 06510
| | - Ruth McCorkle
- Florence Schorske Wald Professor of Nursing Yale School of Nursing 100 Church Street South New Haven, CT 06536
| | - Stanislav Kasl
- Yale School of Public Health 60 College Street New Haven CT 06510
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Unroe KT, Greiner MA, Johnson KS, Curtis LH, Setoguchi S. Racial differences in hospice use and patterns of care after enrollment in hospice among Medicare beneficiaries with heart failure. Am Heart J 2012; 163:987-993.e3. [PMID: 22709751 DOI: 10.1016/j.ahj.2012.03.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 03/08/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND We examined racial differences in patterns of care and resource use among Medicare beneficiaries with heart failure after enrollment in hospice. METHODS We conducted a retrospective cohort study of a 5% nationally representative sample of Medicare beneficiaries with heart failure who died between 2000 and 2008. Outcomes of interest included adjusted and unadjusted associations of race with hospice enrollment for any diagnosis, disenrollment, and resource use after enrollment. RESULTS The study population included 219,275 Medicare beneficiaries with heart failure, of whom 31.4% of white patients and 24.3% of nonwhite patients enrolled in hospice in the last 6 months of life (P < .001). Despite increasing rates of hospice use for both white and nonwhite patients, nonwhite patients were 20% less likely to enroll in hospice (adjusted relative risk, 0.80; 95% CI, 0.79-0.82). After enrollment, nonwhite patients were more likely to have an emergency department visit (42.6% vs 33.9%; P<.001), to be hospitalized (46.8% vs 38.5%; P<.001), and to have an intensive care unit stay (16.9% vs 13.3%; P<.001). These differences persisted after adjustment for patient characteristics. Nonwhite patients were also more likely to disenroll from hospice (11.6% vs 7.2%; P<.001). Among patients who remained in hospice until death, nonwhite patients had higher rates of acute care resource use and higher overall costs. CONCLUSION Rates of hospice use have increased over time for both white and nonwhite patients. Nonwhite patients were less likely than white patients to enroll in hospice and had higher resource use after electing hospice care, regardless of disenrollment status.
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Affiliation(s)
- Kathleen T Unroe
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC 27715, USA
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Abstract
BACKGROUND The National Quality Forum (NQF) identified hospice services as a national priority area for health care quality improvement and endorsed a set of preferred practices for quality palliative and hospice care. This study reports the first national data regarding hospices' self-reported implementation of the NQF preferred practices and identifies hospice characteristics associated with more comprehensive implementation. METHODS We conducted a national cross-sectional survey of a random sample of hospices (n=591; response rate, 84%) from September 2008 to November 2009. We evaluated the reported implementation of NQF preferred practices in the care of both patients and families. RESULTS The range of reported implementation of individual NQF preferred practices among hospices was 45% to 97%. Twenty-one percent of hospices reported having implemented all patient-centered preferred practices, 26% all family-centered preferred practices, and 10% all patient and family-centered preferred practices. In adjusted analyses, large hospices (100 or more patients per day) were significantly more likely than small hospices (<20 patients per day) to report having implemented all patient-centered preferred practices [odds ratio (OR)=2.46; 95% CI, 1.24, 4.90] and all family-centered preferred practices (OR=1.88; 95% CI, 1.02, 3.45). Similarly, chain-affiliated hospices were significantly more likely than free-standing hospices to report having implemented all patient-centered preferred practices (OR=2.45; 95% CI, 1.23, 4.87) and all family-centered preferred practices (OR=1.85; 95% CI, 1.01, 3.41). CONCLUSIONS Hospices' reported implementation of individual preferred practices for palliative and hospice care quality was high; however, reported comprehensive implementation of preferred practices was rare and may be difficult to achieve for small, free-standing hospices.
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Ramey SJ, Chin SH. Disparity in hospice utilization by African American patients with cancer. Am J Hosp Palliat Care 2011; 29:346-54. [PMID: 22025746 DOI: 10.1177/1049909111423804] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Stephen J Ramey
- Department of Medicine, Division of Hematology and Oncology, Charleston, SC, USA
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Legler A, Bradley EH, Carlson MDA. The effect of comorbidity burden on health care utilization for patients with cancer using hospice. J Palliat Med 2011; 14:751-6. [PMID: 21548813 PMCID: PMC3107582 DOI: 10.1089/jpm.2010.0504] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The treatment of patients with advanced cancer with multiple comorbid illnesses is complex. Although an increasing number of such patients are being referred to hospice, the comorbidity burden of this patient population is largely unknown but has implications for the complexity of care provided by hospices. This study reports the comorbidity burden in a national sample of hospice users with cancer and estimates the effect of higher comorbidity on health care use and site of death. METHODS Cross-sectional study using Surveillance, Epidemiology and End Results-Medicare data for hospice users who died of cancer in 2002 (N = 27,166). We measured comorbidity burden using the Charlson comorbidity index and used multivariable generalized estimating equations to estimate the association between comorbidity burden and the following outcomes: emergency department and intensive care unit (ICU) admission, hospitalization, hospice disenrollment, and hospital death. RESULTS Patients with cancer who used hospice had an average Charlson comorbidity index value of 1.24, including 18.8% who suffered from comorbid dementia. In analyses adjusted for patient demographics, site of primary cancer, and number of days with hospice, higher comorbidity burden was associated with higher likelihood of emergency department admission (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.52, 1.87), ICU admission (OR = 3.28, 95% CI 2.45, 4.38), inpatient hospitalization (OR = 2.14, 95% CI 1.90, 2.42), hospice disenrollment (OR = 1.41, 95% CI 1.29, 1.56) and hospital death (OR = 2.51, 95% CI 2.08, 3.02). CONCLUSION These findings underscore the complexity of the hospice patient population and highlight a potential need to risk adjust the per diem hospice reimbursement rates to account for increased resource requirements for hospices serving patients with higher comorbidity burden.
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Affiliation(s)
- Aron Legler
- Mount Sinai School of Medicine, New York, New York 10029, USA
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Affiliation(s)
- Robert E. Enck
- East Tennessee State University College of Medicine, Johnson City, TN, USA,
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Miller SC, Lima JC, Mitchell SL. Hospice care for persons with dementia: The growth of access in US nursing homes. Am J Alzheimers Dis Other Demen 2010; 25:666-73. [PMID: 21131673 PMCID: PMC3009455 DOI: 10.1177/1533317510385809] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/RATIONALE Persons with dementia often die in nursing homes (NHs); however, concerns exist about their low use of Medicare hospice. METHODS For 1999 through 2006 in all US states and DC we merged NH resident assessment data with Medicare claims and enrollment data to identify NH decedents with dementia and hospice use. We studied two groups, those with advanced dementia and those with mild-to-moderately severe dementia. RESULTS Across study years, 22.2% of all NH decedents had mild-to-moderately severe dementia and 19.6% had advanced dementia. In 1999, 14.5% of decedents with advanced and 13.2% with mild-to-moderately severe dementia accessed hospice, increasing to 42.5% and 37.9% respectively in 2006. Between 1999 and 2006, mean days of hospice stays increased from 46 to 118 for advanced dementia and from 39 to 79 for mild-to-moderately severe dementia. These mean length of stay differences resulted from a relatively lower proportion of short hospice stays (≤ 7 days) together with higher proportions of longer stays (≥ 181 days) among advanced versus mild-to-moderately severe dementia decedents. Hospice access and lengths of stay among US states varied widely. CONCLUSIONS Over 40% of US NH decedents have mild-to-moderately severe or advanced dementia. For these NH decedents, access to and duration of Medicare hospice has increased. However, there is considerable variation in hospice use across US states.
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Affiliation(s)
- Susan C Miller
- Department of Community Health, Brown University, Providence, RI, USA.
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Carlson MDA, Bradley EH, Du Q, Morrison RS. Geographic access to hospice in the United States. J Palliat Med 2010; 13:1331-8. [PMID: 20979524 DOI: 10.1089/jpm.2010.0209] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Melissa D A Carlson
- Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York, USA.
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Carlson MDA, Herrin J, Du Q, Epstein AJ, Barry CL, Morrison RS, Back AL, Bradley EH. Impact of hospice disenrollment on health care use and medicare expenditures for patients with cancer. J Clin Oncol 2010; 28:4371-5. [PMID: 20805463 DOI: 10.1200/jco.2009.26.1818] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with cancer represent the largest diagnostic group of hospice users, with 560,000 referred for hospice in 2008. Oncologists rely on hospice teams to provide care for patients who have completed disease-directed treatment and desire to remain at home. However, 11% to 15% of hospice users disenroll from hospice, and little is known about their health care use and Medicare expenditures. PATIENTS AND METHODS We used Surveillance, Epidemiology and End Results-Medicare data for hospice users who died as a result of cancer between 1998 and 2002 (N = 90,826) to compare rates of hospitalization, emergency department, and intensive care unit admission and hospital death for hospice disenrollees and those who remained with hospice until death. We also compared per-day and total Medicare expenditures across the two groups. RESULTS Patients with cancer who disenrolled from hospice were more likely to be hospitalized (39.8% v 1.6%; P < .001), more likely to be admitted to the emergency department (33.9% v 3.1%; P < .001) or intensive care unit (5.7% v 0.1%; P < .001), and more likely to die in the hospital (9.6% v 0.2%; P < .001). Patients who disenrolled from hospice died a median of 24 days following disenrollment, suggesting that the reason for hospice disenrollment was not improved health. In multivariable analyses, hospice disenrollees incurred higher per-day Medicare expenditures than patients who remained with hospice until death (higher per-day expenditures of $124; P < .001). CONCLUSION Hospice disenrollment is a marker for higher health care use and expenditures for care. Strategies to manage a patient's care and support family caregivers following hospice disenrollment may be beneficial and should be explored.
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Affiliation(s)
- Melissa D A Carlson
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Pl, Box 1070, New York, NY 10029, USA.
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