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Cardenas V, Fennell G, Enguidanos S. Hispanics and Hospice: A Systematic Literature Review. Am J Hosp Palliat Care 2022; 40:552-573. [PMID: 35848308 PMCID: PMC9845431 DOI: 10.1177/10499091221116068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background. Hospice has been shown to improve patient and family satisfaction with care, reduce hospitalizations and hospital costs, and reduce pain and symptoms. Despite more than 40 years of hospice care and related research in the U.S., few studies examining hospice experiences have included Hispanics. Thus, little is known about hospice barriers, facilitators, and outcomes among Hispanics.Aim. This systematic literature review aimed to provide a comprehensive overview of studies assessing knowledge of and attitudes toward hospice, barriers and facilitators to hospice use, utilization patterns, and hospice-related outcomes among Hispanics.Design. Between March 2019 and March 2020 we searched Ovid Medline (PubMed), EMBASE, and CINAHL, using search terms for hospice care, end-of-life care, Hispanics, and Latinos. All steps were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. U.S. studies that examined Hispanics' knowledge and attitudes towards hospice, facilitators or barriers to hospice use, hospice use, and hospice-related outcomes were included. Qualitative studies and non-empirical work were excluded. Study quality was assessed using Hawker's quality criteria.Results. Of the 4,841 abstracts reviewed, 41 peer-reviewed articles met the inclusion criteria. These studies largely report lower hospice knowledge and awareness among Hispanics and mixed results around hospice use and outcomes in comparison to Whites.Conclusion. There has been relatively little research focused specifically on Hispanics' experience with hospice. Future research should focus on testing interventions for overcoming hospice-related disparities among Hispanics and on improving access to quality hospice care among terminally ill Hispanics.
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Affiliation(s)
- Valeria Cardenas
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Gillian Fennell
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
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Akbar U, McQueen RB, Bemski J, Carter J, Goy ER, Kutner J, Johnson MJ, Miyasaki JM, Kluger B. Prognostic predictors relevant to end-of-life palliative care in Parkinson's disease and related disorders: a systematic review. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-323939. [PMID: 33789923 PMCID: PMC8142437 DOI: 10.1136/jnnp-2020-323939] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 11/22/2022]
Abstract
Parkinson's disease and related disorders (PDRD) are the second most common neurodegenerative disease and a leading cause of death. However, patients with PDRD receive less end-of-life palliative care (hospice) than other illnesses, including other neurologic illnesses. Identification of predictors of PDRD mortality may aid in increasing appropriate and timely referrals. To systematically review the literature for causes of death and predictors of mortality in PDRD to provide guidance regarding hospice/end-of-life palliative care referrals. We searched MEDLINE, PubMed, EMBASE and CINAHL databases (1970-2020) of original quantitative research using patient-level, provider-level or caregiver-level data from medical records, administrative data or survey responses associated with mortality, prognosis or cause of death in PDRD. Findings were reviewed by an International Working Group on PD and Palliative Care supported by the Parkinson's Foundation. Of 1183 research articles, 42 studies met our inclusion criteria. We found four main domains of factors associated with mortality in PDRD: (1) demographic and clinical markers (age, sex, body mass index and comorbid illnesses), (2) motor dysfunction and global disability, (3) falls and infections and (4) non-motor symptoms. We provide suggestions for consideration of timing of hospice/end-of-life palliative care referrals. Several clinical features of advancing disease may be useful in triggering end-of-life palliative/hospice referral. Prognostic studies focused on identifying when people with PDRD are nearing their final months of life are limited. There is further need for research in this area as well as policies that support need-based palliative care for the duration of PDRD.
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Affiliation(s)
- Umer Akbar
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | | | - Julienne Bemski
- Department of Neurology, University of Colorado, Denver, Colorado, USA
| | - Julie Carter
- Department of Neurology, University of Colorado, Denver, Colorado, USA
| | - Elizabeth R Goy
- Department of Neurology, Portland VA Medical Center, Portland, Oregon, USA
| | - Jean Kutner
- Department of Neurology, University of Colorado, Denver, Colorado, USA
| | - Miriam J Johnson
- Department of Palliative Medicine, Hull York Medical School, Hull, Kingston upon Hull, UK
| | - Janis M Miyasaki
- Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Benzi Kluger
- Department of Neurology, University of Rochester, Rochester, New York, USA
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Live Discharge From Hospice Due to Acute Hospitalization: The Role of Neighborhood Socioeconomic Characteristics and Race/Ethnicity. Med Care 2020; 58:320-328. [PMID: 31876664 DOI: 10.1097/mlr.0000000000001278] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute hospitalization is a frequent reason for live discharge from hospice. Although risk factors for live discharge among hospice patients have been well documented, prior research has not examined the role of neighborhood socioeconomic characteristics, or how these characteristics relate to racial/ethnic disparities in hospice outcomes. OBJECTIVE To examine associations between neighborhood socioeconomic characteristics and risk for live discharge from hospice because of acute hospitalization. The authors also explore the moderating role of race/ethnicity in any observed relationship. RESEARCH DESIGN Retrospective cohort study using electronic medical records of hospice patients (N=17,290) linked with neighborhood-level socioeconomic data (N=55 neighborhoods). Multilevel models were used to identify the independent significance of patient and neighborhood-level characteristics for risk of live discharge because of acute hospitalization. RESULTS Compared with the patients in the most well-educated and affluent sections of New York City [quartile (Q)4], the odds of live discharge from hospice because of acute hospitalization were greater among patients who resided in neighborhoods where lower proportions of residents held college degrees [Q1 adjusted odds ratio (AOR), 1.36; 95% confidence interval (CI), 1.06-1.75; Q2 AOR, 1.41; 95% CI, 1.07-1.84] and median household incomes were lower (Q1 AOR, 1.42; 95% CI, 1.10-1.85; Q2 AOR, 1.43; 95% CI, 1.10-1.85; Q3 AOR, 1.39; 95% CI, 1.07-1.80). However, these observed relationships were not equally distributed by patient race/ethnicity; the association of neighborhood socioeconomic disadvantage and risk for live discharge was significantly lower among Hispanic compared with white patients. CONCLUSIONS Findings demonstrate neighborhood socioeconomic disadvantage poses a significant risk for live discharge from hospice. Additional research is needed to clarify the social mechanisms underlying this association, including greater attention to the experiences of hospice patients from under-represented racial/ethnic groups.
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Luth EA, Russell DJ, Brody AA, Dignam R, Czaja SJ, Ryvicker M, Bowles KH, Prigerson HG. Race, Ethnicity, and Other Risks for Live Discharge Among Hospice Patients with Dementia. J Am Geriatr Soc 2020; 68:551-558. [PMID: 31750935 PMCID: PMC7056492 DOI: 10.1111/jgs.16242] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The end-of-life trajectory for persons with dementia is often protracted and difficult to predict, placing these individuals at heightened risk of live discharge from hospice. Risks for live discharge due to condition stabilization or failure to decline among patients with dementia are not well established. Our aim was to identify demographic, health, and hospice service factors associated with live discharge due to condition stabilization or failure to decline among hospice patients with dementia. DESIGN Retrospective cohort study. SETTING A large not-for-profit agency in New York City. PARTICIPANTS A total of 2629 hospice patients with dementia age 65 years and older. MEASUREMENTS Primary outcome was live discharge from hospice due to condition stabilization or failure to decline (vs death). Measures include demographic factors (race/ethnicity, Medicaid, sex, age, marital status, parental status), health characteristics (primary dementia diagnosis, comorbidities, functional status, prior hospitalization), and hospice service (location, length of service, number and timing of nurse visits). RESULTS Logistic regression models indicated that compared with white hospice patients with dementia, African American and Hispanic hospice patients with dementia experienced increased risk of live discharge (African American: adjusted odds ratio [aOR] = 2.42; 95% confidence interval [CI] = 1.34-4.38; Hispanic: aOR = 2.99; 95% CI = 1.81-4.94). Home hospice (aOR = 7.57; 95% CI = 4.04-14.18), longer length of service (aOR = 1.04; 95% CI = 1.04-1.05), and more days between nurse visits and discharge (aOR = 1.86; 95% CI = 1.56-2.21) were also associated with live discharge. CONCLUSION To avoid burdensome and disruptive transitions out of hospice in patients with dementia, interventions to reduce live discharge due to condition stabilization or failure to decline should be tailored to meet the needs of African American, Hispanic, and home hospice patients. Policies regarding sustained hospice eligibility should account for the variable and protracted end-of-life trajectory of patients with dementia. J Am Geriatr Soc 68:551-558, 2020.
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Affiliation(s)
| | - David J. Russell
- Center for Home Care Policy & Research, Visiting Nurse
Service of New York
- Department of Sociology Appalachian State University
| | - Abraham A. Brody
- New York University College of Nursing
- James J Peters Bronx VA Medical Center, GRECC
| | - Ritchell Dignam
- Center for Home Care Policy & Research, Visiting Nurse
Service of New York
| | | | - Miriam Ryvicker
- Center for Home Care Policy & Research, Visiting Nurse
Service of New York
| | - Kathryn H. Bowles
- Center for Home Care Policy & Research, Visiting Nurse
Service of New York
- University of Pennsylvania School of Nursing
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5
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Ankuda CK, Fonger E, O'Neil T. Electing Full Code in Hospice: Patient Characteristics and Live Discharge Rates. J Palliat Med 2017; 21:297-301. [PMID: 28872978 DOI: 10.1089/jpm.2017.0276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND It is unknown how many hospice enrollees elect to be full code and if this is associated with higher hospice live discharge rates. OBJECTIVE To measure the rates of hospice enrollees electing full code, the characteristics predicting full code status, and the association of full code status with various hospice live discharge patterns. DESIGN Retrospective cohort study of electronic medical record data. SETTING/SUBJECTS A total of 25,636 decedents enrolled in two Michigan hospices between 2009 and 2014. MEASUREMENTS Code status was defined as full code versus do-not-resuscitate (DNR) orders. Covariates include demographics, location (home, hospice facility, nursing home, and hospital), primary diagnosis, and length of stay. Hospice live discharge was defined as short (0-14 days), medium (15-179 days), and long (>179 days). RESULTS A total of 12.9% of hospice enrollees elected full code status. This was significantly (p < 0.05) predicted by male sex, younger age, nonwhite race, home setting of care, and cancer diagnosis. Those with full code status had 1.76 times the adjusted odds of hospice live discharge compared with those with DNR orders (95% confidence interval [CI] 1.44-2.16) and 2.47 times the odds of short live discharge (95% CI 1.69-3.62) with no significant difference in long live discharge. The association of full code orders with hospice live discharge was stronger for nonwhite enrollees, with a live discharge rate of 23.8% versus 11.6% for African Americans with full code versus DNR orders. CONCLUSIONS Those electing full code status on admission to hospice are at high risk of live hospice discharge after short enrollments, particularly nonwhite enrollees.
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Affiliation(s)
- Claire K Ankuda
- 1 Robert Wood Johnson Clinical Scholars Program, University of Michigan , Ann Arbor, Michigan.,2 Department of Family Medicine, University of Michigan , Ann Arbor, Michigan
| | - Evan Fonger
- 3 Hospice of Michigan , Detroit, Michigan.,4 Arbor Hospice , Ann Arbor, Michigan
| | - Thomas O'Neil
- 4 Arbor Hospice , Ann Arbor, Michigan.,5 Department of Geriatric and Palliative Medicine, University of Michigan , Ann Arbor, Michigan
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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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Russell D, Diamond EL, Lauder B, Dignam RR, Dowding DW, Peng TR, Prigerson HG, Bowles KH. Frequency and Risk Factors for Live Discharge from Hospice. J Am Geriatr Soc 2017; 65:1726-1732. [DOI: 10.1111/jgs.14859] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- David Russell
- Center for Home Care Policy & Research; Visiting Nurse Service of New York; New York City New York
| | - Eli L. Diamond
- Department of Neurology; Memorial Sloan Kettering Cancer Center; New York City New York
- Center for Research on End of Life Care; Weill Cornell Medicine; New York City New York
| | - Bonnie Lauder
- Visiting Nurse Service of New York Hospice and Palliative Care; New York City New York
| | - Ritchell R. Dignam
- Visiting Nurse Service of New York Hospice and Palliative Care; New York City New York
| | - Dawn W. Dowding
- Center for Home Care Policy & Research; Visiting Nurse Service of New York; New York City New York
- Columbia University School of Nursing; New York City New York
| | - Timothy R. Peng
- Center for Home Care Policy & Research; Visiting Nurse Service of New York; New York City New York
| | - Holly G. Prigerson
- Center for Research on End of Life Care; Weill Cornell Medicine; New York City New York
| | - Kathryn H. Bowles
- Center for Home Care Policy & Research; Visiting Nurse Service of New York; New York City New York
- University of Pennsylvania School of Nursing; Philadelphia Pennsylvania
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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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Campbell RW. Being discharged from hospice alive: the lived experience of patients and families. J Palliat Med 2015; 18:495-9. [PMID: 25719562 DOI: 10.1089/jpm.2014.0228] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Approximately 259,000 patients were discharged alive from U.S. hospices in 2010. There is a paucity of research describing the experiences of these individuals and their family members. OBJECTIVE The study objective was to explore the experiences of adults discharged from a hospice program due to decertification related to ineligibility or extended prognosis, from the perspective of the individual and his or her adult family members. Research questions were, How do participants perceive and describe (1) the experience of being discharged alive from hospice, and (2) their quality of life after a live hospice discharge? METHODS A transcendental phenomenological design guided this study. Purposive, snowball sampling was used to recruit 12 volunteers, aged 35-92 years, who had experienced live hospice discharge due to decertification. Data collection included open-ended interviews and journals. RESULTS Findings included two primary themes: suffering "AS…" and the paradox of hospice discharge. These primary themes were supported by 12 subthemes: abandonment, unanswered questions, loss of security, loneliness, uncertainty, anger and frustration, physical decline, bearing exhaustive witness, having and needing support, mixed feelings, not dying fast enough, and hospice equals life. CONCLUSION Understanding this experience may enhance understanding and aid health care providers to anticipate the unique needs of the hospice population.
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Dingfield L, Bender L, Harris P, Newport K, Hoover-Regan M, Feudtner C, Clifford S, Casarett D. Comparison of Pediatric and Adult Hospice Patients Using Electronic Medical Record Data from Nine Hospices in the United States, 2008–2012. J Palliat Med 2015; 18:120-6. [DOI: 10.1089/jpm.2014.0195] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Laura Dingfield
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Bender
- Penn Home Care and Hospice Services, BalaCynwyd, Pennsylvania
| | - Pamela Harris
- Kansas City Hospice and Palliative Care, Kansas City, Missouri
| | - Kristina Newport
- Hospice and Community Care of Lancaster County, Lancaster, Pennsylvania
| | - Margo Hoover-Regan
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Chris Feudtner
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - David Casarett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Masel EK, Huber P, Schur S, Kierner KA, Nemecek R, Watzke HH. Coming and going: predicting the discharge of cancer patients admitted to a palliative care unit: easier than thought? Support Care Cancer 2015; 23:2335-9. [PMID: 25577505 DOI: 10.1007/s00520-015-2601-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 01/05/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Discharging a patient admitted to an inpatient palliative care unit (PCU) is a major challenge. A predictor of the feasibility of home discharge at the time of admission would be very useful. We tried to identify such predictors in a prospective observational study. METHODS Sixty patients with advanced cancer admitted to a PCU were enrolled. Sociodemographic data were recorded and a panel of laboratory tests performed. The Karnofsky performance status scale (KPS) and the palliative performance scale (PPS) were determined. A palliative care physician and nurse independently predicted whether the patient would die at the ward. The association of these variables with home discharge or death at the PCU was determined. RESULTS Sixty patients (26 men and 34 women) with advanced cancer were included in the study. Discharge was achieved in 45 % of patients, while 55 % of patients died at the PCU. The median stay of discharged patients was 15.2 days, and the median stay of deceased patients 13.6 days. Median KPS and PPS on admission was 56.2 % for the entire group and significantly higher for discharged patients (60.7 %) compared to deceased patients (52.4 %). Median BMI on admission was 22.8 in the entire group and was similar in discharged and deceased patients. No correlation was found between a panel of sociodemographic variables and laboratory tests with regard to discharge or death. In a binary logistic regression model, the probability of discharge as estimated by the nurse/physician and the KPS and PPS were highly significant (p = 0.008). CONCLUSION Estimation by a nurse and a physician were highly significant predictors of the likelihood of discharge and remained significant in a multivariate logistic regression model including KPS and PPS. Other variables, such as a panel of laboratory tests or sociodemographic variables, were not associated with discharge or death.
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Affiliation(s)
- Eva K Masel
- Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria,
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12
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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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13
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Rothenberg LR, Doberman D, Simon LE, Gryczynski J, Cordts G. Patients surviving six months in hospice care: who are they? J Palliat Med 2014; 17:899-905. [PMID: 24933676 DOI: 10.1089/jpm.2013.0512] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND On January 1, 2011, the Centers for Medicare and Medicaid Services (CMS) began requiring U.S. hospices to conduct a "face-to-face" (F2F) assessment of eligibility for continued hospice care with patients entering their third certification period (180 days after initial enrollment). Understanding which patient populations require F2F assessment is important for evaluating the impact of the CMS regulation and gauging the appropriateness of the 6-month prognosis criteria for different patient groups. METHODS Retrospective program records were obtained for patients enrolled in a large hospice 6 months prior to implementation of the CMS regulation (N=375). Patients who remained in hospice and received a F2F (n=140) were compared to patients who were no longer in hospice (n=235) on demographics, terminal condition (categorized as debility/dementia, cancer, or other), presence of serious comorbidity, length of stay, setting of care prior to admission, and hospice outcome using bivariate statistics. Predictors of F2F recertification were examined using a multivariable logistic regression model controlling for demographics, setting of care prior to admission, comorbidity, and primary terminal diagnosis. RESULTS At the bivariate level, patients who received an F2F were older (p<0.001), and more likely to have lived in a facility care setting prior to hospice admission (p<0.001) than their non-F2F counterparts. Findings from the logistic regression analysis indicate that initial setting of care (odds ratio [OR] for inpatient versus home=0.20; p=0.01), presence of serious comorbidity (OR=2.84; p<0.001), and primary diagnosis (OR for debility/dementia versus cancer=3.35; p<0.001) were significant predictors of F2F recertification. CONCLUSIONS Unlike hospice patients with cancer, patients with a primary diagnosis of dementia or debility are more likely to remain in hospice care beyond 6 months and require F2F recertification. Still, these patients need the services provided by hospice care and may be limited by the 6-month recertification criteria.
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LeSage K, Borgert AJ, Rhee LS. Time to Death and Reenrollment After Live Discharge From Hospice: A Retrospective Look. Am J Hosp Palliat Care 2014; 32:563-7. [PMID: 24848665 DOI: 10.1177/1049909114535969] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The purpose of our study was to identify time to death and/or reenrolled patients alive at the time of hospice discharge. METHODS Medical records of all adults alive at hospice discharge during a 5-year period were retrospectively reviewed. RESULTS In all, 83 patients were alive at discharge, with 3 lost to follow-up. Average time from discharge to death was 199.9 days for all patients and 50 days for the 17 patients who reenrolled. Average time from discharge to reenrollment was 245 days. CONCLUSION Our research supports past findings that over a third of patients disenrolled from hospice die within 6 months, indicating ongoing hospice eligibility up to the time of death. Interestingly, if enrollment was revoked by patient or family, as often was done to allow the patient to pursue more aggressive treatments, the mortality risk was higher in the 6 months after discharge. This should prompt careful reevaluation of disenrolled hospice patients in the months after disenrollment, and hospice reenrollment should be continually available and offered during this time.
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Affiliation(s)
- Kirstin LeSage
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Laura S Rhee
- Department of Palliative Medicine, Gundersen Health System, La Crosse, WI, USA
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Lam PT, Ma SY, Ng HY, Wong MS, Leung MW, Chan KS. Service outcomes 6 years after implementing strategies in optimizing bed utilization at a palliative care unit. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/1743291x11y.0000000002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Unroe KT, Sachs GA, Hickman SE, Stump TE, Tu W, Callahan CM. Hospice use among nursing home patients. J Am Med Dir Assoc 2012. [PMID: 23181979 DOI: 10.1016/j.jamda.2012.10.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Among hospice patients who lived in nursing homes, we sought to: (1) report trends in hospice use over time, (2) describe factors associated with very long hospice stays (>6 months), and (3) describe hospice utilization patterns. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective study from an urban, Midwest cohort of hospice patients, aged ≥ 65 years, who lived in nursing homes between 1999 and 2008. MEASUREMENTS Demographic data, clinical characteristics, and health care utilization were collected from Medicare claims, Medicaid claims, and Minimum Data Set assessments. Patients with overlapping nursing home and hospice stays were identified. χ(2) and t tests were used to compare patients with less than or longer than a 6-month hospice stay. Logistic regression was used to model the likelihood of being on hospice longer than 6 months. RESULTS A total of 1452 patients received hospice services while living in nursing homes. The proportion of patients with noncancer primary hospice diagnoses increased over time; the mean length of hospice stay (114 days) remained high throughout the 10-year period. More than 90% of all patients had 3 or more comorbid diagnoses. Nearly 20% of patients had hospice stays longer than 6 months. The hospice patients with stays longer than 6 months were observed to have a smaller percentage of cancer (25% vs 30%) as a primary hospice diagnosis. The two groups did not differ by mean cognitive status scores, number of comorbidities, or activities of daily living impairments. The greater than 6 months group was much more likely to disenroll before death: 33.9% compared with 13.8% (P < .0001). A variety of patterns of utilization of hospice across settings were observed; 21% of patients spent some of their hospice stay in the community. CONCLUSIONS Any policy proposals that impact the hospice benefit in nursing homes should take into account the difficulty in predicting the clinical course of these patients, varying utilization patterns and transitions across settings, and the importance of supporting multiple approaches for delivery of palliative care in this setting.
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Johnson KS, Elbert-Avila K, Kuchibhatla M, Tulsky JA. Characteristics and outcomes of hospice enrollees with dementia discharged alive. J Am Geriatr Soc 2012; 60:1638-44. [PMID: 22905714 PMCID: PMC3738294 DOI: 10.1111/j.1532-5415.2012.04117.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the characteristics of hospice enrollees with dementia who were discharged alive because their condition stabilized or improved and predictors of death in the year after discharge. DESIGN Cross-sectional analysis of clinical and administrative data. SETTING For-profit hospice provider. PARTICIPANTS Hospice enrollees aged 65 and older with an admission diagnosis of dementia who died or were discharged alive because their condition stabilized or improved between January 1, 1999, and December 31, 2003. MEASUREMENTS Demographic variables and hospice length of stay; data did not include functional status or comorbidities. RESULTS Of 24,111 enrollees with dementia, 1,204 (5.0%) were discharged alive because their condition stabilized or improved; the remainder died while receiving hospice. The median length of stay for those who died was 12 versus 236 days for those discharged alive. Those discharged alive were more likely to be female or have a length of stay exceeding 180 days and less likely to be in the oldest age group (≥ 85), be African American, or reside in a nursing home. In a subgroup of 303 patients discharged alive, 75.5% were still alive at 1 year; none of the demographic variables were associated with death after hospice discharge. CONCLUSION A small proportion of hospice enrollees with dementia was discharged alive. Most died shortly after enrollment. Future research should examine other factors that may predict which hospice enrollees with dementia are likely to be discharged alive and their subsequent trajectory, such as functional status, comorbidities, and preferences for care.
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Affiliation(s)
- Kimberly S Johnson
- Department of Medicine, Duke University, Durham, North Carolina 27710, USA.
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Relationships among advance directives, principal diagnoses, and discharge outcomes in critically ill older adults. Palliat Support Care 2012; 11:315-22. [PMID: 22892195 DOI: 10.1017/s1478951512000259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the relationships among advance directive status, principal diagnoses, and the discharge outcomes in community-dwelling, critically ill older adults. METHOD Using administrative and clinical data (n = 1673), multinomial logit regressions were used to examine the relationships among advance directive status, principal diagnoses, and discharge outcomes (in-hospital deaths, hospice discharges, and transition to institutions). RESULTS In the overall sample, the adjusted probability of in-hospital deaths with advance directives (12%) was lower than that without advance directives (17%; odds ratio [OR] = 0.56; p = 0.007) and the adjusted probability of hospice discharges with advance directives (11%) was higher than that without advance directives (7%; OR = 1.96; p = 0.03). Subgroup analysis showed that the magnitude of the abovementioned changes was aggregated when their principal diagnoses were a group of diseases with more difficult prognostication (circulatory and respiratory diseases) and more potential for reversibility (infectious diseases). By contrast, the magnitude of the abovementioned findings was diminished with other principal diagnoses. On the other hand, the presence of advance directives did not make a contribution to transition from communities to institutions. SIGNIFICANCE OF RESULTS Significantly fewer in-hospital deaths in addition to higher hospice discharges were observed with any advance directives in community-dwelling, critically ill older adults. The magnitude of these findings was aggregated when their principal diagnoses were a group of diseases with more difficult prognostication (circulatory and respiratory diseases) and more potential for reversibility (infectious diseases). By contrast, the magnitude of these findings was diminished with other principal diagnoses.
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Affiliation(s)
- Robert E. Enck
- East Tennessee State University College of Medicine, Johnson City, TN, USA,
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Van Houtven CH, Taylor DH, Steinhauser K, Tulsky JA. Is a home-care network necessary to access the Medicare hospice benefit? J Palliat Med 2009; 12:687-94. [PMID: 19591625 DOI: 10.1089/jpm.2008.0255] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To test whether the presence of an informal or formal care network in the home leads to different hospice utilization patterns near death. To examine how the informal care relationship affects hospice use patterns. DATA SOURCES Medicare Current Beneficiary Survey (MCBS), 1997-2001. STUDY DESIGN Using logistic regression and ordinary least squares, we examine the association between a person's in-home network of care and the use of Medicare hospice services in the last year of life. We also examine whether the care-dyad relationship is associated with different hospice use patterns. DATA EXTRACTION All individuals in the MCBS who lived at home at the time of the interview and who died between 1998 and 2001, 1404 persons. PRINCIPAL FINDINGS People receiving formal home care had a much higher chance of enrolling in hospice prior to death. Informal care did not influence the likelihood of hospice but was associated with longer use among hospice users. Daughter caregivers increased the likelihood and duration of hospice use whereas sons significantly decreased the likelihood. CONCLUSIONS Because formal care is associated with increased use of hospice, future work should examine whether patients without an in-home network faced access barriers. Caregiver relationships had large effects on length of hospice stays, yet we do not know whether changes moved a patient closer to or further away from their optimum use of the benefit.
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Affiliation(s)
- Courtney Harold Van Houtven
- Center for Health Services Research and Development in Primary Care, VA Medical Center, Durham, North Carolina 27705, USA.
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Taylor DH, Steinhauser K, Tulsky JA, Rattliff J, Van Houtven CH. Characterizing hospice discharge patterns in a nationally representative sample of the elderly, 1993-2000. Am J Hosp Palliat Care 2008; 25:9-15. [PMID: 18198361 DOI: 10.1177/1049909107310136] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The aim of this study is to identify the prevalence and correlates of individuals discharged alive from hospice in the Medicare program to determine whether the current hospice benefit matches the needs of dying patients. Using a nationally representative sample of age-eligible Medicare beneficiaries who died from 1993 to 2000, the use of hospice and other Medicare-financed care was analyzed during the last year of life for different groups of hospice users. It was found that 84.5% (n = 1029) of hospice users initiate and use it continuously until death; 15.5% of hospice users are discharged alive, with some later reinitiating hospice. The main difference between continuous hospice users and those discharged alive is the time survived after initial hospice use (those discharged alive live longer). After controlling for survival time, costs per day survived are similar for all groups. This study suggests several motivations for being discharged alive that are worthy of more research.
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Affiliation(s)
- Donald H Taylor
- Terry Sanford Institute of Public Policy, Duke University, Durham, NC 27708, USA.
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Abernethy AP, Hanson LC, Main DS, Kutner JS. Palliative Care Clinical Research Networks, a Requirement for Evidence-Based Palliative Care: Time for Coordinated Action. J Palliat Med 2007; 10:845-50. [PMID: 17803401 DOI: 10.1089/jpm.2007.0044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kutner JS, Main DS, Westfall JM, Pace W. The practice-based research network as a model for end-of-life care research: challenges and opportunities. Cancer Control 2005; 12:186-95. [PMID: 16062166 DOI: 10.1177/107327480501200309] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jean S Kutner
- Population-based Palliative Care Research Network and Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver 80262 USA.
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Kapo J, MacMoran H, Casarett D. "Lost to Follow-up": Ethnic Disparities in Continuity of Hospice Care at the End of Life. J Palliat Med 2005; 8:603-8. [PMID: 15992202 DOI: 10.1089/jpm.2005.8.603] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hospice has become the major provider of comprehensive end-of-life care in the United States, but is underutilized by African American patients. It is likely that whatever factors are responsible for lower rates of hospice utilization among African Americans also lead to lower rates of return to hospice after discharge, but this is not known. OBJECTIVE To determine whether African American patients who leave hospice are less likely to return before death. DESIGN Retrospective cohort study. SETTING University-affiliated hospice. PARTICIPANTS All patients discharged after a first admission. MEASUREMENTS All patient characteristics were defined by abstraction of electronic medical records at the time of hospice discharge. RESULTS Of 358 discharged patients, 98 (27%) were decertified and 260 (73%) left voluntarily. Ninety-six patients returned to hospice during the study period. In bivariate analysis, African Americans were less likely to return than were other patients (odds ratio (OR) 0.47, 95% CI: 0.28-0.80; p = .005). In a multivariable logistic regression model, African American ethnicity was independently associated with a decreased likelihood of return. CONCLUSIONS Ethnic disparities in hospice utilization may extend even to those patients who do enroll in hospice. African Americans who leave hospice during their first admission and their families may be less likely to have access to the comprehensive services that hospice programs provide near the end of life, including intensive nursing care, pain and symptom management, and education.
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Affiliation(s)
- Jennifer Kapo
- University of Pennsylvania, Department of Medicine Division of Geriatrics and the Institute on Aging, Philadelphia Veterans Affairs Medical Center, USA.
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