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Algu K, Wales J, Anderson M, Omilabu M, Briggs T, Kurahashi AM. Naming racism as a root cause of inequities in palliative care research: a scoping review. BMC Palliat Care 2024; 23:143. [PMID: 38858646 PMCID: PMC11163751 DOI: 10.1186/s12904-024-01465-9] [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] [Received: 12/29/2023] [Accepted: 05/22/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist. OBJECTIVE To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings. METHODS Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results. RESULTS We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common. CONCLUSION While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.
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Affiliation(s)
- Kavita Algu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada.
| | - Joshua Wales
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Michael Anderson
- Waakebiness-Bryce Institute for Indigenous Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Mariam Omilabu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Thandi Briggs
- Home and Community Care Support Services Toronto Central, 250 Dundas St. W, Toronto, ON, M5T 2Z5, Canada
| | - Allison M Kurahashi
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
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Wladkowski SP, Wallace CL, Coccia K, Hyde RC, Hinyard L, Washington KT. Live Discharge of Hospice Patients with Alzheimer's Disease and Related Dementias: A Systematic Review. Am J Hosp Palliat Care 2024; 41:228-239. [PMID: 36977504 PMCID: PMC10763573 DOI: 10.1177/10499091231168401] [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: 03/30/2023] Open
Abstract
Background: Hospice is intended to promote the comfort and quality of life of dying patients and their families. When patients are discharged from hospice prior to death (ie, experience a "live discharge"), care continuity is disrupted. This systematic review summarizes the growing body of evidence on live discharge among hospice patients with Alzheimer's Disease and related dementias (ADRD), a clinical subpopulation that disproportionately experiences this often burdensome care transition. Methods: Researchers conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Reviewers searched AgeLine, APA PsycINFO (Ovid), CINAHL Plus with Full Text, ProQuest Dissertations & Theses Global, PubMed, Scopus, and Web of Science (Core Collection). Reviewers extracted data and synthesized findings from 9 records, which reported findings from 10 individual studies. Results: The reviewed studies, which were generally of high quality, consistently identified diagnosis of ADRD as a risk factor for live discharge from hospice. The relationship between race and live hospice discharge was less clear and likely dependent upon the type of discharge under investigation and other (eg, systemic-level) factors. Research on patient and family experiences underscored the extent to which live hospice discharge can be distressing, confusing, and associated with numerous losses. Conclusion: Research specific to live discharge among ADRD patients and their families is limited. Synthesis across included studies points to the importance for future research to differentiate between types of live discharge-revocation vsversus decertification-as these are vastly different experiences in choice and circumstances.
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Affiliation(s)
- Stephanie P Wladkowski
- College of Health and Human Services, Bowling Green State University Department of Human Services, Bowling Green, OH, USA
| | - Cara L Wallace
- School of Social Work, Saint Louis University, St. Louis, MO, USA
| | - Kathryn Coccia
- School of Social Work, Saint Louis University, St. Louis, MO, USA
| | - Rebecca C Hyde
- Pius XII Memorial Library, Saint Louis University, St. Louis, MO, USA
| | - Leslie Hinyard
- Department of Health and Clinical Outcomes Research, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Karla T Washington
- Division of Palliative Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, 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: 2] [Impact Index Per Article: 2.0] [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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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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Lackraj D, Kavalieratos D, Murali KP, Lu Y, Hua M. Implementation of Specialist Palliative Care and Outcomes for Hospitalized Patients with Dementia. J Am Geriatr Soc 2021; 69:1199-1207. [PMID: 33523466 PMCID: PMC8202070 DOI: 10.1111/jgs.17032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with serious illness, use of specialist palliative care may result in improved quality of life, patient and caregiver satisfaction and advance care planning, as well as lower health care utilization. However, evidence of efficacy is limited for patients with dementia, particularly in the setting of an acute hospitalization. OBJECTIVE To determine whether implementation of hospital-based specialist palliative care was associated with differences in treatment intensity outcomes for hospitalized patients with dementia. DESIGN Retrospective cohort study. SETTING Fifty-one hospitals in New York State that either did or did not implement a palliative care program between 2008 and 2014. Hospitals that consistently had a palliative care program during the study period were excluded. PARTICIPANTS Hospitalized patients with dementia. MEASUREMENTS The primary outcome of this study was discharge to hospice from an acute hospitalization. Secondary outcomes included hospital length of stay, use of mechanical ventilation and dialysis, and days in intensive care. Difference-in-difference analyses were performed using multilevel regression to assess the association between implementing a palliative care program and outcomes, while adjusting for patient and hospital characteristics and time trends. RESULTS During the study period, 82,118 patients with dementia (mean (SD) age, 83.04 (10.04), 51,170 (62.21%) female) underwent an acute hospitalization, of which 41,227 (50.27%) received care in hospitals that implemented a palliative care program. In comparison to patients who received care in hospitals without palliative care, patients with dementia who received care in hospitals after the implementation of palliative care were more 35% likely to be discharged to hospice (adjusted odds ratio (aOR) = 1.35 (1.19-1.51), P < .001). No meaningful differences in secondary outcomes were observed. CONCLUSION Implementation of a specialist palliative care program was associated with an increase in discharge to hospice following acute hospitalization in patients with dementia.
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Affiliation(s)
- Deven Lackraj
- Department of Anesthesiology, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventative Medicine, Emory University, Atlanta, Georgia, USA
| | - Komal P Murali
- School of Nursing, Columbia University, New York, New York, USA
| | - Yewei Lu
- Department of Anesthesiology, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - May Hua
- Department of Anesthesiology, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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Luth EA, Russell DJ, Xu JC, Lauder B, Ryvicker MB, Dignam RR, Baughn R, Bowles KH, Prigerson HG. Survival in hospice patients with dementia: the effect of home hospice and nurse visits. J Am Geriatr Soc 2021; 69:1529-1538. [PMID: 33608869 DOI: 10.1111/jgs.17066] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/15/2021] [Accepted: 01/26/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hospice patients with dementia are at increased risk for live discharge and long lengths of stay (>180 days), causing patient and family caregiver stress and burden. The location and timing of clinician visits are important factors influencing whether someone dies as expected, in hospice, or experiences a live discharge or long length of stay. OBJECTIVE Examine how home hospice and nurse visit frequency relate to dying in hospice within the Medicare-intended 6-month period. DESIGN Retrospective cohort study. SETTING Non-profit hospice agency. PARTICIPANTS Three thousand eight hundred and thirty seven patients with dementia who received hospice services from 2013 to 2017. METHODS Multivariable survival analyses examined the effects of receiving home hospice (vs. nursing home) and timing of nurse visits on death within 6 months of hospice enrollment, compared to live discharge or long length of stay. Models adjust for relevant demographic and clinical factors. RESULTS Thirty-nine percent (39%) of patients experienced live discharge or long length of stay. Home hospice patients were more likely to experience live discharge or long length of stays (HR for death: 0.77, 95%CI: 0.69-0.86, p < 0.001). Frequency of nurse visits was inversely associated with live discharge and long lengths of stay (HR for death: 2.87, 95%CI: 2.47-3.33, p < 0.001). CONCLUSION Nearly 40% of patients with dementia in our study experienced live discharge or a long length of stay. Additional research is needed to understand why home hospice may result in live discharge or a long length of stay for patients with dementia. Nurse visits were associated with death, suggesting their responsiveness to deteriorating patient health. Hospice guidelines may need to permit longer stays so community-dwelling patients with dementia, a growing segment of hospice patients, can remain continuously enrolled in hospice and avoid burden and costs associated with live discharge.
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Affiliation(s)
- Elizabeth A Luth
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David J Russell
- Center for Home Care & Policy Research, Visiting Nurse Service of New York, New York, New York, USA.,Department of Sociology, Appalachian State University, Boone, North Carolina, USA
| | - Jiehui Cici Xu
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Bonnie Lauder
- Hospice and Palliative Care Services, Visiting Nurse Service of New York, New York, New York, USA
| | - Miriam B Ryvicker
- Center for Home Care & Policy Research, Visiting Nurse Service of New York, New York, New York, USA
| | - Ritchell R Dignam
- Hospice and Palliative Care Services, Visiting Nurse Service of New York, New York, New York, USA
| | - Rosemary Baughn
- Hospice and Palliative Care Services, Visiting Nurse Service of New York, New York, New York, USA
| | - Kathryn H Bowles
- Center for Home Care & Policy Research, Visiting Nurse Service of New York, New York, New York, USA.,Biobehavioral Health Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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Wladkowski SP, Wallace CL, Gibson A. A Theoretical Exploration of Live Discharge from Hospice for Caregivers of Adults with Dementia. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2020; 16:133-150. [PMID: 32223695 DOI: 10.1080/15524256.2020.1745351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Patients with dementia may be discharged from hospice if their condition stabilizes. The loss of professional support and an already complex grief process needs careful attention. A live discharge presents a unique experience for each hospice patient, caregiver, and hospice team, which varies from traditional bereavement theories used to describe the grieving process. This article explores live discharge from hospice for caregivers of adults with dementia through a theoretical lens of Symbolic Interactionism (SI) and Attachment Theory (AT). The theories of SI and AT support and assist in understanding the experience of caregivers who lose hospice support due to ineligibility. In addition, caregivers watch the gradual deterioration and psychological loss of someone with dementia while they remain alive described as an ambiguous loss. Ambiguous loss as a subset of traditional bereavement theories provides a framework for this exploration and provides a relevant illustration of the complex needs. This article will conclude with implications for social work practice. It is important for hospice clinicians to be aware of current termination practices necessary to manage appropriate attachments, support the symbolic meaning of the hospice experience, validate the ambiguous losses, and maintain a sense of hope through a live discharge from hospice.
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Affiliation(s)
| | - Cara L Wallace
- College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri, USA
| | - Allison Gibson
- College of Social Work, University of Kentucky, Lexington, Kentucky, USA
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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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10
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Wladkowski SP, Wallace CL. Current Practices of Live Discharge from Hospice: Social Work Perspectives. HEALTH & SOCIAL WORK 2019; 44:30-38. [PMID: 30561640 DOI: 10.1093/hsw/hly040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 03/13/2018] [Indexed: 06/09/2023]
Abstract
Hospice provides holistic support for individuals living with terminal illness and to their caregivers during the bereavement period. However, some individuals who enroll in hospice services are decertified as they do not experience a decline in health as quickly as required by current regulations, a practice referred to as a live discharge. The interruption in care can affect the physical and psychosocial care needs for individuals and caregivers and leave hospice clinicians with questions about how to best support them. However, there are no formal guidelines to support this process. This qualitative study (N = 24) explored the current practices of hospice social workers across the United States engaged in the live discharge process. Results from this study emphasize the need to bridge the gaps between policy and practice. Specifically, results highlight the challenges hospice social workers face to replicate or supplement the holistic support and unique services hospice provides for individuals discharged alive, and suggest further research to develop live discharge guidelines to identify appropriate support for patients and their caregivers who no longer meet hospice eligibility requirements.
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Affiliation(s)
- Stephanie P Wladkowski
- Stephanie P. Wladkowski, PhD, LMSW, is assistant professor, School of Social Work, Eastern Michigan University, 317 Marshall Hall, Ypsilanti, MI 48197; e-mail: . Cara L. Wallace, PhD, LMSW, is assistant professor, School of Social Work, Saint Louis University
| | - Cara L Wallace
- Stephanie P. Wladkowski, PhD, LMSW, is assistant professor, School of Social Work, Eastern Michigan University, 317 Marshall Hall, Ypsilanti, MI 48197; e-mail: . Cara L. Wallace, PhD, LMSW, is assistant professor, School of Social Work, Saint Louis University
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Travers JL, Schroeder KL, Blaylock TE, Stone PW. Racial/Ethnic Disparities in Influenza and Pneumococcal Vaccinations Among Nursing Home Residents: A Systematic Review. THE GERONTOLOGIST 2018; 58:e205-e217. [PMID: 28329831 PMCID: PMC6044397 DOI: 10.1093/geront/gnw193] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Indexed: 11/13/2022] Open
Abstract
This systematic review analyzes research examining racial/ethnic disparities in influenza and pneumococcal vaccination coverage between White and racial/ethnic minority (Black and Hispanic) nursing home residents. A review of the literature for years 1966-2014 using Medline, Web of Science, and PubMed was conducted. The Epidemiological Appraisal Instrument was used to appraise the quality of the 13 included studies. Overall, articles were strong in reporting and data analysis, but weak in sample selection and measurement quality. Disparities between vaccination coverage among racial/ethnic minorities versus Whites ranged from 2% to 20% for influenza and 6% to 15% for pneumococcal vaccination. Researchers reported racial/ethnic minorities were more likely to refuse vaccinations and less likely to have vaccinations offered and their vaccination status tracked compared to Whites. Policies/strategies that focus on ensuring racial/ethnic minorities are offered influenza and pneumococcal vaccinations and their vaccination status are tracked in nursing homes are warranted. Updated evaluation on vaccination disparities is also needed.
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Affiliation(s)
- Jasmine L Travers
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia
| | | | - Thomas E Blaylock
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York
| | - Patricia W Stone
- Center for Health Policy, Columbia University School of Nursing, New York, New York
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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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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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Wladkowski SP. Dementia Caregivers and Live Discharge from Hospice: What Happens When Hospice Leaves? JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2017; 60:138-154. [PMID: 27997295 DOI: 10.1080/01634372.2016.1272075] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Hospice offers holistic support for individuals living with terminal illness and their caregivers. Some individuals receiving hospice services experience a slower decline in health as than expected, resulting in a 'live discharge' from hospice. A live discharge affects both patient and caregiver(s).The current study (N=24) explored the experiences of caregivers of adults with dementia who experienced a live discharge from hospice. Findings emphasize the comprehensive services covered under the Medicare Hospice benefit and those lost after a live discharge. Implications for social workers supporting caregivers are discussed, including the need to view the patient-caregiver unit during a live discharge.
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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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Sternberg S, Bentur N, Shuldiner J. Quality of Care of Older People Living with Advanced Dementia in the Community in Israel. J Am Geriatr Soc 2014; 62:269-75. [DOI: 10.1111/jgs.12655] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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