Hospice Care of Veterans in Medicare Advantage and Traditional Medicare: A Risk-Adjusted Analysis

Hospice Administrators' and Providers' Perspectives on Providing Upstream Palliative Care: Facilitators, Barriers, and Policy Prescriptions

Background: Among patients with serious illness, palliative care before hospice enrollment is associated with improved quality of life, reduced symptom burden, and earlier transitions to hospice. However, fewer than half of eligible patients receive specialty palliative care referrals. As most hospice clinicians and administrators have experience in specialty palliative care, several emerging programs propose engaging hospice clinicians to provide early palliative care. Objective: We sought to identify barriers and facilitators to upstream palliative care. Design: We conducted a key informant qualitative study among hospice administrators and clinicians. Setting/Subjects: We conducted semi-structured interviews with 23 hospice administrators and clinicians in eight states from March to August 2022. We identified participants using snowball and purposive sampling using states that participate in Medicare Advantage's value-based insurance design Model. Results: Respondents indicated that barriers to early palliative care included inadequate staffing and reimbursement. Hospice clinicians providing community-based palliative care can address access barriers and improve transitions to hospice. Respondents expressed desire for payer guidance in identifying eligible patients but were cautious about payers acting as direct palliative care providers. However, payers could facilitate uptake by broadening and specifying coverage of services to include goals of care conversations and symptom management. Routine referrals initiated by objective measures could potentially increase access. Conclusions: Utilizing hospice providers to provide upstream palliative care can increase access, improve outcomes, and ease the transition to hospice.

Effects of Medicare advantage on patterns of end-of-life care among Medicare decedents

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on patterns of end-of-life care.

DATA SOURCES

We used data from the Master Beneficiary Summary File, the Medicare Provider Analysis and Review, hospice claims, the Minimum Data Set, the Outcome and Assessment Information Set, the Area Health Resources File, and Geographic Variation Public Use File for 2012-2014.

STUDY DESIGN

To address selective enrollment into MA, we exploited a discontinuity in payment rates by county population (urban floor payments) as an instrument.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries continuously enrolled in MA or TM during their last year of life between 2012 and 2014 using Medicare administrative data.

PRINCIPAL FINDINGS

We did not find evidence that MA enrollment led to a change in hospital admissions in the last 30 days of life, but MA enrollment decreased hospital as the site of death by 11.0 (95% CI: -13.9 to -8.1) percentage points. Once hospitalized, however, MA enrollment increased use of intensive care by 6.7 (95% CI: 0.3 to 13.1) percentage points and non-invasive mechanical ventilation by 9.2 (95% CI: 5.5 to 12.9) percentage points. MA enrollment increased hospice use by 6.2 (95% CI: 2.3 to 10.1) percentage points at time of death and 7.7 (95% CI: 3.8 to 11.6) percentage points in the last 30 days of life. Particularly, MA enrollment increased hospice admissions among those who were admitted to the hospital within 30 days prior to hospice admission by 18.8 (95% CI: 13.8 to 23.8) percentage points. However, MA enrollment decreased hospice admissions among those who were admitted to home health within 30 days prior to hospice admission by 18.6 (95% CI: -21.9 to -15.2) percentage points.

CONCLUSIONS

MA plans may improve end-of-life care by reducing hospital death while also improving access to hospice, especially among recently hospitalized persons.

Symptom Burden and Activity of Daily Living (ADL) Dependency Among Home Health care Patients Discharged to Home Hospice

Background: We sought to examine sociodemographic and clinical characteristics present on admission to HHC associated with discharge to hospice. Methods: We used a 5% random sample of 2017 national Outcome and Assessment Information Set (OASIS) data. A Cox proportional hazards regression model was estimated for the primary outcome (discharge to hospice) to examine the associations with sociodemographic and clinical characteristics of HHC patients. Results: Among 489, 230 HHC patients, 4268 were discharged to hospice. The median (interquartile range) length of HHC stay for patients discharged to hospice care was 33 (14-78) days. Compared to White patients, Black, Hispanic, and other race, (hazard ratio [HR] = .50 [95% confidence interval, CI = .44-.57]), (HR = .53 [95% CI = .46-.62]), and (HR = .49 [95% CI = .40-.61], respectively) was associated with shorter time to discharge to hospice care. Clinical characteristics including severe dependence in activities of daily (ADL) (HR = 1.68 [95% CI = 1.01-2.78]), cognitive impairment (HR = 1.10 [95% CI = 1.01-1.20]), disruptive behavior daily (HR = 1.11 [95% CI = 1.02-1.22]), and inability to feed oneself (HR = 4.78, 95% CI = 4.30, 5.31) was associated with shorter time to discharge to hospice. Symptoms of anxiety daily (HR = 1.55 [95% CI = 1.43-1.68]), and pain daily or all the time (HR = 1.54 [95% CI = 1.43-1.64]) were associated with shorter time to discharge to hospice. Conclusions: High symptom burden, ADL dependency, and cognitive impairment on admission to HHC services was associated with greater likelihood of discharge to hospice.

Factors Associated With Home-Hospice Utilization

Utilization of hospice for end-of-life care is known to be lower among racial and ethnic minority groups than among White populations when controlling for other socioeconomic factors. Certain patient, provider, and community characteristics may influence home-hospice use. We sought to identify patient, provider, and community factors associated with home-hospice use. Our final analytic sample included 1,208,700 hospice patients who received home-hospice from 2,148 Medicare-certified hospice providers in 2016. We found that an increase in the proportion of hospice patients with a primary diagnosis of dementia decreased the odds that home-hospice was provided (OR = 1.42, 95% CI = 1.36-1.48). Patients who received hospice care from a provider with a higher proportion of dually enrolled patients were less likely to receive home-hospice (OR = 1.42, 95% CI = 1.36-1.48) and hospices located in ZIP-codes with higher proportion of Hispanic resident were less likely to provide home-hospice (OR = 1.00, 95% CI = 0.99-0.99). Additional research is needed to clarify the mechanisms underlying these associations.

Duration of palliative care before death in international routine practice: a systematic review and meta-analysis

BACKGROUND

Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature.

METHODS

We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death).

RESULTS

One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries.

CONCLUSIONS

Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.