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Jordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Edwards HL, Chapman EJ, Deliens L, Bennett MI. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med 2020; 18:368. [PMID: 33239021 PMCID: PMC7690105 DOI: 10.1186/s12916-020-01829-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Roberta I Jordan
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew J Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Yousuf ElMokhallalati
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Catriona E Jackson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Helen L Edwards
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Emma J Chapman
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University, Ghent, Belgium.,Vrije Universiteit Brussel, Brussels, Belgium
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Abstract
BACKGROUND Hospice performance is an overlooked area in the health care field due to the difficulty of measuring quality of care and the infrequent quality inspection. Based on the daily reimbursement mechanism for different levels of hospice care, inpatient services provision could influence both hospice-level length of stay (LOS) and financial performance. PURPOSE The objective of this study was to explore the relationship between hospice inpatient services provision and hospice utilization and financial performance. METHODOLOGY/APPROACH A longitudinal secondary data set (2009-2013) was merged from three sources: (a) Hospice Cost Reports from the Centers for Medicare & Medicaid Services, (b) the Provider of Services files, and (c) the Area Health Resources Files. The dependent variable in this study was hospice average LOS and financial performance measured by total operating margin (TOM) and return on assets. The independent variable was hospice inpatient services' offering. Mixed-effects regression models were used in the multivariate regression analyses. RESULTS When comparing to hospices not providing inpatient services, offering inpatient services by staff was negatively related to average LOS (b = -0.063, p < .05) and TOM (b = -0.022, p < .05). The combination method with providing inpatient services by staff and under arrangement was negatively associated with return on assets (b = -0.073, p < .05). CONCLUSION Hospice inpatient services provision was associated with average LOS and financial performance. PRACTICE IMPLICATIONS Offering the inpatient services to patients by staff decreased average LOS and TOM. Hospice agencies may seek strategies to maintain their financial sustainability through outsourcing.
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Kuo SC, Chou WC, Hou MM, Wu CE, Shen WC, Wen FH, Tang ST. Changes in and modifiable patient- and family caregiver-related factors associated with cancer patients’ high self-perceived burden to others at the end of life: A longitudinal study. Eur J Cancer Care (Engl) 2018; 27:e12942. [DOI: 10.1111/ecc.12942] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 05/18/2018] [Accepted: 09/02/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Su-Ching Kuo
- Department of Nursing; Yuanpei University of Medical Technology; Hsinchu Taiwan
- Graduate Institute of Clinical Medical Sciences; Chang Gung University; Taoyuan Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan Taiwan
| | - Ming-Mo Hou
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan Taiwan
| | - Chiao-En Wu
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan Taiwan
| | - Wen-Chi Shen
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan Taiwan
| | - Fur-Hsing Wen
- Department of International Business; Soochow University; Taipei Taiwan
| | - Siew-Tzuh Tang
- Division of Hematology-Oncology; Chang Gung Memorial Hospital at Linkou; Taoyuan Taiwan
- School of Nursing; Chang Gung University; Taoyuan Taiwan
- Department of Nursing; Chang Gung Memorial Hospital at Kaohsiung; Kaohsiung Taiwan
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Mendieta M, Miller A. Sociodemographic Characteristics and Lengths of Stay Associated With Acute Palliative Care: A 10-Year National Perspective. Am J Hosp Palliat Care 2018; 35:1512-1517. [PMID: 29986594 DOI: 10.1177/1049909118786409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patient demographics and characteristics are essential components associated with length of stay in hospice. Race, age, gender, health insurance status, income level, and location of hospice care services are indicators that are associated with differing lengths of stay. Hospice care demand is on the rise, and with 70 million boomers retiring in the next few decades, demand is expected to increase. It is because of demand that exploring the factors that affect a patient's length of stay is essential for understanding beneficiary care and family experience. These insights are key for medical and clinical practitioners in providing hospice patients and their families with the intended benefits and care of the Medicare Hospice Program. This study uses Medicare hospice services data from 2006 to 2014 to examine how race, age, gender, health insurance status, income level, and location before entering acute care are associated with acute care lengths of stay. Overall, this study found that race, age, gender, health insurance status, and income level have a statistically significant association with whether a patient was from home-based or from facility-based hospice. These findings suggest that racial disparities remain a relevant matter in access to hospice, palliative care, and length of stay and can assist future research in moving knowledge forward about the association between length of stay and patient characteristics.
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Affiliation(s)
- Maximiliano Mendieta
- 1 Department of Public Health and Health Sciences, University of Michigan-Flint, Flint, MI, USA
| | - Alysa Miller
- 1 Department of Public Health and Health Sciences, University of Michigan-Flint, Flint, MI, USA
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Kaufman BG, Klemish D, Kassner CT, Reiter JP, Li F, Harker M, O'Brien EC, Taylor DH, Bhavsar NA. Predicting Length of Hospice Stay: An Application of Quantile Regression. J Palliat Med 2018; 21:1131-1136. [PMID: 29762075 DOI: 10.1089/jpm.2018.0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Use of the Medicare hospice benefit has been associated with high-quality care at the end of life, and hospice length of use in particular has been used as a proxy for appropriate timing of hospice enrollment. Quantile regression has been underutilized as an alternative tool to model distributional changes in hospice length of use and hospice payments outside of the mean. OBJECTIVE To test for heterogeneity in the relationship between patient characteristics and hospice outcomes across the distribution of hospice days. SETTING Medicare Beneficiary Summary File and survey data (2014) for hospice beneficiaries in North and South Carolina with common terminal diagnoses. MEASUREMENTS Distributional shifts associated with patient characteristics were evaluated at the 25th and 75th percentiles of hospice days and hospice payments using quantile regressions and compared to the mean shift estimated by ordinary least squares (OLS) regression. PRINCIPAL FINDINGS Significant (p < 0.001) heterogeneity in the marginal effects on hospice days and costs was observed, with patient characteristics associated with generally larger shifts in the 75th percentile than the 25th percentile. Mean effects estimated by OLS regression overestimate the magnitude of the median marginal effects for all patient characteristics except for race. Results for hospice payments in 2014 were similar. CONCLUSIONS Methodological decisions can have a meaningful impact in the evaluation of factors influencing hospice length of use or cost.
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Affiliation(s)
- Brystana G Kaufman
- 1 Department of Health Policy and Management, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
| | - David Klemish
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | | | - Jerome P Reiter
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | - Fan Li
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | - Matthew Harker
- 5 Margolis Center for Health Policy , Duke University, Durham, North Carolina
| | - Emily C O'Brien
- 2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
| | - Donald H Taylor
- 6 Sanford School of Public Policy , Duke University, Durham, North Carolina
| | - Nrupen A Bhavsar
- 2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
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Ellington L, Clayton MF, Reblin M, Donaldson G, Latimer S. Communication among cancer patients, caregivers, and hospice nurses: Content, process and change over time. PATIENT EDUCATION AND COUNSELING 2018; 101:414-421. [PMID: 28964559 PMCID: PMC5857410 DOI: 10.1016/j.pec.2017.09.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/08/2017] [Accepted: 09/22/2017] [Indexed: 05/21/2023]
Abstract
OBJECTIVE First, to describe communication of home hospice nurse visits to cancer patient-caregiver dyads. Second, to assess change in communication related to domains of care over the course of visits. METHODS Multi-site prospective observational longitudinal study of audio-recorded home hospice visits (N=537 visits; 101 patient-caregiver dyads; 58 nurses). Communication was coded using the Roter Interaction Analysis System to describe content and process. Conversation representing three care domains (physical, psychosocial/daily life, and emotional) was calculated from RIAS categories across speakers and analyzed to assess change in communication over time. RESULTS On average, nurses spoke 54% of total utterances, caregivers 29%, and patients 17%. For all participants, the predominant conversational focus was on physical care. Linear mixed effects models indicated that combined participant emotional talk showed a small systematic decrease over time; however, the results for all domains indicated variability unexplained by time or speaker effects. CONCLUSIONS Home hospice conversations are predominantly focused on physical care. Systematic change in communication versus responsiveness to the dynamic effects of patient death and family response over time are discussed. PRACTICE IMPLICATIONS Communication strategies already in use by hospice nurses could be leveraged and expanded upon to better facilitate family competence and confidence.
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Affiliation(s)
- Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, USA
| | | | - Maija Reblin
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, USA.
| | - Gary Donaldson
- College of Nursing, University of Utah, Salt Lake City, USA
| | - Seth Latimer
- College of Nursing, University of Utah, Salt Lake City, USA
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Tabler J, Utz RL, Ellington L, Reblin M, Caserta M, Clayton M, Lund D. Missed Opportunity: Hospice Care and the Family. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2015; 11:224-243. [PMID: 26654059 PMCID: PMC4741375 DOI: 10.1080/15524256.2015.1108896] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A typical mission statement of hospice services is to provide quality, compassionate care to those with terminal illness and to support families through caregiving and bereavement. This study explored the ways that bereavement needs of caregivers, either predeath or postdeath of their spouse/partner, were addressed using qualitative retrospective phone interviews with 19 caregivers whose spouse/partner was enrolled in hospice care for cancer. Overall, participants expressed high satisfaction with hospice care, most often noting a high satisfaction with the quality of care provided to their spouse/partner. During the predeath phase, caregivers recalled being so focused on their spouse/partner's needs that they rarely spoke with hospice staff about their own personal needs and emotions. Participants said that bereavement counseling occurred primarily after the death of the spouse/partner, in the form of generic pamphlets or phone calls from someone they had not met during prior interactions with hospice staff. These findings suggest that caregivers' high satisfaction with hospice may be more associated with the quality of care provided to the spouse/partner than with bereavement support they received. Our findings illustrated a potential missed opportunity for hospices to address the family-oriented goals that are commonly put forward in hospice mission statements.
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Affiliation(s)
| | | | | | - Maija Reblin
- Department of Health Outcomes & Behavior, Moffitt Cancer Center
| | | | | | - Dale Lund
- Department of Sociology, California State San Bernardino
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Kirkendall A, Shen JJ, Greenway J, Bai W. Socioeconomic Factors Associated With Posthospitalization Hospice Care Settings: A 5-Year Perspective. Am J Hosp Palliat Care 2014; 33:233-9. [PMID: 25366183 DOI: 10.1177/1049909114556877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Investigating whether socioeconomic characteristics determine if hospice is received at home or in a medical facility is important to examine, considering most patients prefer to die at home. This study relied upon The State Inpatient Data of Nevada. A total of 19 206 discharges were analyzed from the data set between 2009 and 2013. The results indicate that increasingly patients are being discharged to home and overall socioeconomic characteristics appear to have less of an influence over whether hospice is received at home or in a medical facility. Further research on the perspectives of patients would provide insight into whether patients' preferences or socioeconomic characteristics are more influential on where hospice services are received.
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Affiliation(s)
- Abbie Kirkendall
- School of Social Work, Greenspun College of Urban Affairs, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Jay J Shen
- Department of Health Care Administration and Policy, School of Community Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Joseph Greenway
- Center for Health Information Analysis, School of Community Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Wenbo Bai
- Wellesley College, Wellesley, MA, USA
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