Are Trends in Hospitalization Prior to Hospice Use Associated With Hospice Episode Characteristics?

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice

Importance

Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied.

Objective

To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services.

Design, Setting, and Participants

This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024.

Exposure

Live hospice discharge.

Main Outcomes and Measures

Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death.

Results

This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions.

Conclusion and Relevance

This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.

The Association of Standardized Documentation of Serious Illness Conversations With Healthcare Utilization in Hospitalized Patients: A Propensity Score Matched Cohort Analysis

Background: Serious Illness Conversations (SICs) conducted during hospitalization can lead to meaningful patient participation in the decision-making process affecting medical management. The aim of this study is to determine if standardized documentation of a SIC within an institutionally approved EHR module during hospitalization is associated with palliative care consultation, change in code status, hospice enrollment prior to discharge, and 90-day readmissions. Methods: We conducted retrospective analyses of hospital encounters of general medicine patients at a community teaching hospital affiliated with an academic medical center from October 2018 to August 2019. Encounters with standardized documentation of a SIC were identified and matched by propensity score to control encounters without a SIC in a ratio of 1:3. We used multivariable, paired logistic regression and Cox proportional-hazards modeling to assess key outcomes. Results: Of 6853 encounters (5143 patients), 59 (.86%) encounters (59 patients) had standardized documentation of a SIC, and 58 (.85%) were matched to 167 control encounters (167 patients). Encounters with standardized documentation of a SIC had greater odds of palliative care consultation (odds ratio [OR] 60.10, 95% confidence interval [CI] 12.45-290.08, P < .01), a documented code status change (OR 8.04, 95% CI 1.54-42.05, P = .01), and discharge with hospice services (OR 35.07, 95% CI 5.80-212.08, P < .01) compared to matched controls. There was no significant association with 90-day readmissions (adjusted hazard ratio [HR] .88, standard error [SE] .37, P = .73). Conclusions: Standardized documentation of a SIC during hospitalization is associated with palliative care consultation, change in code status, and hospice enrollment.

Comparison of the Pathway to Hospice Enrollment Between Medicare Advantage and Traditional Medicare

Importance

Older adults in Medicare Advantage (MA) enroll in hospice at higher rates than those in traditional Medicare (TM), but it is unclear whether the pathway of care prior to hospice use differs between MA and TM.

Objective

To examine the site of care prior to hospice enrollment for MA beneficiaries compared with those in TM.

Design, Setting, and Participants

This population-based, retrospective cross-sectional study used Medicare claims data for decedents in calendar years 2011, 2013, 2016, and 2018 who enrolled in hospice in the last 90 days of life. Data were analyzed from February 11, 2022, to October 24, 2022.

Exposures

Enrollment in MA or TM in the last month of life.

Main Outcomes and Measures

The main outcome was the site of care prior to hospice enrollment, defined as hospital, nursing home, and home with or without home health, dichotomized as community vs hospital in a logistic regression model. Covariates included decedent demographics, hospice primary diagnosis, and county-level MA penetration. Differences in hospice length of stay between MA beneficiaries and TM beneficiaries were assessed using linear and logistic regression models.

Results

In this study of 3 164 959 decedents, mean (SD) age was 83.1 (8.6) years, 55.8% were female, and 28.8% were enrolled in MA. Decedents in MA were more likely to enroll in hospice from a community setting than were those in TM, although the gap narrowed over time from an unadjusted 11.1% higher rate of community enrollment in MA vs TM in 2011 (50.1% vs 39.0%) to 8.1% in 2018 (46.4% vs 38.3%). In the primary adjusted analysis over the entire study period, MA enrollment was associated with an 8.09-percentage point (95% CI, 7.96-8.21 percentage points) higher rate of hospice enrollment from the community vs all other sites. This association remained in multiple sensitivity analyses to account for potential differences in the populations enrolled in MA vs TM. The mean overall hospice length of stay was 0.29 days (95% CI, 0.24-0.34 days) longer for MA decedents compared with TM decedents.

Conclusions and Relevance

Compared with TM beneficiaries, those in MA were more likely to enroll in hospice from community settings vs following inpatient stays. However, hospice length of stay was not substantially different between MA and TM. Further research is needed to understand how MA plans influence hospice use and the direct association with quality of end-of-life care as reported by older adults and their families.

Development and Validation of a 30-Day In-hospital Mortality Model Among Seriously Ill Transferred Patients: a Retrospective Cohort Study

BACKGROUND

Predicting the risk of in-hospital mortality on admission is challenging but essential for risk stratification of patient outcomes and designing an appropriate plan-of-care, especially among transferred patients.

OBJECTIVE

Develop a model that uses administrative and clinical data within 24 h of transfer to predict 30-day in-hospital mortality at an Academic Health Center (AHC).

DESIGN

Retrospective cohort study. We used 30 putative variables in a multiple logistic regression model in the full data set (n = 10,389) to identify 20 candidate variables obtained from the electronic medical record (EMR) within 24 h of admission that were associated with 30-day in-hospital mortality (p < 0.05). These 20 variables were tested using multiple logistic regression and area under the curve (AUC)-receiver operating characteristics (ROC) analysis to identify an optimal risk threshold score in a randomly split derivation sample (n = 5194) which was then examined in the validation sample (n = 5195).

PARTICIPANTS

Ten thousand three hundred eighty-nine patients greater than 18 years transferred to the Indiana University (IU)-Adult Academic Health Center (AHC) between 1/1/2016 and 12/31/2017.

MAIN MEASURES

Sensitivity, specificity, positive predictive value, C-statistic, and risk threshold score of the model.

KEY RESULTS

The final model was strongly discriminative (C-statistic = 0.90) and had a good fit (Hosmer-Lemeshow goodness-of-fit test [X² (8) =6.26, p = 0.62]). The positive predictive value for 30-day in-hospital death was 68%; AUC-ROC was 0.90 (95% confidence interval 0.89-0.92, p < 0.0001). We identified a risk threshold score of -2.19 that had a maximum sensitivity (79.87%) and specificity (85.24%) in the derivation and validation sample (sensitivity: 75.00%, specificity: 85.71%). In the validation sample, 34.40% (354/1029) of the patients above this threshold died compared to only 2.83% (118/4166) deaths below this threshold.

CONCLUSION

This model can use EMR and administrative data within 24 h of transfer to predict the risk of 30-day in-hospital mortality with reasonable accuracy among seriously ill transferred patients.

Survival in hospice patients with dementia: the effect of home hospice and nurse visits

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.

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.

Live Discharge From Hospice: A Systematic Review

Live discharges from hospice may occur because of patient choice or provider choice. However, when discharges occur before death, patients and families may feel abandoned and left to manage care needs previously provided by hospice. The purpose of this systematic review was to better understand the nature of live discharges, including frequency, patient characteristics, and hospice characteristics. Of 44 studies identified for review, 13 met inclusion criteria and were published between 2008 and 2018. Live discharge rates varied from 5% to 23%. Patients' prehospice characteristics varied widely based on diagnosis, comorbidities, gender, race, and ethnicity. Hospice characteristics indicated that the likelihood of a live discharge was increased for patients enrolled in for-profit hospices and in rural areas. Only 2 studies captured the patient/family perspective of the live discharge experience, finding that the loss of hospice support was fraught with difficulties. A need for further study of the live discharge experience and the practices of hospices with high live discharge rates was identified.

Predicting Length of Hospice Stay: An Application of Quantile Regression

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.

Enhancing the Infrastructure of the Atherosclerosis Risk in Communities (ARIC) Study for Cancer Epidemiology Research: ARIC Cancer

Background: We describe the expansion of the Atherosclerosis Risk in Communities (ARIC) Study into a cancer cohort. In 1987 to 1989, ARIC recruited 15,792 participants 45 to 64 years old to be sex (55% female), race (27% black), and geographically diverse. ARIC has exceptional data collected during 6 clinical visits and calls every 6 months, repeated biospecimens, and linkage to Medicare claims data.Methods: We established a Cancer Coordinating Center to implement infrastructure activities, convened a Working Group for data use, leveraged ARIC staff and procedures, and developed protocols. We initiated a cancer-specific participant contact, added questions to existing contacts, obtained permission to collect medical records and tissue, abstracted records, linked with state cancer registries, and adjudicated cases and characterizing data.Results: Through 2012, we ascertained and characterized 4,743 incident invasive, first, and subsequent primary cancers among 4,107 participants and 1,660 cancer-related deaths. We generated a total cancer incidence and mortality analytic case file, and analytic case files for bladder, breast, colorectal, liver, lung, pancreas, and prostate cancer incidence, mortality, and case fatality. Adjudication of multiple data sources improved case records and identified cancers not identified via registries. From 2013 onward, we ascertain cases from self-report coupled with medical records. Additional cancer registry linkages are planned.Conclusions: Compared with starting a new cohort, expanding a cardiovascular cohort into ARIC Cancer was an efficient strategy. Our efforts yielded enhanced case files with 25 years of follow-up.Impact: Now that the cancer infrastructure is established, ARIC is contributing its unique features to modern cancer epidemiology research. Cancer Epidemiol Biomarkers Prev; 27(3); 295-305. ©2017 AACR.