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Svynarenko R, Cozad MJ, Lindley LC. An Age Group Comparison of Concurrent Hospice Care: A Cost-Effectiveness Analysis. J Hosp Palliat Nurs 2024; 26:219-223. [PMID: 38748541 PMCID: PMC11233226 DOI: 10.1097/njh.0000000000001037] [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: 07/10/2024]
Abstract
This study aimed to examine the cost-effectiveness of concurrent hospice care compared with standard care among pediatric patients of different age groups. Using a national Medicaid database of 18 152 pediatric patients enrolled in hospice care between 2011 and 2013, this study calculated and analyzed incremental cost-effectiveness ratios (ICERs) for concurrent care versus standard hospice care for children of 4 age categories: <1 year, 1 to 5 years, 6 to 14 years, and 15 to 20 years. The results indicated that the total Medicaid cost of hospice care was $3229 per patient per month (PPPM; SD, $8709) for those younger than 1 year, $4793 PPPM (SD, $8178) for those aged 1 to 5 years, $5411 PPPM (SD, $7456) for those aged 6 to 14 years, and $5625 PPPM (SD, $11459) for those aged 15 to 20 years. Incremental cost-effectiveness ratio values across all age groups showed that children enrolled in concurrent care had fewer live discharges but at a higher Medicaid cost of care as compared with those enrolled in standard hospice care. Concurrent hospice care was the most cost-effective in the age groups of <1 year and 1 to 5 years, with ICERs equal to $45 (95% confidence interval [CI], $23-$66) and $49 (95% CI, $8-$76), respectively. For the other older age groups, benefits of enrollment in concurrent care came at a much higher cost: in the age group of 6 to 14 years, ICER was equal to $217 (95% CI, $129-$217), and in the age group of 15 to 20 years, it was $107 (95% CI, $82-$183). Concurrent hospice is an effective way to reduce live discharges but has a higher total Medicaid cost than standard hospice care.
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Affiliation(s)
- Radion Svynarenko
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
| | - Melanie J. Cozad
- Department of Health Services Research and Administration, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Lisa C. Lindley
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
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Boyden JY, Umaretiya PJ, D'Souza L, Johnston EE. Disparities in Pediatric Palliative Care: Where are We and Where Do We Go from Here? J Pediatr 2024:114194. [PMID: 39004168 DOI: 10.1016/j.jpeds.2024.114194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/12/2024] [Accepted: 07/08/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Jackelyn Y Boyden
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA; Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Puja J Umaretiya
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Louise D'Souza
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Emily E Johnston
- Institute for Cancer Outcomes and Survivorship, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Pediatric Hematology/Oncology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
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Boyden JY, Ersek M, Widger KA, Shea JA, Feudtner C. The Home-Based Experiences of Palliative and Hospice Care for Children and Caregivers (EXPERIENCE) Measure: Evaluation of Psychometric Properties. J Pain Symptom Manage 2024:S0885-3924(24)00838-8. [PMID: 38942094 DOI: 10.1016/j.jpainsymman.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/15/2024] [Accepted: 06/19/2024] [Indexed: 06/30/2024]
Abstract
CONTEXT Home-based pediatric palliative and hospice care (PPHC) supports the hundreds of thousands of children with serious illness and complex care needs and their families in the home setting. Considerable variation, however, exists in the provision and quality of home-based PPHC in the U.S. Ensuring equitable, high-quality home-based PPHC for all children requires the evaluation of families' care experiences and assessment of whether these experiences are aligned with their needs and priorities. OBJECTIVES To evaluate the psychometric properties of the previously developed 23-item home-based PPHC EXPERIENCE Measure for use with families of children receiving home-based PPHC in the United States. METHODS Participants included families recruited from the Children's Hospital of Philadelphia, Courageous Parents Network, and several other hospital- and community-based PPHC programs across the U.S. who provide home-based PPHC services. Participants completed the EXPERIENCE Measure at baseline and again at retest. We evaluated the factor structure of the EXPERIENCE Measure, as well as evidence regarding score reliability and validity. RESULTS Eighty-two family participants completed the baseline and 53 completed the retest questionnaire from 15 states across the U.S. We found evidence for the score reliability and validity of a four-domain EXPERIENCE measure. CONCLUSION The EXPERIENCE Measure is a tool with evidence for reliable and valid scores to evaluate family-reported home-based PPHC experiences at the time care is being received. Future work will evaluate the usability (i.e., acceptability, feasibility, and clinical actionability) of EXPERIENCE, including the sensitivity of the instrument to change over time and its impact on real-time clinical actions.
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Affiliation(s)
- Jackelyn Y Boyden
- Department of Family and Community Health (J.Y.B.), Department of Biobehavioral Health Sciences (M.E.), School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Pediatrics (J.Y.B., C.F.), Children's Hospital of Philadelphia; Philadelphia, Pennsylvania, USA.
| | - Mary Ersek
- Department of Family and Community Health (J.Y.B.), Department of Biobehavioral Health Sciences (M.E.), School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center (M.E.), Philadelphia, Pennsylvania, USA
| | - Kimberley A Widger
- Lawrence Bloomberg Faculty of Nursing (K.A.W.), University of Toronto; Toronto, Ontario, Canada; Pediatric Advanced Care Team, Hospital for Sick Children (K.A.W.), Toronto, Ontario, Canada
| | - Judy A Shea
- Department of Medicine (J.A.S.), Department of Pediatrics (C.F.), Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Department of Pediatrics (J.Y.B., C.F.), Children's Hospital of Philadelphia; Philadelphia, Pennsylvania, USA; Department of Medicine (J.A.S.), Department of Pediatrics (C.F.), Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
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Ernecoff NC, Anhang Price R. Concurrent Care as the Next Frontier in End-of-Life Care. JAMA HEALTH FORUM 2023; 4:e232603. [PMID: 37594744 DOI: 10.1001/jamahealthforum.2023.2603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Importance Hospice care is a unique type of medical care for people near the end of life and their families, with an emphasis on providing physical and psychological symptom management, spiritual care, and family caregiver support to promote quality of life. However, many people in the US who could benefit from hospice have very short stays or do not enroll at all due to current hospice policy. Changing policy to allow for concurrent availability of disease-directed therapy and hospice care-known as concurrent care-offers an opportunity to increase hospice use and lengths of stay. Observations Under Medicare payment policy, hospices are responsible for covering all costs related to patients' terminal conditions under a per diem rate. This payment structure has led to a de facto requirement that patients forgo costly therapies (including life-prolonging treatments or those with palliative intent) on enrollment in hospice because they are prohibitively expensive. In other countries, in Medicaid for children, and in the Veterans Health Administration in the US, there is greater flexibility in providing hospice services alongside life-prolonging care. Often paired with innovative payment models, concurrent care smooths practical, psychological, and physical care transitions when patient goals prioritize comfort. For example, allowing simultaneous receipt of hospice care and dialysis for people living with end-stage kidney disease-a group with relatively low hospice enrollment-can act as a bridge to hospice and potentially promote longer lengths of stay. Conclusions and Relevance Medicare and health care delivery systems are increasingly testing payment and care delivery models to improve hospice use via concurrent care, offering an important opportunity for innovation to better meet the needs of people living with serious illness and their families.
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Lotstein D, Klein MJ, Lindley LC, Wolfe J. From Hospital to Home: Referrals to Pediatric Hospice and Home-based Palliative Care. J Pain Symptom Manage 2023; 65:570-579. [PMID: 36828291 DOI: 10.1016/j.jpainsymman.2023.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
CONTEXT Hospital-based pediatric palliative care (PPC) may help optimize referrals to community-based hospice and home-based palliative care (HBPC) for children with serious illness, yet little is known about their referral practices. OBJECTIVES To describe community-based program referrals from a PPC team, identifying factors associated with referral type, and potential misalignment between patient needs and referral received. METHODS Chart abstraction of patients seen in 2017 by the PPC team of a large, urban children's hospital, followed for at least 6 months or until death, including clinical and demographic characteristics, and referrals to hospice and HBPC. RESULTS Of the 302 study-eligible patients, 25% died during the hospitalization of the first 2017 visit. Of the remaining 228 patients, 42 (18.4%) were referred to HBPC and 58 (25.4%) to hospice. Excluding patients referred to hospice care, only one-third with demographic eligibility were referred to HBPC; those seen in the ICU were least likely to be referred. Over half of the 58 patients referred to hospice died within the study period (n = 34, 58.6%); descendants were more likely to have cancer (P = 0.002) and less likely to have a neurologic (P = 0.021) diagnosis. CONCLUSION Despite demographic eligibility, a minority of patients seen by a hospital-based PPC team received referrals for hospice or HBPC. Children discharged from an ICU and those with neurologic conditions may be at higher risk of missing referrals best aligned with their needs. Future research should identify and address causes of referral misalignment. Advocacy for programs adaptable to patients' changing needs may also be needed.
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Affiliation(s)
- Debra Lotstein
- Division of Comfort and Palliative Care, Department of Anesthesia Critical Care Medicine (D.L.), Children's Hospital Los Angeles, Los Angeles, CA, USA and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
| | - Margaret J Klein
- Department of Anesthesia Critical Care Medicine (M.J.K.), Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Lisa C Lindley
- College of Nursing, University of Tennessee (L.C.L.), Knoxville, Tennessee, USA
| | - Joanne Wolfe
- Department of Pediatrics (J.W.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Sharp WS, Svynarenko R, Fornehed MLC, Cozad MJ, Malpass JK, Mack JW, Hinds PS, Mooney-Doyle K, Mendola A, Lindley LC. Conceptualizing the Value of Pediatric Concurrent Hospice Care. J Hosp Palliat Nurs 2023; 25:31-38. [PMID: 36289556 PMCID: PMC9839492 DOI: 10.1097/njh.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Given that pediatric concurrent hospice care has been available for more than a decade, it is appropriate to seek an understanding of the value of this care delivery approach. Value is the cost associated with achieving beneficial health outcomes. In pursuit of this goal, the current literature on pediatric concurrent hospice care was synthesized and used to develop a model to explain its value. Because of its relevance, the Value Assessment Framework was used to conceptualize the value of pediatric concurrent hospice care. This framework gauges the value of a health care service through 2 components: long-term effect and short-term affordability. The framework considers comparative clinical effectiveness, cost-effectiveness, other benefits or disadvantages, contextual considerations, and potential budget impact. Evidence from the literature suggested that the value of concurrent care depended on clinical outcomes evaluated, costs examined, medical services used, care coordinated, context considered, and budget impacted. The literature demonstrated that pediatric concurrent hospice care does offer significant value for children and their families. The conceptual model highlighted the need for a comprehensive approach to assessing value. The model is a useful framework for future research examining the value of concurrent hospice care.
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Affiliation(s)
| | | | | | | | | | | | - Pamela S. Hinds
- Children's National Hospital, School of Medicine and Health Sciences
| | | | - Annette Mendola
- Department of Medicine, University of Tennessee Medical Center
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Lindley LC, Svynarenko R, Mooney-Doyle K, Mendola A, Naumann WC, Harris R. A National Study of Healthcare Service Patterns at the End of Life Among Children With Cardiac Disease. J Cardiovasc Nurs 2023; 38:44-51. [PMID: 34935739 PMCID: PMC9209569 DOI: 10.1097/jcn.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Heart diseases are one of the leading causes of health-related deaths among children. Concurrent hospice care offers hospice and nonhospice healthcare services simultaneously, but the use of these services by children with cardiac disease has been rarely investigated. OBJECTIVE The aims of this study were to identify patterns of nonhospice healthcare services used in concurrent hospice care and describe the profile of children with cardiac disease in these clusters. METHODS This study was a retrospective cohort analysis of Medicaid claims data collected between 2011 and 2013 from 1635 pediatric cardiac patients. The analysis included descriptive statistics and latent class analysis. RESULTS Children in the sample used more than 314 000 nonhospice healthcare services. The most common services were inpatient hospital procedures, durable medical equipment, and home health. Latent class analysis clustered children into "moderate intensity" (60.0%) and "high intensity" classes (40.0%). Children in "moderate intensity" had dysrhythmias (31.7%), comorbidities (85.0%), mental/behavioral health conditions (55%), and technology dependence (71%). They commonly resided in urban areas (60.1%) in the Northeast (44.4%). The health profile of children in the "high intensity" class included dysrhythmias (39.4%), comorbidities (97.6%), mental/behavioral health conditions (71.5%), and technology dependence (85.8%). These children resided in rural communities (50.7%) in the South (53.1%). CONCLUSIONS Two patterns of use of nonhospice healthcare services were identified in this study. This information may be used by nurses and other healthcare professionals working in concurrent hospice care to assess the healthcare service needs of children with cardiac conditions at the end of life.
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Home-Based Care for Children with Serious Illness: Ecological Framework and Research Implications. CHILDREN 2022; 9:children9081115. [PMID: 35892618 PMCID: PMC9330186 DOI: 10.3390/children9081115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
Abstract
Care for U.S. children living with serious illness and their families at home is a complex and patchwork system. Improving home-based care for children and families requires a comprehensive, multilevel approach that accounts for and examines relationships across home environments, communities, and social contexts in which children and families live and receive care. We propose a multilevel conceptual framework, guided by Bronfenbrenner’s ecological model, that conceptualizes the complex system of home-based care into five levels. Levels 1 and 2 contain patient and family characteristics. Level 3 contains factors that influence family health, well-being, and experience with care in the home. Level 4 includes the community, including community groups, schools, and providers. Level 5 includes the broader regional system of care that impacts the care of children and families across communities. Finally, care coordination and care disparities transcend levels, impacting care at each level. A multilevel ecological framework of home-based care for children with serious illness and families can be used in future multilevel research to describe and test hypotheses about aspects of this system of care, as well as to inform interventions across levels to improve patient and family outcomes.
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Cozad MJ, Svynarenko R, Hinds PS, Mack JW, Keim-Malpass J, Lindley LC. Pediatric Concurrent Hospice Care: Cost Implications of a Hybrid Payment Model. Am J Hosp Palliat Care 2022; 39:1436-1442. [PMID: 35437021 DOI: 10.1177/10499091221089337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Implementation of concurrent hospice care led to a new hybrid payment model that combines hospice payments with payments for non-hospice medical care. Little is known about the cost implications of this new hybrid payment model. OBJECTIVE The purpose was to identify costs and compare concurrent care and standard hospice care costs by estimating the average incremental Medicaid cost of care over time. METHODS Using national Medicaid data of 18 147 hospice children and a multilevel generalized linear model, we calculated the incremental costs of receiving concurrent vs standard hospice care. We used the total cost of care over the last year of life. Increments for the analysis were hospice length of stay, stratified to 1 day, 2-14 days, and 15 + days. RESULTS Overall, compared to standard hospice care, enrollment in concurrent hospice care was significantly associated with an increase in outpatient care and prescription drug costs. For a stay of 1 day, concurrent hospice care decreased inpatient costs and increased costs of prescription drugs. For stays between 2 and 14 days, concurrent hospice decreased total costs and inpatient costs, but increased prescription drug costs. With a hospice stay of 15 + days, concurrent hospice had significantly higher costs across all measures, including total costs, inpatient costs, outpatient costs, and prescription drug costs. CONCLUSION This study provides critical insight into incremental costs of receiving concurrent vs standard hospice care. More research is needed to understand how concurrent hospice lengthy hospice stays are associated with increases of costs.
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Affiliation(s)
- Melanie J Cozad
- Department of Health Services Policy and Management, University of South Carolina, Columbia, SC, USA
| | - Radion Svynarenko
- College of Nursing, 16166University of Tennessee, Knoxville, TN, USA
| | | | - Jennifer W Mack
- Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Boston Children's Hospital, Boston, MA, USA
| | | | - Lisa C Lindley
- College of Nursing, 16166University of Tennessee, Knoxville, TN, USA
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Lindley LC, Laird JM, Mack JW, Keim-Malpass J, Cozad MJ, Mooney-Doyle K, Docherty SL. Who is coordinating pediatric concurrent hospice care? J Pain Symptom Manage 2021; 62:e1-e4. [PMID: 34333096 DOI: 10.1016/j.jpainsymman.2021.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Affiliation(s)
| | | | - Jennifer W Mack
- Dana-Farber Cancer Institute/Boston Children's Hospital, Boston, Massachusetts, USA
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