Factors in hospice patients' length of stay

Sociodemographic Characteristics and Lengths of Stay Associated With Acute Palliative Care: A 10-Year National Perspective

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.

Demographics, Resource Utilization, and Outcomes of Elderly Patients With Chronic Liver Disease Receiving Hospice Care in the United States

OBJECTIVES

Hospice offers non-curative symptomatic management to improve patients' quality of life, satisfaction, and resource utilization. Hospice enrollment among patients with chronic liver disease (CLD) is not well studied. The aim of tis tudy is to examine the characteristics of Medicare enrollees with CLD, who were discharged to hospice.

METHODS

Medicare patients discharged to hospice between 2010 and 2014 were identified in Medicare Inpatient and Hospice Files. CLDs and other co-morbidities were identified by International Classification of Diseases-ninth revision codes. Generalized linear model was used to estimate regression coefficients with P-values. Logistic regression was used to calculate odds ratios and 95% confidence intervals.

RESULTS

A total of 2,179 CLD patients and 34,986 controls without CLD met the inclusion criteria. Non-alcoholic fatty liver disease, alcoholic liver disease, and hepatitis C virus (HCV) were the most frequent cause of CLD. CLD patients were younger (70 vs. 83 years), more likely to be male (57.7 vs. 39.3%), had longer hospital stay (length of stay, LOS) (19.4 vs. 13.0 days), higher annual charges ($175,000 vs. $109,000), higher 30-day re-hospitalization rates (51.6 vs. 34.2%), and shorter hospice LOS (13.7 vs. 17.7 days) than controls (all P<0.001). Presence of HCV and congestive heart failure were the strongest contributors to increased total annual costs (34% and 31% higher, P<0.001), increased total annual LOS (26% and 43% higher, P<0.001), and increased 30-day readmission risk (2.20 and 2.19 times, respectively).

CONCLUSIONS

Patients with CLD have longer and costly hospitalizations before hospice enrollment as compared with patients without CLD. It was highly likely that these patients were enrolled relatively late, which could potentially lead to less benefit from hospice.

Association of admission date with cancer patient survival at a regional hospice: Utility of a statistical process control analysis

Previously published multivariate analyses have not considered date of entry as a possible factor associated with length of stay (LOS), nor has the pattern of decreasing LOS been analyzed. We set out to assess mean LOS over time and to determine the factors, including date of death, which are independently associated with LOS. Cancer patients admitted to our hospice from 1996 through 2001 were assessed for dates of admission/discharge/death, age, gender, race, specific cancer diagnosis, referring physician characteristics, place of death, and heath insurance type. Statistical process control (SPC) charts and proportional hazard models were constructed for patients prioritized by date of admission, with active or discharged patients censored. A total of 2126 patients were analyzed. An abrupt and significant drop in mean LOS was seen for all cancer patients and for most cancer sites from April to December 1998 (temporally associated with a “Special Fraud Alert” issued by the Office of Inspector General) and again in the second and third quarter of 2000. A proportional hazards model revealed that LOS was associated with cancer site (p < 0.0001), quarter in which patient was admitted (p = 0.0020), and sex (women surviving longer, p=0.013), age (older patients surviving longer, p 0.0149), and insurance (p = 0.071). Mean LOS is associated with date of admission to hospice independent of other associated factors. LOS decreases do not occur in a gradual, continuous fashion but suddenly and intermittently, and they are not associated with changes in referral numbers or read-missions. SPC charts proved to be an effective method of tracking and evaluating hospice LOS on an ongoing basis.

Rapid death after admission to palliative care

BACKGROUND

Palliative care units provide non-curative treatment and support to patients with terminal illness. Brief end-of-life admissions are disruptive for patients and their families, and increase staff stress. Extremely rapid deaths (survival <24 h from admission) are particularly challenging for all involved. From 1 January 2010 to 23 August 2011, 256 patients died on the Palliative Care Unit (Caritas Christi) at St Vincent's Hospital Melbourne. Forty-two died within 24 h (16%), while 214 survived beyond 24 h (84%).

AIMS

A retrospective chart audit was conducted, aiming to identify factors characterising those patients who died within 24 h.

METHODS

Groups were compared for age, gender, country of birth, preferred language, ward of origin, primary pathology, time trends, whether an emergency code was called, Palliative Care Outcomes Collaboration (PCOC) phase, modified Karnofsky score and commencement of a syringe driver for medication.

RESULTS

Results showed that admission from neurosurgery (P= 0.0001), a vascular or infective pathology (P= 0.0001), PCOC phase ≥ 3 (P= 0.0001), modified Karnofsky score ≤ 20% (P= 0.0001), and commencement of a syringe driver prior to or at admission (P= 0.0001) were all significantly associated with death within 24 h of admission. On binary logistic regression, the only independent predictor of patients likely to die in <24 h from admission was PCOC phase ≥ 3 (P= 0.002).

Predictors of home care expenditures and death at home for cancer patients in an integrated comprehensive palliative home care pilot program

PURPOSE

Empirical understanding of predictors for home care service use and death at home is important for healthcare planning. Few studies have examined these predictors in the context of the publicly funded Canadian home care system. This study examined predictors for home care use and home death in the context of a "gold standard" comprehensive palliative home care program pilot in Ontario where patients had equal access to home care services.

METHODS

Secondary clinical and administrative data sources were linked using a unique identifier to examine multivariate factors (predisposing, enabling, need) on total home care expenditures and home death for a cohort of cancer patients enrolled in the HPCNet pilot.

RESULTS

SUBJECTS WITH GASTROINTESTINAL SYMPTOMS (OR: 1.64; p=0.03) and those with higher income had increased odds of dying at home (OR: 1.14; p<0.001), whereas age, number of GP visits, gastrointestinal symptoms (i.e., nausea, vomiting, bowel obstruction) and eating problems (i.e., anorexia/cachexia) predicted home care expenditures.

CONCLUSIONS

Predictors of home death found in earlier studies appeared less important in this comprehensive palliative home care pilot. An income effect for home death observed in this study requires examination in future controlled studies.

RELEVANCE

Access to palliative home care that is adequately resourced and organized to address the multiple domains of issues that patients/families experience at the end of life has the potential to enable home death and shift care appropriately from limited acute care resources.

Analysis of long-stay patients in the Hospice Palliative Ward of a Medical Center

BACKGROUND

The Pilot Project on Per-diem Payment for Inpatient Hospice Services of Taiwan's National Health Insurance Program was begun in July 2000. The project monitors hospices to control for a median length of stay (LOS) of not longer than 16 days to prevent inappropriate stasis in hospices. To determine the best utilization of palliative care, patients remaining in the hospice for more than 28 days were analyzed to discover their characteristics and reasons for not being discharged.

METHODS

The study sample included 1,670 hospice patients who were admitted to the Hospice Palliative Unit in Taipei Veterans General Hospital between July 16, 1997 and December 31, 2002. Two hundred and sixty admissions (21.5%) with LOS > 28 days were identified. Further instrument survey of selected items was performed by 2 trained staff via chart review independently. The basic data were analyzed and comparison between long-stay patients and non-long-stay patients was made.

RESULTS

The mean LOS of 1,670 hospice patients was 16.0 +/- 14.9 days. Two hundred and sixty-eight patients (16.1%) admitted for longer than 28 days were surveyed. Those who had longer mean survival time, a diagnosis of prostate cancer, a metastatic site in the bone, and readmitted patients were associated with long stay. The study also revealed a significant difference in LOS between fee-for-service (FFS) patients and per-diem payment (PDP) patients (mean LOS, 17.5 +/- 16.4 vs. 14.3 +/- 13.4, p < 0.001). Conditions of major physical distress on Day 29 were delirium (41.9%), depression and/or anxiety (20.4%), and severe dyspnea (21.2%). The main reasons for being unable to be discharged on Day 29 after admission included "prolonged terminal phase" (34.2%), "difficult symptom control" (25.8%), "placement problem" (16.9%), and "need of parenteral medication" (15.0%).

CONCLUSION

Better understanding of the factors related to LOS can help staff in the palliative ward of medical centers to identify patients who are apt to have long stay, and shorten their LOS by successfully dealing with their problems.

Late referral to hospice and bereaved family member perception of quality of end-of-life care

The Family Evaluation of Hospice Services was used to document bereaved family members' perceptions of whether their loved ones were referred too late to hospice and to examine the association of that perception and quality of end-of-life care. A mortality follow-back survey of bereaved family members from two not-for-profit hospices found that 13.7% of decedents were referred at a time too late for hospice services. Family members of persons referred too late reported lower satisfaction with hospice services, a higher rate of unmet needs for information about what to expect at time of death, lower confidence in participating in patient care at home, more concerns with coordination of care, and lower overall satisfaction. Families reported physicians as an important barrier to earlier hospice referral in nearly one-half of cases. These results indicate a need for improved services for shorter-stay hospice patients/families and for physicians to help facilitate earlier hospice admission.

At the crossroads: Making the transition to hospice

Objective:Previous studies reveal that many terminally ill patients never receive hospice care. Among those who do receive hospice, many enroll very close to the time of death. Nationally, between 1992 and 1998, the median length of stay at hospice declined 27%, from 26 to 19 days. In our prior study of 206 patients diagnosed with terminal cancer and using hospice, we found that one-third enrolled with hospice within 1 week prior to death. Late hospice enrollment can have deleterious effects on patients and their family members. The aim of the present study was to characterize common experiences of patients and primary family caregivers as they transition to hospice, focusing on caregiver perceptions of factors that might contribute to delays in hospice enrollment.

Methods:We conducted in-depth interviews with a purposive sample of 12 caregivers selected from a population of primary family caregivers of patients with terminal cancer who enrolled with hospice in Connecticut between September 2000 and September 2001. Respondents represented different ages, genders, and kinship relationships with patients. Respondents were asked about the patient's care trajectory, how they first learned about hospice, and their experiences as they transitioned to hospice. NUD*IST software was used for qualitative data coding and analysis.

Results:Constant comparative analysis identified three themes common to the experience of transitioning to hospice: (1) caregivers' acceptance of the impending death, (2) challenges in negotiating the health care system across the continuum of care, and (3) changing patient–family dynamics.

Significance of results:Identification of these themes from the caregivers' perspective generates hypotheses about potential delays in hospice and may ultimately be useful in the design of interventions that are consistent with caregivers' needs.

The prognostication problem

With increased focus on end-of-life care; prognosis may be finally receiving the attention it deserves. Hopefully, this will result in further research, the development of effective tools, and adequate education and training related to prognostication.

Factors associated with length of stay in a mid-sized, urban hospice

A recent study by Frantz et al. investigated the relationship between length of stay (LOS) and several factors in a small, rural hospice and found significant differences in LOS by primary physician specialty, referral source, and diagnosis (American Journal of Hospice & Palliative Care, March/April 1999). The purpose of the present study was to replicate and extend the Frantz et al. study in a midsized, urban hospice setting and to examine the relationship of LOS with additional variables, such as living status, discharge status, race, and religion. Significant differences in LOS by gender, diagnosis, physician specialty, referral source, type of insurance, living status, and discharge status were found. No significant differences in LOS were found by race, religion, and place of death. Results are interpreted in the light of previous research findings regarding LOS and in the context of the sample size. Strategies are suggested for increasing patients' LOS.