Medicare Hospice Policy Changes and Beneficiaries' Rate of Live Discharge and Length-of-Stay

CONTEXT

The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of long hospice stays, and the 2016 two-tier payment system decreased daily reimbursement rates after 60 days of enrollment. Both aimed to reduce long stays.

OBJECTIVES

Examine how live discharge rates and length of stay changed in relation to the policies.

METHODS

We computed monthly hospice-level percent live discharges and length of stay using 2008-2019 Medicare hospice claims. We compared prepolicies trends and postpolicies trends overall, within Alzheimer's disease and related dementias (ADRD) patients, within lung cancer patients, and stratified by hospice ownership (for-profit vs. nonprofit/government-owned).

RESULTS

We included 10,539,912 and 10,453,025 episodes of care in the analytical samples for live discharge and length of stay analyses, respectively. Overall percent live discharges declined during the prepolicies period (-0.13 percentage-points per month, 95% CI: -0.14, -0.12), but exhibited no significant change during the postpolicies period. Trends were driven primarily by for-profits, with similar patterns within ADRD and lung cancer patients. Overall, mean length of stay increased over time, with greater rate of increase during the postpolicies period (0.41 days per month, 95% CI: 0.39, 0.42) compared to the prepolicies period (0.12 days per month, 95% CI: 0.10, 0.14). Length-of-stay increased faster among ADRD patients, but changed minimally for lung cancer patients.

CONCLUSION

Live discharge rates declined significantly during the prepolicies period, but plateaued after implementation of the policies, driven by changes in for-profits. However, the policies did not reduce length of stay, which increased at faster rates, suggesting that postpolicies excess live discharges were not restricted to long-stay patients.

Risks and Benefits of Clinical Diagnosis Around the Time of Dementia Onset

Diagnostic delay in dementia is common in the U.S. Drivers of diagnostic delay are poorly understood, but appear related to misconceptions about dementia, stigma, concerns about autonomy, the nature of the diagnostic process, and provider-related factors. There is little quantitative evidence underlying cited risks and benefits of receiving a diagnosis around the time of dementia onset, including impacts on physical health, impacts on mental health, care partner interactions, costs of care, increased time for care planning, or earlier access to treatment. While various groups continue to push for reductions in diagnostic delay, realization of benefits and mitigation of harms will require new research on potential benefits and harms. Workforce and resource constraints, coupled with the expected growth in the number of persons living with dementia, may be a barrier to realization of potential benefits and mitigation of identified harms, which will require adequate access to providers, services, and supports.

Evaluation of Federal Policy Changes to the Hospice Benefit and Use of Hospice for Persons With ADRD

Question

Did hospice use for persons with Alzheimer disease and related dementias (ADRD) change between 2008 and 2019 in conjunction with Medicare policy changes that aimed to reduce long hospice stays?

Findings

In this cross-sectional study of Medicare claims data from 11 124 992 unique hospice episodes, there were immediate declines in the share of patients receiving hospice care with ADRD and a slower growth in use of hospice care among patients with ADRD after implementation of the US Improving Medicare Post-Acute Care Transformation Act and the 2-tier payment system compared with prepolicy trends.

Meaning

The study results suggest that reduced utilization of hospice by patients with ADRD following these policy changes may be negatively associated with end-of-life experience and outcomes for persons with ADRD.

Importance

Hospice is an important end-of-life service for patients with Alzheimer disease and related dementias (ADRD).

Objective

To determine whether hospice use among patients with ADRD changed in association with recent policies aimed at reducing hospice misuse and long hospice stays, an outcome that may have disproportionately affected patients with ADRD because of their lengthy end-of-life trajectories.

Design, Setting, and Participants

This observational cross-sectional study used Medicare hospice claims data from Medicare hospice episodes of care beginning between July 2008 and December 2019 among Medicare hospice beneficiaries 65 years or older at time of enrollment. Data analysis was conducted between September 2019 and June 2021.

Exposures

The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which systematized audits of hospices with a high proportion of long stays, and the 2016 2-tier payment system, which reduced daily reimbursement rates after 60 days.

Main Outcomes and Measures

Monthly percentage of (1) new patient enrollees, (2) patient census, and (3) care days provided to patients with an ADRD code.

Results

The sample included 11 124 992 unique hospice episodes between 2008 and 2019; mean (SD) patient enrollment age ranged from 82.0 (8.2) years to 82.8 (8.7) years; the percentage of male patients ranged from 40.5% to 42.7%, and the percentage of Black, Hispanic, and White patients ranged from 7.7% to 8.2%, 1.5% to 2.0%, and 86.2% to 88.8%, respectively, across years. The percentage of new enrollees with an ADRD code dropped significantly during the months of IMPACT passage (−1.42 percentage points; 95% CI, −2.13 to −0.71) and implementation (−1.98 percentage points; 95% CI, −2.70 to −1.26) but rose again during the following months. While no significant changes were observed at the time of 2-tier payment implementation (0.15 percentage points; 95% CI, −0.21 to 0.51), the average rate of increase during the subsequent period was slower (0.01 percentage points per month; 95% CI, 0-0.02) than in earlier periods (0.05; 95% CI, 0.04-0.06 during the baseline period). Similar patterns were observed for the percentage of patient census and care days provided to patients with an ADRD code.

Conclusions and Relevance

The results of this cross-sectional study of Medicare hospice claims data suggested that recent Medicare policies were associated with immediate and lasting reductions in the share of patients receiving hospice care with an ADRD code compared with expectations from preimplementation trends. Future research should examine mechanisms through which hospices enacted change and consequences for quality of care.

Challenges in Resource Utilization for Caregivers of Persons With Dementia: A qualitative Study

This study highlights primary caregivers’ experiences with health department policies designed to support people with cognitive impairment/Alzheimer’s Disease and Related Dementias (ADRD). Caregivers were defined as individuals aged 45-85 that provide at least 10 hours of unpaid care. Five, 90-minute focus groups were conducted virtually with 24 caregivers of individuals with cognitive impairment/ADRD. Transcripts were analyzed thematically. Caregivers were primarily Black females (75%) with at least a high school education (42%). Care recipients were likely to be community-dwelling parents (71%), with moderate or advanced (79%) dementia. Caregivers described challenges with accessing resources intended for care recipients, especially as cognitive impairment worsened. Caregivers reported providing care 24/7 as traumatizing. Home-based personal aides and companionship services did not reduce this burden. COVID-19 impacted caregivers and care recipient’s access to resources increasing burden. Policies need to be flexible for ever-changing needs of individuals with ADRD and support the overall well-being of the caregivers.

Brain Health

Brain health and the health of the aging brain are topics of increased interest in recent years given the expected aging of the world's population. Many conditions associated with memory loss and other disorders of cognition have age as a risk factor. This article describes the healthy aging brain and theories about how to maintain brain health through later life. The role of gender in brain health and whether women are at increased risk of neurodegenerative disorders leading to dementia are discussed. Important factors that contribute to brain health, including nutrition, exercise, chronic disease management, and others, also are discussed.

Use of a primary care provider survey to implement a fall prevention program in an urban hospital system

BACKGROUND

Falls are the leading cause of traumatic injury in older adults. Multidisciplinary approaches between trauma surgeons and primary care providers can powerfully advocate for fall prevention. This study explores current fall prevention practices and barriers to falls screening and prevention in the primary care setting and proposes pertinent recommendations to address the deficiencies.

METHODS

A questionnaire was adapted from a previous survey study to explore the beliefs, knowledge, attitudes, and clinical practice regarding falls by primary care providers. The questionnaire was distributed by e-mail to primary care providers at a tertiary urban medical center.

RESULTS

The survey achieved a response rate of 58%. All respondents agreed that older adult patients should be assessed for fall risks and that evidence-based fall prevention programs can reduce the risk of falls. However, 43% of respondents did not agree that they had the expertise to perform fall risk assessments, and similarly 43% did not agree they have the time to perform fall risk assessments in the office. Furthermore, although 52% of respondents were aware of the Medicare reimbursement for fall risk screening, only 24% had billed for fall risk screening and only 5% agreed that they were adequately reimbursed.

CONCLUSION

Several barriers to performing fall prevention care in the primary care setting were identified: unfamiliarity with resources, perceived lack of time, and perceived insufficient reimbursement. We implemented a set of interventions which include an educational series and workflow optimization to overcome barriers identified.

Self-Reported Hearing Loss and Nonfatal Fall-Related Injury in a Nationally Representative Sample

BACKGROUND/OBJECTIVE

To evaluate the relationship between self-reported hearing loss and nonfatal fall-related injury in a nationally representative sample of community-dwelling adults living in the United States.

DESIGN

Cross-sectional analysis of national survey data.

SETTING

National Health Interview Survey (2016).

PARTICIPANTS

A total of 30 994 community-dwelling adults in the United States, aged 18 years and older.

MEASUREMENTS

We evaluated the association between self-reported hearing loss and nonfatal injury resulting from a fall in the previous 3 months. We used multivariate logistic regression to calculate adjusted odds ratios (ORs) and evaluated effect measure modification by age.

RESULTS

The odds of nonfatal fall-related injury were 1.60 times higher among respondents with hearing loss compared to respondents without hearing loss (95% confidence interval [CI] = 1.20-2.12; P = .0012). Results were unchanged when adjusting for demographics (OR = 1.59; 95% CI = 1.18-2.15; P = .002). After adjustment for cardiovascular risk factors, cardiovascular disease, visual impairment, and limitation caused by nervous system/sensory organ conditions and depression, anxiety, or another emotional problem, the OR fell to 1.27 (95% CI = 0.92-1.74; P = .14). In the fully adjusted model, including adjustment for vestibular vertigo, there was little support to link hearing loss and fall-related injury (OR = 1.16; 95% CI = 0.84-1.60; P = .36). Effect modification by age was not observed.

CONCLUSIONS

Self-reported hearing loss may be a clinically useful indicator of increased fall risk, but treatment for hearing loss is unlikely to mitigate this risk, given that there is no independent association between self-reported hearing loss and nonfatal falls after accounting for vestibular function and other potential confounders.

Review article: current treatment options and management of functional dyspepsia

BACKGROUND

Functional dyspepsia (FD), a common functional gastrointestinal disorder, is defined by the Rome III criteria as symptoms of epigastric pain or discomfort (prevalence in FD of 89-90%), postprandial fullness (75-88%), and early satiety (50-82%) within the last 3 months with symptom onset at least 6 months earlier. Patients cannot have any evidence of structural disease to explain symptoms and predominant symptoms of gastroesophageal reflux are exclusionary. Symptoms of FD are non-specific and the pathophysiology is diverse, which explains in part why a universally effective treatment for FD remains elusive.

AIM

To present current management options for the treatment of FD (therapeutic gain/response rate noted when available).

RESULTS

The utility of Helicobacter pylori eradication for the treatment of FD is modest (6-14% therapeutic gain), while the therapeutic efficacy of proton pump inhibitors (PPI) (7-10% therapeutic gain), histamine-type-2-receptor antagonists (8-35% therapeutic gain), prokinetic agents (18-45%), tricyclic antidepressants (TCA) (response rates of 64-70%), serotonin reuptake inhibitors (no better than placebo) is limited and hampered by inadequate data. This review discusses dietary interventions and analyses studies involving complementary and alternative medications, and psychological therapies.

CONCLUSIONS

A reasonable treatment approach based on current evidence is to initiate therapy with a daily PPI in H. pylori-negative FD patients. If symptoms persist, a therapeutic trial with a tricyclic antidepressant may be initiated. If symptoms continue, the clinician can possibly initiate therapy with an anti-nociceptive agent, a prokinetic agent, or some form of complementary and alternative medications, although evidence from prospective studies to support this approach is limited.

A multicentre evaluation of the laser assisted ratio analyser (LARA): a novel device for measurement of 13CO2 in the 13C-urea breath test for the detection of Helicobacter pylori infection

BACKGROUND

The laser assisted ratio analyser (LARA) was developed as a novel device to measure 13CO2 in the urea breath test for the detection of H. pylori infection. The analyser was tested in a prospective multicentre study in 444 patients in North America (Phase 1) followed by second study involving 160 patients (Phase 2).

METHODS

Patients undergoing endoscopy for clinical indications had antral and gastric biopsies taken for histological examination, culture and CLO test. One hour after endoscopy, a baseline breath sample was obtained, 100 mg of 13C-urea were ingested and breath samples were obtained at 30 and 60 min post ingestion. Data obtained with the LARA were compared with the results of culture, rapid urease testing and central pathology in two different combinations {reference standards}. The study was conducted in two phases: in Phase 2, a modification was made to the LARA that improved the removal of water vapour from the breath sample.

RESULTS

In Phase I, data from 331 patients were analysed using a cut off of (delta) 7.8 +/- 0.8, the sensitivity of the method was 91.7% and the specificity was 86.5%, using the reference standard of 2 of 3 tests (CLO, culture or histology) being positive. Positive and negative predictive values were, respectively, 85.2% and 92.5%. In Phase 2 of the study, 160 patients were enrolled and 141 patients were analysed using the same standards. We used the same reference standards but with a cut off of (delta) 6.1 +/- 0.6. The sensitivity and specificity increased to 96.8% and 98.6%, respectively. Positive and negative predictive values were, respectively, 98.4% and 97.3%. The detection rates for H. pylori were similar in patients with peptic ulcer or H. pylori associated gastritis.

CONCLUSIONS

The LARA provides an accurate non-invasive means of detecting 13CO2 in the 13C-urea breath test for H. pylori in a multicentre clinical environment that compares well with invasive 'gold standard' methods.

The nurse's role in office hysteroscopy

In recent years, hysteroscopy has been developed to provide physicians with direct visibility of the uterine cavity. Using carbon dioxide gas as a distending medium, office hysteroscopy has few side effects for women. It is also more cost effective than outpatient surgery. The nurse's role is pivotal in simplifying office hysteroscopy through empathetic preparation and support of women, careful planning, procurement of necessary items, and finally, conscientious care of the instruments.

Definitive nonsurgical therapy of epithelial malignancies of the anal canal. A report of 12 cases

Twelve patients with epidermoid carcinoma of the anal region ranging in age from 40-89 years were treated with combined chemotherapy (CT) and radiotherapy (RT) in lieu of abdominal-perineal resection. Ten patients received no prior treatment and two patients were treated for local recurrence following limited surgical excision. Two courses of 5-FU infusion and mitomycin C were given 3-4 weeks apart simultaneously with whole pelvis RT to 3000-4140 rad. One patient received an additional tumor volume dose of 3094 rad by interstitial Iridium implant and one patient received an orthovoltage boost of 1000 rad to the anal ring. All patients completed treatment. Complete regression of the anal mass occurred in all patients. Biopsies of the anal region performed after completion of therapy revealed no evidence of residual cancer. Ten of the 12 patients are alive without evidence of disease 4-24 months (median, 14 months) after completion of treatment. Two patients have died seven months after treatment of unrelated causes and were tumor-free at autopsy. All patients developed proctitis, diarrhea, and moist perineal desquamation which resolved by four weeks posttreatment. Based on their experience and that of others recently reported, the authors conclude that the described CT-RT protocol offers a definitive alternative to surgery of epidermoid cancer of the anal region.