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Rezaeiahari M, Brown CC, Schmit T, Tilford JM. Economic Report of General Inpatient Hospice in an Academic Medical Center. Am J Hosp Palliat Care 2024; 41:800-804. [PMID: 37772492 DOI: 10.1177/10499091231204971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
This study examined if there was difference in cost of care after implementation of scattered bed inpatient hospice, first implemented in October 2021 in an Academic Medical Center in Arkansas. This retrospective, cross-sectional study compared the cost of care during the pre-implementation phase (n = 121, July 2020-March 2021) to patients admitted to hospice care (n = 84, October 2021-June 2022). Hospice length of stay (LOS) was 4 times longer than the LOS after a Do Not Resuscitate order (DNR) was placed for patients in the pre-implementation period. The end of life costs after the implementation of inpatient hospice was 69% less than the end of life costs in the pre-implementation period.
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Affiliation(s)
- Mandana Rezaeiahari
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Clare C Brown
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Troy Schmit
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J Mick Tilford
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Tucker M, Hovern D, Liantonio J, Collins E, Binder AF. End of Life Outcomes Following Comfort Care Orders: A Single Center Experience. Am J Hosp Palliat Care 2024:10499091241253561. [PMID: 38739433 DOI: 10.1177/10499091241253561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Background: Few studies have explored the outcomes of patients placed on comfort care with respect to hospice disposition. The objective of this study was to perform a retrospective analysis of patients who transitioned to comfort care. Methods: We conducted a retrospective study of patients placed on the comfort care order set between July 1st, 2021, until June 30th, 2022. Each individual patient chart was then analyzed to collect multiple clinical variables. IRB approval was obtained as per institutional guidelines. Results: 541 patients were included in the analysis. An average of 1.5 patients were placed on comfort care a day. 424 (78.37%) patients died while in the hospital. The median time on comfort care was 1 day. For subspecialty and hospital medicine patients the median time was 2 days. 40% of non-ICU patients were discharged with hospice services. 60% of patients were in the intensive care unit (ICU) and spent a median of 2.33 hours on comfort care. 19% of these patients were on comfort care for over 12 hours. 94% of the patients placed on comfort care in the ICU died in the hospital as compared to 53% of subspecialty and 59% of hospital medicine patients. Conclusions: The majority of patients placed on comfort care died during their hospitalization demonstrating a real need for comprehensive end of life care and immediate hospice services. For those discharged with hospice services, they spent an excessive amount of time in the hospital waiting for services to be arranged.
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Affiliation(s)
- Matthew Tucker
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Dayna Hovern
- Department of Family and Community Medicine, Division of Geriatric Medicine and Palliative Care, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - John Liantonio
- Department of Family and Community Medicine, Division of Geriatric Medicine and Palliative Care, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Elizabeth Collins
- Department of Family and Community Medicine, Division of Geriatric Medicine and Palliative Care, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Adam F Binder
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
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Kozhevnikov D, Loho H, Prestia B. Factors Associated With Inpatient Hospice Utilization Among Hospitalized Decedents With Comfort Measures Only Status. J Palliat Med 2023; 26:1048-1055. [PMID: 36716262 DOI: 10.1089/jpm.2022.0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background: Patients with serious illness may elect to transition their care to comfort measures only (CMO) while in the hospital. Although studies have shown that routine hospice care is underutilized, the rate of general inpatient hospice (GIP) use among CMO patients during their terminal admission remains unclear. Objectives: We sought to (1) examine the rate of GIP utilization and (2) identify factors associated with its use among hospitalized CMO decedents. Methods: CMO decedents in two academic, tertiary care hospitals in the United States who died between October 1, 2020 and October 31, 2021, were subgrouped based on their primary medical service (GIP vs. non-GIP) at the time of inpatient death. Data abstracted from the electronic health record included demographics, primary diagnosis codes, Rothman Index (RI), time of CMO order, ordering clinician type, time of death, and length of stay (LOS). Multivariable logistic regression analysis was performed, adjusting for relevant covariates. Results: Of 1475 CMO decedents, only 321 (n = 22%) patients received GIP. On multivariable analysis, CMO patients who died in an ICU were five times less likely (odds ratio [OR] = 0.18, confidence interval [95% CI] 0.11-0.29) to receive GIP. Every 10-point increase in RI raised the likelihood of receiving GIP by 59% (OR = 1.59, 95% CI 1.39-1.80). Conclusions: Most CMO decedents died in the hospital without GIP. Compared with GIP decedents, non-GIP decedents were less acutely ill. There was no difference in total LOS between the two groups. CMO decedents were much less likely to receive GIP in an ICU. The RI may help clinicians identify CMO patients who would benefit from GIP earlier in their terminal admission.
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Affiliation(s)
- Dmitry Kozhevnikov
- Yale School of Medicine, New Haven, Connecticut, USA
- Yale Palliative Care Program, New Haven, Connecticut, USA
| | | | - Brett Prestia
- Yale School of Medicine, New Haven, Connecticut, USA
- Yale Palliative Care Program, New Haven, Connecticut, USA
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Sarkar A, Parulekar M, Sanders A. Impact of COVID-19 Pandemic on Utilization of the Inpatient Hospice Services (General Inpatient Hospice). Am J Hosp Palliat Care 2022; 39:996-1000. [PMID: 35040704 PMCID: PMC9297071 DOI: 10.1177/10499091211064833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Our institution has been offering the General inpatient hospice (GIP) services within the premises of our hospital since 2013. Our previous data had suggested increased acceptance of hospice and GIP care with this model. We wanted to study the impact of the current COVID-19 pandemic, on utilization of Hospice with this model of care. Objectives: Compare utilization of GIP at HUMC during the first COVID-19 surge, (3/1/2020–6/30/2020) to pre-COVID period (11/1/2019–2/29/2020). Methods: Using a retrospective chart review was done for GIP admissions from 11/2019 to 6/2020 at Hackensack University Medical Center (HUMC), an academic hospital in New Jersey which was approved by HUMC institutional review board. Data was collected for demographics and comorbidities. Descriptive statistics were reported. Results: The primary findings show increased hospice referrals during the study period (3.02%) compared to the pre-covid time period (2.63%), P = .0592. Furthermore, GIP admissions increased from 122/13 440 (.91%) in the pre-covid period to 146/11 480 (1.27%) during covid, P = .0055. There were 54 patients admitted to GIP with COVID-19. Descriptive statistics showed male and female distribution was almost equal (53.70% vs. 46.30%), and mean age of 82 years. In GIP patients with COVID-19, majority patients were white patients, (66.67%) age group of 76–95 years old and had < 3 comorbidities (85.19%), about half were with hypertension, next chronic condition was diabetes. Conclusions: COVID-19 outbreak increased both hospice referral and admission in our model of care. Availability of GIP in the hospital setting may help acceptance and facilitation of these essential end-of-life care services.
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Affiliation(s)
- Arunima Sarkar
- Hackensack University Medical Center (HUMC)RINGGOLD, Hackensack, NJ, USA
| | - Manisha Parulekar
- Hackensack University Medical Center (HUMC)RINGGOLD, Hackensack, NJ, USA
| | - Angeline Sanders
- Hackensack University Medical Center (HUMC)RINGGOLD, Hackensack, NJ, USA
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Cross SH, Kaufman BG, Quest TE, Warraich HJ. National Trends in Hospice Facility Deaths in the United States, 2003-2017. J Pain Symptom Manage 2021; 61:350-357. [PMID: 32858165 DOI: 10.1016/j.jpainsymman.2020.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Hospice facilities are increasingly preferred as a location of death, but little is known about the characteristics of patients who die in these facilities in the U.S. OBJECTIVES We sought to examine the trends and factors associated with death in a hospice facility. METHODS Retrospective cross-sectional study using mortality data for years 2003-2017 for deaths attributed to natural causes in the U.S. RESULTS The proportion of natural deaths occurring in hospice facilities increased from 0.2% in 2003 to 8.3% in 2017, resulting in nearly 1.7 million deaths during this time frame. Females had increased odds of hospice facility deaths (odds ratio [OR] = 1.04; 95% CI = 1.04, 1.05). Nonwhite race was associated with lower odds of hospice facility death (black [OR = 0.915; 95% CI = 0.890, 0.940]; Native American [OR = 0.559; 95% CI = 0.515, 0.607]; and Asian [OR = 0.655; 95% CI = 0.601, 0.713]). Being married was associated with hospice facility death (OR = 1.06; 95% CI = 1.04, 1.07). Older age was associated with increased odds of hospice facility death (85 and older [OR = 1.40; 95% CI = 1.39, 1.41]). Having at least some college education was associated with increased odds of hospice facility death (OR = 1.13; 95% CI = 1.11, 1.15). Decedents from cardiovascular disease had the lowest odds of hospice facility death (OR = 0.278; 95% CI = 0.274, 0.282). CONCLUSION Hospice facility deaths increased among all patient groups; however, striking differences exist by age, sex, race, marital status, education level, cause of death, and geography. Factors underlying these disparities should be examined.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA.
| | - Brystana G Kaufman
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA; Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiology Section, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
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Otani H, Morita T, Igarashi N, Shima Y, Miyashita M. A Nationwide Survey of Bereaved Family Members' Perception of the Place Patients Spent Their Final Days: Is the Inpatient Hospice Like or Unlike a Home? Why? Palliat Med Rep 2020; 1:174-178. [PMID: 34223474 PMCID: PMC8241350 DOI: 10.1089/pmr.2020.0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2020] [Indexed: 11/14/2022] Open
Abstract
Background: During end-of-life care, the place in which the patients spend time influences their quality of life. Objective: To clarify what it means to spend last days at home and in inpatient hospice. Design: This study was a part of a nationwide multicenter questionnaire survey of bereaved family members of cancer patients evaluating the quality of end-of-life care in Japan. Setting/Subjects: A nationwide questionnaire survey was conducted with 779 family members of cancer patients who had died at inpatient hospices. We asked participants about the perceived benefits of spending last days at home and inpatient hospice during the patient's last days. Measurements: A nationwide questionnaire. Results: Of participants, 37.6% (n = 185 [95% confidence interval, 33%–42%]) felt that the inpatient hospice was like a home. The family members who reported that the inpatient hospice felt like home significantly tended to report high satisfaction with the level of care (p < 0.01). Factors that the participants perceived as benefits of the inpatient hospice were: “If anything changes, as health care professionals are easily available, he/she can handle it” (88.1%), “he/she is reassured” (78.4%), and “he/she is safe” (72.7%). On the contrary, factors that they perceived as benefits of home were: “He/she can do what he/she wants to do without worrying about the eye of other people” (44.1%), “he/she can relax” (43.5%), and “he/she is free” (42.0%). Conclusions: Spending the last days of life in either an inpatient hospice or at home has specific benefits. The place a patient spends his/her end-of-life days should be based on patient and family values.
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Affiliation(s)
- Hiroyuki Otani
- Department of Palliative Care Team, and Palliative and Supportive Care, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan.,Department of Palliative Care Team, and Palliative and Supportive Care, St. Mary's Hospital, Fukuoka, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Naoko Igarashi
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Abstract
Background: Opioid refractory pain is a common problem in pain management. Dexmedetomidine is suggested to have opioid-sparing effects, with well-described use in surgical and intensive care unit settings. Some authors advocate its benefit in reducing delirium. Its effects are thought to be exhibited through agonism of pre- and postsynpatic α2-receptors in the central nervous system. It is more selective on α2-receptors than clonidine, accounting for its relatively lower incidence of hypotension. Its use in sedation is favored because it does not depress the respiratory system. The main side effects reported include bradycardia. Case Description: Twenty-eight-year-old woman with triple negative left breast cancer and a locally destructive tumor was admitted to hospice after exhausting her disease-directed therapy options. Her chief complaint was a throbbing, burning pain to the left chest wall, lower back, and bilateral lower extremities, rated 8/10 on a 10-point verbal scale. Multiple pharmacologic agents for pain, including patient-controlled analgesia infusions with adjuvant methadone and steroids, had failed to provide consistent pain management. Symptoms were difficult to control in the home setting, and she required multiple admissions to our inpatient hospice unit for pain management. She also developed episodes of delirium shortly after hospice admission. We attributed her symptoms to rapid disease progression. After failed pain control with opioids, ketamine, and lidocaine, we trialed a dexmedetomidine infusion. While on the infusion, her pain rating decreased to 0/10 and she had no delirium. Pain recurred soon after cessation of the infusion, initially rated 6/10. Conclusion: Dexmedetomidine is safe for opioid refractory pain in the hospice inpatient setting. However, its effects may not be sustained. There is potential for use in end-of-life care, with added benefit for possible control of delirium.
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Affiliation(s)
- Charles T Mupamombe
- Division of Geriatrics and Palliative Medicine, University at Buffalo, The State University of New York, Buffalo, Buffalo, New York
| | - Debra Luczkiewicz
- Hospice Inpatient Unit, Center for Hospice and Palliative Care, Buffalo, New York
| | - Christopher Kerr
- Hospice Inpatient Unit, Center for Hospice and Palliative Care, Buffalo, New York
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Abstract
Although place of death has been routinely studied in end-of-life (EOL) care, more analysis on place of death within hospice is needed because of the recent, dramatic rise in the number of hospice patients dying in inpatient settings. Using a case study to illustrate the complexity of determinants of place of death within hospice, this article highlights important known factors and elucidate gaps for further research. Individual and system level factors, sociocultural meanings, caregiving and preferences are shown to have important implications. Additionally, the unique components of home hospice, inpatient hospice and transitions between these settings may have a fundamental role in the future of quality EOL care. Further research on determinants of hospice settings of care is essential to the care of older adults at the end of life.
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