Hospice Length Of Stay Research Articles

Impact and cost-effectiveness of synergy between embedded palliative care and quality improvement teams on EOL quality metrics and resources utilization in a community-based oncology practice.

32 Background: There is evidence that Palliative Care (PC) brings value to health care organizations by positively affecting outcomes and quality-of-care metrics, however hiring a full PC team may be challenging for community practices. This report describes the impact on end-of-life (EOL) quality metrics of a close collaboration between an embedded PC provider and the Quality Programs and Process Improvement (QPPI) team in a community-based oncology practice. Methods: Blue Ridge Cancer Care (BRCC) hired a PC physician in October of 2021 and in the following months created a QPPI team composed of a Senior Director, Nurse Navigators, Social Worker, and Health Equity Administrator. The PC provider and QPPI team established a close collaboration to optimize support and referrals to PC for patients with advanced cancer. This retrospective cohort review compared patients who received PC with those who did not. Metrics reviewed where hospice admissions and hospice length of stay (LOS) categorized in average LOS, >3 days and >30 days. Results: BRCC serves about 15,000 active patients a year, with more than 6,000 new consults, and a total of more than 60,000 visits. This analysis reviewed a total of 3,352 decedents from October 2021 through April 2024. Cumulative data are shown (Table). Conclusions: Our experience suggests that PC embedded in an Oncology practice can collaborate with the existing QPPI team to improve EOL quality metrics and save resources. Patients with PC Patients without PC Admitted to hospice 61% (n=166) 30% (n=962) Hospice > 3 days 84% (n=140) 52% (n=477) Hospice LOS >30 days 43% (n=71) 22% (n=202)

End-of-Life Outcomes in Patients with Acute Myeloid Leukemia Receiving Non-Curative Chemotherapy

Background: Patients with acute myeloid leukemia (AML) frequently have poor-quality end of life (EOL) care including intensive care unit admissions and prolonged hospitalizations. Prognostic uncertainty and restrictions on transfusions during hospice are barriers that prevent patients with AML from having access to palliative care services. There is a paucity of data on EOL care on patients with AML that are unable to continue a venetoclax and hypomethylating agent (HMA-ven) treatment. Methods: A query was conducted using Northwell Cancer Institute's electronic health records to identify all transplant-ineligible patients with AML who received HMA-ven between January 2019 and December 2022 that had died. We retrospectively analyzed the charts of 84 patients who fit the criteria. EOL outcomes including rate of advanced care planning, location of death, and resource utilization were recorded. Overall survival (OS) was defined as the time from start of the last line of chemotherapy to death for patients that had disease-modifying treatment at EOL. For those that continued to best supportive care (BSC), OS was defined as the time from stopping the last dose of chemotherapy to death. Hospice length of stay (HLOS) was the time from a hospice referral to death for patients that chose to stop transfusions and pursue hospice. Kaplan-Meier method and log rank testing were used to compare time to event data. Results: In our cohort of 84 patients, 43% of patients died on hospice, 53% of patients died in the hospital, with 23% requiring an ICU admission at the end of life. 18% had either cardiopulmonary resuscitation (CPR) or an activation of the emergency response system within 24 hours of death. While more than half of patients opted to not have CPR, 15% of these decisions were made within the last 24 hours of life. Furthermore, of the patients only 65% saw a palliative care physician while admitted for treatment. Of note, 42 patients tolerated HMA-ven and were continued to take this medication until their death. However, 42 patients stopped HMA-Ven due to progression of disease (69%) or intolerance (31%). Of this cohort, 15 patients continued to subsequent line therapy following HMA-ven with a median OS of 56 days. 24 patients continued on to hospice without transfusion support, with a median HLOS of 7 days. Seven patients continued BSC with median OS of 41 days, requiring an average of 1.6 transfusions weekly. Of note, the patients that continued BSC did not transition to hospice as these patients were unable or unwilling to stop transfusions. There was no statistical difference in OS between receiving subsequent chemotherapy and BSC at EOL (p = 0.40). Patients receiving BSC had a lower percentage of patients dying in the ICU (55% vs 40%) and documented advanced directives with a health care proxy (29% vs 7%) compared to those that had received chemotherapy at EOL. Discussion: Our study identified opportunities to improve EOL care and goal-concordant care in patients with AML receiving non-curative therapy. A subset of this population significantly benefitted from transfusion-only support and stopping disease modifying treatment. Opting for BSC may drastically improve the EOL quality by decreasing ICU deaths and improving access to goal-concordant care. Further research on the timing of best supportive care to patients with AML undergoing non-curative intent therapy as opposed to continuing subsequent line chemotherapy regimens is needed.

Differential impact of inpatient and outpatient palliative care on end-of-life outcomes in hospitalized patients with cancer.

24 Background: Palliative care (PC) improves outcomes for patients with advanced cancer, and current ASCO guidelines recommend early outpatient referral. However, recent data show that PC teams at many cancer centers see more inpatient consults than outpatient visits; the comparative impact of inpatient versus outpatient PC is not well-described. For this reason, we conducted a retrospective cohort study of hospitalized cancer patients to quantify exposure to inpatient/outpatient PC, and to describe associations between PC exposure and end-of-life (EOL) quality measures including hospice utilization, advance care planning (ACP), and intensity of care. Methods: We identified all patients admitted to one cancer center’s inpatient oncology unit during one fiscal year (10/1/2017-9/30/2018). Demographics, admission statistics, inpatient/outpatient PC visits, and EOL outcomes were abstracted from the electronic medical record. Decedents were identified through chart review and public obituaries. Results were summarized by descriptive statistics, and standard statistical tests were used to evaluate associations between PC exposure and EOL outcomes. Results: 842 patients were hospitalized in one year. 522 patients died by the study end-date of 10/1/2020 and were included in analysis. 50% of decedents had any PC exposure prior to death, but only 21% had an outpatient PC visit. Patients seen by PC were younger at time of death, (median: 67 vs 72 years; p <.001) and more likely to be female (52% vs 42%; p =.03). Compared to patients never seen by PC, patients with any PC exposure were significantly more likely to enroll in hospice (78% vs 44%; p <.0001), have do-not-resuscitate status (87% vs 55%; p <.0001), have scanned ACP documents (53% vs 31%; p <.0001), and die at home or inpatient hospice instead of in the hospital (67% vs 40%; p <.01). PC exposure was not associated with differences in 30-day re-admissions, systemic cancer therapy in the last 14 days of life, or intensive care (ICU) utilization in the last 30 days of life. Notably, PC exposure was associated with longer hospital length-of-stay (LOS) (8.4 vs 7.2 days), but this association was reversed for patients seen by outpatient PC versus all others (6.3 vs 8.2 days; p <.01). Patients seen by outpatient PC also had longer hospice LOS (46.5 vs 27.1 days; p <.01) and less EOL ICU use (6% vs 15%; p <.05) compared to all others. Conclusions: In this large retrospective study of hospitalized patients with cancer, PC exposure was associated with significant improvements in multiple EOL quality measures. The subset of patients seen by outpatient PC experienced additional benefits, including shorter hospital LOS, longer hospice LOS, and less EOL ICU utilization. These findings point to differential effects between inpatient and outpatient PC, underscoring the importance of early, longitudinal PC involvement.

Association between perceptions of prognosis and end-of-life outcomes for patients with advanced lung and gastrointestinal cancer.

6503 Background: Many patients with advanced cancer maintain misperceptions of their prognosis and are thus unprepared to make difficult decisions regarding their end-of-life (EOL) care. However, studies examining the associations between patients’ perceptions of their prognosis and their EOL outcomes are limited. Methods: We conducted a secondary analysis using longitudinal data from a randomized controlled trial of a palliative care intervention for patients with newly diagnosed incurable lung and non-colorectal gastrointestinal cancer. We administered the Prognosis and Treatment Perceptions Questionnaire to assess patients’ perceptions of their prognosis at baseline, week-12, and week-24, using the final assessment closest to death. We used multivariate logistic and linear regression models, adjusting for age, gender, marital status, cancer type, and randomization to the palliative care intervention, to examine the associations among patients’ perceptions of their prognosis with the following EOL care outcomes abstracted from the electronic health record: 1) hospice utilization and length-of-stay (LOS); 2) hospitalizations in the last 30 days of life; 3) receipt of chemotherapy in the last 30 days of life; and 4) location of death. Results: We enrolled 350 patients in the parent trial, of which 80.5% (281/350) died during the study period and were included in this analysis. Overall, 59.4% (164/276) of patients reported that they were terminally ill, and 66.1% (154/233) reported that their cancer was likely curable at the assessment closest to death. In multivariate analyses, patients who reported that their cancer was likely curable were less likely to utilize hospice (OR = 0.25, 95%CI 0.10-0.61, P = 0.002) or die at home (OR = 0.56, 95%CI 0.32-0.98, P = 0.043), and more likely to be hospitalized in the last 30 days of life (OR = 2.28, 95%CI 1.20-4.32, P = 0.011). In contrast, patients’ report that they were terminally ill was only associated with lower likelihood of hospitalizations in the last 30 days of life (OR = 0.52, 95%CI 0.29-0.92, P = 0.025). Patients’ perceptions of their prognosis were not associated with hospice LOS or chemotherapy administration in the last 30 days of life. Conclusions: Patients’ perceptions of their prognosis are associated with important EOL outcomes including hospice utilization, hospitalizations at the EOL, and death at home. Interventions are needed to enhance patients’ perceptions of their prognosis in order to optimize their EOL care.

Differential impact of inpatient and outpatient palliative care on end-of-life outcomes in hospitalized patients with cancer.

e24069 Background: Palliative care (PC) improves outcomes for patients with advanced cancer, and current ASCO guidelines recommend early outpatient referral. However, recent data show that PC teams at many cancer centers see more inpatient consults than outpatient visits; the comparative impact of inpatient versus outpatient PC is not well-described. For this reason, we conducted a retrospective cohort study of hospitalized cancer patients to quantify exposure to inpatient/outpatient PC, and to describe associations between PC exposure and end-of-life (EOL) quality measures including hospice utilization, advance care planning (ACP), and intensity of care. Methods: We identified all patients admitted to one cancer center’s inpatient oncology unit during a fiscal year (10/1/2017 - 9/30/2018). Demographics, admission statistics, inpatient/outpatient PC visits, and EOL outcomes were abstracted from the electronic medical record. Deceased patients were identified through chart review and public obituaries. Results were summarized by descriptive statistics, and standard statistical tests were used to evaluate associations between PC exposure and EOL outcomes. Results: 842 patients were hospitalized in one year. 522 patients died by the study end-date of 10/1/2020 and were included in analysis. 50% of deceased patients had any PC exposure prior to death, but only 21% had an outpatient PC visit. Patients seen by PC were younger at time of death (median: 67 vs 72 years; p < .001) and more likely to be female (52% vs 42%; p = .03). Compared to patients never seen by PC, patients with any PC exposure were significantly more likely to enroll in hospice (78% vs 44%; p < .0001), have do-not-resuscitate status (87% vs 55%; p < .0001), have scanned ACP documents (53% vs 31%; p < .0001), and die at home or inpatient hospice instead of in the hospital (67% vs 40%; p < .01). PC exposure was not associated with differences in 30-day re-admissions, systemic cancer therapy in the last 14 days of life, or intensive care (ICU) utilization in the last 30 days of life. Notably, PC exposure was associated with longer hospital length-of-stay (LOS) (8.4 vs 7.0 days), but this association was reversed for patients seen by outpatient PC versus all others (6.3 vs 8.3 days; p < .01). Patients seen by outpatient PC also had longer hospice LOS (46.5 vs 27.1 days; p < .01) and less EOL ICU use (6% vs 15%; p < .05) compared to all others. Conclusions: In this large retrospective study of hospitalized cancer patients, PC exposure was associated with significant improvements in multiple EOL quality measures. The subset of patients seen by outpatient PC experienced additional benefits, including shorter hospital LOS, longer hospice LOS, and less EOL ICU utilization. These findings point to differential effects between inpatient and outpatient PC, underscoring the importance of early, longitudinal PC involvement.

Hospice care utilisation among elderly patients who died with hepatocellular carcinoma in the United States

Background & AimsThe benefits of hospice care in Medicare recipients with hepatocellular carcinoma (HCC) have not been fully evaluated, which we aimed to study.MethodsWe used nationally representative samples of the Medicare beneficiaries in the USA (2011–2016) to assess the impact of hospice care on the outcomes of patients with HCC. Hospice care benefits on the survival time, length of stay (LOS), 30-day readmissions, and daily charges during the last year and month of life were assessed by logistic regression and generalised linear regression.ResultsAmong 2,230 Medicare beneficiaries with HCC (mean age, 74.9 years; non-Hispanic White 79.1%; male 66.6%), median survival from HCC diagnosis was 68 days; 556 (24.9%) received hospice services; median hospice LOS was 12 days (4–35 days). Hospice users increased from 20.1% to 31.1% over time, driven by enrolment ≤15 days (45.1–59.2%, respectively). In the last year of life, hospice users (vs. no hospice care) had longer median survival time (76.5 vs. 66 days), lower in-hospital mortality (1.1% vs. 25.5%) and lower median daily charges ($951 vs. $1,004) despite more inpatient admissions and higher comorbid diseases. Hospice enrolment was associated with 48.6% reduction in daily charges (95% CI: -54.9% to -41.5%). Longer hospice LOS was associated with lower rates of healthcare utilisation. Patients with chronic liver disease were less likely to enrol in hospice care (odds ratio = 0.18, 95% CI: 0.14–0.24).ConclusionsAlthough hospice provides a significant decrease in healthcare utilisation and some benefit in survival, most care is given in the last 2 weeks of life. Efforts to encourage earlier use of hospice services must continue.Lay summaryThe purpose of hospice care is to provide comfort and lessen suffering at the end of life. Hospice care allows one to die outside the hospital environment which is the wish of most people. However, we found that among persons aged 65 years and older who were diagnosed with liver cancer (which has a poor prognosis), only 25% were enrolled in hospice care and the majority used a hospice only in the last weeks of life. This is a disheartening finding as liver cancer patients with longer hospice enrolment had lower costs and improved survival. We suggest that healthcare practitioners consider discussion of palliative and hospice care routinely with patients suffering from liver cancer.

Hospice inpatient services provision, utilization, and financial performance.

Hospice performance is an overlooked area in the health care field due to the difficulty of measuring quality of care and the infrequent quality inspection. Based on the daily reimbursement mechanism for different levels of hospice care, inpatient services provision could influence both hospice-level length of stay (LOS) and financial performance. The objective of this study was to explore the relationship between hospice inpatient services provision and hospice utilization and financial performance. A longitudinal secondary data set (2009-2013) was merged from three sources: (a) Hospice Cost Reports from the Centers for Medicare & Medicaid Services, (b) the Provider of Services files, and (c) the Area Health Resources Files. The dependent variable in this study was hospice average LOS and financial performance measured by total operating margin (TOM) and return on assets. The independent variable was hospice inpatient services' offering. Mixed-effects regression models were used in the multivariate regression analyses. When comparing to hospices not providing inpatient services, offering inpatient services by staff was negatively related to average LOS (b = -0.063, p < .05) and TOM (b = -0.022, p < .05). The combination method with providing inpatient services by staff and under arrangement was negatively associated with return on assets (b = -0.073, p < .05). Hospice inpatient services provision was associated with average LOS and financial performance. Offering the inpatient services to patients by staff decreased average LOS and TOM. Hospice agencies may seek strategies to maintain their financial sustainability through outsourcing.

Comparison of End-of-Life Care Quality Outcomes and Indicators of Palliative Needs between Medicare Beneficiaries with Solid and Hematologic Malignancies

Comparison of End-of-Life Care Quality Outcomes and Indicators of Palliative Needs between Medicare Beneficiaries with Solid and Hematologic Malignancies

Randomized trial of a hospice video decision aid for patients with advanced cancer and their caregivers.

42 Background: Although hospice provides high-quality end-of-life care for patients with advanced cancer, the service remains underutilized in part due to lack of adequate information provided to patients and families about hospice care. Methods: We conducted a single-site randomized clinical trial of a hospice video decision aid versus a verbal description in 150 hospitalized patients with advanced cancer and their caregivers. Patients without an available caregiver were eligible to participate. Intervention participants (75 patients; 18 caregivers) received a verbal description about hospice plus a six-minute video depicting hospice care. Control participants (75 patients; 26 caregivers) received only the verbal description. The primary endpoint was patient preference for hospice care immediately after the intervention, adjusting for baseline preferences. Secondary outcomes included patient and caregiver knowledge and perceptions of hospice, and hospice utilization. Results: Between 2/2017 and 1/2019, we enrolled 55.7% (150/269) of potentially eligible patients and 44 caregivers. Post-intervention, patients assigned to the video group were more likely to prefer hospice care (86.7% vs. 82.7%, OR = 2.85, P = 0.08), but this was not statistically significant. Patients in the video group reported greater knowledge about hospice (B = 0.50, P = 0.024) and were less likely to endorse that hospice care is only about death (6.7% vs. 21.6%, OR = 0.28, P = 0.035). Among patients who died (n = 116), those assigned to the intervention were more likely to utilize hospice (85.2% vs. 63.6%, P = 0.01) and had a longer hospice length-of-stay (LOS) (median 12 vs. 3 days, P &lt; 0.001). Post-intervention, caregivers assigned to the video were more likely to prefer hospice care for their loved ones (94.4% vs. 65.4%, P = 0.031), reported greater knowledge about hospice (B = 1.94, P &lt; 0.001), and were less likely to endorse that hospice care is only about death (0.0% vs. 23.1%, P = 0.066). Conclusions: Patients with advanced cancer and their caregivers who viewed a hospice video decision aid were more informed about hospice, reported more favorable perceptions of hospice, and were more likely to utilize hospice and have a longer hospice LOS. Clinical trial information: NCT03040102.

A community oncology end-of-life care program: Results for hospice length of stay analysis.

e23008 Background: Michigan Health Professionals (MHP) is a large multispecialty physician group. MHP Oncology Division participates in quality improvement projects. Palliative and End of Life (EOL) care has been identified as one of the quality improvement areas. A comprehensive community oncology program for early and timely involvement of palliative and EOL care was launched in October 2017. Methods: MHP Palliative and End of life care committee was created of mostly oncologists who are board certified in Palliative care and Hospice. The program, which included pre-program training, user-friendly referral process, and live physician engagement for early involvement of palliative care (PC) and EOL care was developed and implemented. A partnership was created with Premier Hospice to integrate EOL care services with the oncology offices and to collect data. Historical data for average hospice length of stay (LOS) in hospice service for MHP oncology patients was analyzed by Integra Connect. Results: From 1/1/2018 to 12/31/2018 a total of 133 patients (MHP-T) were referred and admitted to Hospice service. Sixty-one patients were on PC service (PC group) and 72 patients (NonPC group) were referred directly to hospice. Total of 527 patients from 2012 to 2017 were analyzed for historical comparison group (HC) and 124 patients were analyzed for MHP-T group. Average LOS was 16.8 days in the HC group. Average LOS for the MHP-T, PC group and NonPC group improved to 34, 35 and 33 days respectively. HC group had 82.2% of patients with average LOS &lt; 30 days. After program implementation average LOS &lt; 30 days improved to 63.7% MHP-T group, 60.0% PC group and 66.7% NonPC group. In HC group, 92 out of 527 patients had average LOS of 2 days or less. Only 2 patients out of 124 patients had average LOS of 2 days or less since the launch of MHP community oncology program. Conclusions: Early and timely patient referral to the EOL care services resulted in average hospice LOS which is more than double as compared to historical comparison group. Fewer number of patients had average LOS of &lt; 30 days and LOS of 2 days or less as compared to the historical comparison group. There was a trend towards higher LOS observed for patients who were under palliative care (PC) before hospice admission.

Implications of Palliative Care Consultation Timing among a Cohort of Hospice Decedents.

Background: Earlier palliative care consultation is associated with less intensive medical care and improved quality outcomes for patients with cancer. However, there are limited data about how the timing of palliative care affects utilization among noncancer patients exposed to palliative care consultation. Objective: Comparison of health care utilization for hospice decedents who received early versus late palliative care. Design: A retrospective cohort study utilizing hospital and hospice administrative databases. Setting/Subjects: Patients with cancer and noncancer diagnoses who received specialty palliative care consultation before dying at a local hospice. Measurements: Comparing early (>90 days before death) versus late (<90 days before death) palliative care, outcome measures included intensive care unit (ICU) utilization and hospice length of stay (LOS). Results: Of 233 hospice decedents in 2014 who had palliative care referrals, 36 (15.4%) had early and 197 (84.5%) had late referrals. Nearly half of the patients had a noncancer hospice diagnosis. Only 6% of the early group used the ICU in the last month of life, whereas 56% of the late group did. Patients receiving early palliative care had a longer median hospice LOS than those with late palliative care (138 days vs. 8 days). Conclusions: Early palliative care appears to reduce intensive medical care and increase hospice LOS for patients with a variety of end-stage diseases.

Health Disparities in Hospice Utilization and Length of Stay in a Diverse Population With Lung Cancer.

Lung cancer is the leading cause of cancer deaths globally. Individuals are diagnosed at an advanced stage with limited life expectancy. To explore potential health disparities in hospice utilization and length of stay (LOS) in a diverse sample of patients with lung cancer. Demographic and clinical information as well as data for hospice utilization and LOS was extracted from electronic health records. Data were analyzed using descriptive statistics, χ2 tests, and an analysis of variance test. Data from 242 patients were analyzed. In the sample, 33% (n = 80) were Black and 51% (n = 124) lived in a rural county. At the time of data collection, 67% of the sample was deceased and 36% (n = 86) chose to enroll in hospice. No disparities were found for race, age, gender, or rural/urban dwellers in hospice enrollment. No disparities were found for race, gender, or rural/urban dwellers for hospice LOS. Age was associated with hospice LOS ( P = .004). Those who were older were more likely to have a longer LOS. Hospice utilization and LOS were low for all groups with lung cancer in a geographically and racially diverse region of the United States. Given the rates of mortality in lung cancer, discussions about the goals and benefits of hospice care may be beneficial and should be part of an ongoing dialogue throughout the disease trajectory.

Examining the intersection of palliative care, hospice, and concurrent care in Veterans Affairs (VA).

139 Background: The VA advocates for both palliative care and concurrent care (hospice care and cancer-directed treatment). Studies indicate that these policies have increased hospice use and have improved family-reported outcomes and other quality metrics. However, little is known about how palliative care, hospice care and concurrent care may interact to obtain these outcomes. Methods: This was a retrospective cohort study of veterans dying with stage IV non-small cell lung cancer in 2012. VA and Medicare administrative data were used to identify the cohort, chemotherapy and radiation use, hospitalizations, hospice use and length of stay (LOS). Palliative care use was determined by VA data only. Analyses included descriptive statistics, chi-square and analysis of variance. Results: Of the 1763 veterans, 850 (48.2%) received both palliative care and hospice, 392 (22.2%) received hospice only, 241 (13.7%) received palliative care only and 280 (15.9%) received neither. Receipt of cancer-directed treatment or hospitalization in the last 30 days of life was significantly different across these groups (p &lt; 0.0001) and was highest at 65% (182/280) in the neither palliative care or hospice group. In the remaining groups, rates of cancer-directed treatment or hospitalization in the last 30 days were: 39.4% (95/241) in palliative care only, 29.3% (115/392) in hospice only and 23% (198/850) with both palliative care and hospice. Concurrent care was received by 314 veterans (17.8%), 275 also receiving palliative care. Among veterans receiving palliative care and Medicare hospice, concurrent care did not alter hospice utilization rates or LOS: 36.4% (100/275), LOS mean 22.3, median 16.5, range 1-97 and 37.2% (214/575), LOS mean 20.1, median 13, range 1-94, for concurrent care and non-concurrent care respectively. Conclusions: The rates of cancer-directed treatment or hospitalization in the last 30 days of life appeared to be reduced in a continuum from receipt of neither hospice nor palliative care, to receipt of palliative care or hospice alone, followed by receipt of both together. Concurrent care use was facilitated by palliative care without impacting Medicare hospice use or LOS in palliative care recipients.

An economic examination of private insurance claims among adolescents and young adults who were enrolled in hospice during the last year of life.

PurposeThe purpose of this study was to generate baseline data on the health characteristics, health care utilization, and health care spending among privately insured adolescents and young adults (AYA), who were enrolled in hospice care during their last year of life.MethodsA retrospective, nonexperimental design was used to collect and analyze longitudinal claims data from the Truven Health MarketScan™ database. The sample included AYA (aged 15–24 years) who utilized hospice during their last year of life.ResultsTotally, 17,408 AYA were included in this analysis. Mean hospice length of stay (LOS) was low overall, but there was a statistically significant difference in hospice LOS in ages 15–19 years (mean 3.56, SD 15.17 days) compared with those aged 20–24 years (mean 2.26, SD 8.24; P<0.001 days). More than a third (37%) of the AYAs used the emergency department during the last year of life and 83% sought care from a primary care visit. However, only 6% of the sample who were hospice enrollees used frequent inpatient hospital services.ConclusionsThis study provides preliminary data for private insurance expenditures and clinical utilization for AYA who were enrolled in hospice. This analysis also provides initial evidence to suggest extremely short hospice LOS for AYAs prior to the end of life and represents an area of future research need.

PC-FACS

PC-FACS

The Quality of Dying and Death in a Residential Hospice

ContextResidential hospices may be an optimal compromise between home and hospital settings for end-of-life care, but there has been little systematic research regarding the quality of dying and death in such locations. ObjectivesThe objective of this study was to assess the quality of dying and death of patients who received end-of-life care in a residential hospice and its relationship to hospice length of stay (LOS) and prior receipt of palliative care. MethodsA total of 100 caregivers of patients who died in a residential hospice in downtown Toronto, Canada, were recruited four to six months after patient's death. The quality of dying and death was measured, based on interviews with bereaved caregivers, using the Quality of Dying and Death (QODD) questionnaire. ResultsThe overall mean QODD score was 68.85 ± 11.62, which is in the intermediate (“neither good nor bad”) range (30–70) of the scale. The lowest QODD subscale score was on the Transcendence subscale, which evaluates death-related concerns; this was 59.48 ± 25.37, with ratings in 14.6% of the sample in the “terrible to poor” (0–29) range. QODD scores were higher for patients with hospice LOS of more than one week (72.21 ± 9.64) than for those with a shorter LOS (60.38 ± 11.92) (P < 0.001). ConclusionOverall quality of dying and death was perceived as average to above average, in an urban residential hospice, although death-related distress was present in a substantial minority of patients. The association of better QODD with hospice LOS of more than one week may be due to better clinical status on admission and/or longer duration of time that is needed to achieve optimal outcomes.

Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis

Patients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with health care utilization and costs. To examine the association between hospice length of stay and health care utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis. This cross-sectional observational study was conducted via the United States Renal Data System registry. Participants were all 770 191 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were April 2016 to December 2017. Hospital admission, intensive care unit (ICU) admission, and receipt of an intensive procedure during the last month of life; death in the hospital; and costs to the Medicare program in the last week of life. Among 770 191 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for 3 days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for 3 days or fewer were less likely to die in the hospital (13.5% vs 55.1%; P < .001) or to undergo an intensive procedure in the last month of life (17.7% vs 31.6%; P < .001) but had higher rates of hospitalization (83.6% vs 74.4%; P < .001) and ICU admission (54.0% vs 51.0%; P < .001) and similar Medicare costs in the last week of life ($10 756 vs $10 871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred more than 15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were $3221). Overall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population.

End-of-life care for glioblastoma multiforme (GBM) patients at a large academic center.

56 Background: GBM is a uniformly fatal disease with average survival of &lt; 3 years and universal cognitive problems, making advance care planning paramount. End of life (EOL) patterns of GBM care in the US have not been studied. We examined care in a cohort of GBM and brain tumor (BT) patients as part of a program to provide individual provider feedback about EOL care. Methods: We reviewed the care of all GBM patients over 3 years with a random sample of 100, and a 5-yr subset of 45 who received their care at Gilchrist Hospice (GH), our largest provider. We queried EPIC EMR for markers of quality. We also reviewed all 452 advanced cancer pts of the Sidney Kimmel Comprehensive Cancer Center (SKCCC) referred to GH from 7/1/13 to 3/31/15 to find the median length of stay (LOS) and %LOS &lt; 7 days for each division and each physician; 29 BT patients (most GBM) are included. Results: Few patients had documented Advance Directives or code status. Of the 100 pts, 37% were hospitalized in the last 4 weeks of life, and 17% received chemotherapy. Hospice referral and use was 76%. Of those in GH, 64% died at home with hospice and 20% died in inpatient hospice. Variability among physicians in hospice LOS was high (cv = 124.30%) ranging from 6 to 158 days with a median of 33.5 days, exceeding national averages, and 3 of 6 practitioners were below average LOS. Conclusions: In this snapshot of GBM EOL care in the US, improvements can be made in the use of advance care planning, code status, chemotherapy near death, and hospitalization rates. Hospice LOS is above national averages but varies by physician. [Table: see text]

Impact of a Centralized Inpatient Hospice Unit in an Academic Medical Center.

Rush University Medical Center (RUMC) and Horizon Hospice opened the first centralized inpatient hospice unit (CIPU) in a Chicago academic medical center in 2012. This study examined if there was a difference in cost or length of stay (LOS) in a CIPU compared to hospice care in scattered beds throughout RUMC. This retrospective, cross-sectional study compared cost and LOS for patients admitted to the CIPU (n = 141) and those admitted to hospice scattered beds (SBM) throughout RUMC (n = 56). The CIPU patients had a median LOS of 6.0 days versus 2.0 days for SBM patients. The CIPU patients had longer hospice LOS but lower hospital costs. Academic medical centers may benefit from aggregating hospice beds.

Patterns of Hospice Use in Patients Dying from Hematologic Malignancies

Hospice brings substantial clinical benefits to dying patients and families but is underutilized by patients dying of hematologic malignancies (HM); nationwide, only 2% of HM patients use hospice. There are 70,000 deaths among U.S. patients with hematologic malignancies yearly. We measured the use and length of stay (LOS) in hospice among patients with HMs at a large academic cancer center. This was a single center retrospective review of adult patients (≥18 years) with lymphoma, leukemia, myelodysplastic syndrome, aplastic anemia, and multiple myeloma referred for hospice. Information included demographics, transplant, hospice type, LOS, and use of "expanded access" services. Fifty-nine patients were referred to hospice, and 53 utilized hospice services, 25% of 209 HM decedents. Thirty-five received home hospice and 18 used inpatient hospice. The median home hospice LOS was nine days (SD 13) and inpatient hospice six days (SD 10). Nine patients with "expanded access" hospice received only a few blood transfusions, and none received radiation. HM patients are referred late or never for hospice services. Studies evaluating earlier integration of palliative and hospice care with usual HM care are warranted. We present a one-page negotiation form that we have found useful in negotiations among HM physicians, hospice medical directors, and payers.