Hospice Referral Research Articles

Correlation Between Remote Symptom Reporting by Caregivers and Adverse Clinical Outcomes: Mixed Methods Study.

Timely collection of patient-reported outcomes (PROs) decreases emergency department visits and hospitalizations and increases survival. However, little is known about the outcome predictivity of unpaid informal caregivers' reporting using similar clinical outcome assessments. The aim of this study is to assess whether caregivers and adults with cancer adhered to a planned schedule for electronically collecting patient-reported outcomes (PROs) and if PROs were associated with future clinical events. We developed 2 iPhone apps to collect PROs, one for patients with cancer and another for caregivers. We enrolled 52 patient-caregiver dyads from Kaiser Permanente Northern California in a nonrandomized study. Participants used the apps independently for 4 weeks. Specific clinical events were obtained from the patients' electronic health records up to 6 months following the study. We used logistic and quasi-Poisson regression analyses to test associations between PROs and clinical events. Participants completed 97% (251/260) of the planned Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE) surveys and 98% (254/260) of the Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. PRO-CTCAE surveys completed by caregivers were associated with patients' hospitalizations or emergency department visits, grade 3-4 treatment-related adverse events, dose reductions (P<.05), and hospice referrals (P=.03). PROMIS surveys completed by caregivers were associated with hospice referrals (P=.02). PRO-CTCAE surveys completed by patients were not associated with any clinical events, but their baseline PROMIS surveys were associated with mortality (P=.03), while their antecedent or final PROMIS surveys were associated with all clinical events examined except for total days of treatment breaks. In this study, caregivers and patients completed PROs using smartphone apps as requested. The association of caregiver PRO-CTCAE surveys with patient clinical events suggests that this is a feasible approach to reducing patient burden in clinical trial data collection and may help provide early information about increasing symptom severity.

Impact of hospice enrollment timing on overall survival and quality of life indicators in patients with pancreatic ductal adenocarcinoma (PDAC).

243 Background: This study aimed to examine the effects of hospice enrollment timing on survival and end-of-life quality of life indicators for pancreatic ductal adenocarcinoma (PDAC) patients. Methods: A retrospective chart review of 152 patients with biopsy-proven PDAC from August 2009 to December 2022 at a single center was conducted. Patients were categorized based on hospice enrollment timing: Early-Hospice (EH) (≥ 60 days before death), Late-hospice (LH) (&lt; 60 days), and No Hospice (NH). Parameters assessed included overall survival (OS), palliative care service interaction, treatment lines, time from last chemotherapy treatment to death, hospital utilization after last chemotherapy treatment, documentation of advance care directives (ACD), and place of death. Statistical analysis was performed using Chi-squared test with Yates' continuity correction and Kruskal-Wallis test. The time-to-event endpoint was estimated using the Kaplan-Meier method. Results: Analysis of 152 patients showed that hospice enrollment timing did not significantly influence OS in PDAC patients (p=0.6). Median OS for EH (n=10), LH (n=84), and NH (n=58) groups were 10.1 months, 15.7 months, and 12.5 months, respectively. Subgroup analysis of patients with unresectable tumors at diagnosis (EH [n=7], LH [n=61], and NH [n=40]) showed no statistically significant difference in survival (9.19 vs. 12.22 vs. 9.08, p=0.08). The time from first interaction with the Palliative Care team to death was not different between groups. However, patients in EH had a notably longer median duration between their last chemotherapy session and death compared to LH and NH (201 vs. 43 vs. 31.5 days, p&lt;0.01), as well as fewer days hospitalized after the last chemotherapy session (0.5 vs. 5 vs 8 days, p=0.02). Hospice enrollees had a substantially higher rate of documented ACD, and were far more likely to die at home. Conclusions: Although the timing of hospice enrollment did not significantly impact overall survival in PDAC patients, it played a significant role in influencing end-of-life quality of life indicators. Interaction with the palliative care team did not vary across groups, implying that hospice referral by oncology is acceptable and effective. However, documentation of ACDs for non-hospice enrollees was very low, a clear area for improvement.[Table: see text]

The association between telemedicine visits and downstream utilization among patients with cancer at a large academic health center.

515 Background: The COVID-19 pandemic and associated policies such as lockdowns spurred the widespread adoption of telemedicine throughout the U.S. Telemedicine has played a particularly important role for oncology patients by reducing potential exposure to infection and improving access for patients with poor performance status. However, as policymakers consider extending payment for telemedicine into the post-pandemic era, it is important to understand the impact of telemedicine on downstream care utilization in this population. We conducted a retrospective cohort study investigating the relationship between telemedicine use in oncology and subsequent outpatient oncology encounters, emergency department (ED) visits and hospitalizations at a large academic health center. Methods: We studied all outpatient oncology encounters occurring between 2018 and 2022 at the University of California, Los Angeles (UCLA) Health system, including in-person visits and telemedicine (audio-visual &amp; audio-only) visits. We used multiple linear regression to predict the number of outpatient visits, ED visits, and hospitalizations within 30 days of an index visit based on visit modality, adjusting for demographic and clinical characteristics including patient age, race, ethnicity, sex, insurance, distance to clinic, distance to the nearest UCLA hospital, hospice referral, palliative care visits, median visit interval, appointment length, whether the visit occurred off the patient’s chemotherapy schedule, and the month and year of visit. Results: Our cohort included 62,815 patients with 672,427 outpatient encounters, of which 623,890 (92.7%) were in-person visits, 40,392 (6.0%) were video visits, and 8,145 (1.2%) were telephone visits. Overall, patients on average had 0.90 downstream outpatient visits, 0.16 ED visits, and 0.18 hospitalizations within 30 days of an index outpatient encounter. In our adjusted analyses, telemedicine encounters were associated with less outpatient utilization (270 fewer downstream visits [95% CI: 241 to 299] per 1000 encounters; p &lt; 0.001). Telemedicine was also associated with greater ED visits (42.1 more ED visits [95% CI 18.5 to 65.8] per 1000 encounters; p &lt; 0.001) and hospitalizations (54.8 more admissions [95% CI 33.6 to 76.1] per 1000 encounters; p &lt; 0.001). Conclusions: Oncology patients who had a telemedicine visit rather than an in-person visit were less likely to have a follow-up outpatient encounter but more likely to have an ED visit or hospitalization within 30 days. Our findings suggest that telemedicine has largely played a substitutive role in the outpatient setting, but patients may require higher levels of care after these visits when compared to in-person visits. Additional research should further evaluate the effectiveness of telemedicine in oncology and define appropriate contexts for telemedicine use in this population.

Assessing the utilization of palliative care services in the management of patients with metastatic pancreatic adenocarcinoma.

256 Background: Pancreatic Cancer is known to be associated with poor survival outcomes and high symptom burden. Integration of early palliative care has been associated with improved end of life care, including reduced hospitalizations and emergency room visits. We conducted a retrospective study to determine the utilization rates of specialist palliative care in patients diagnosed with metastatic pancreatic cancer at an academic teaching hospital and summarize the impact on end-of-life care. Methods: A database of patients diagnosed with metastatic pancreatic cancer on index presentation from 2011 and 2022 was analyzed for utilization of specialist palliative care. Patients who transitioned cancer care to other centers and those who were lost to follow-up were excluded. Data on patient demographics, treatment course, and end-of-life care were collected, and descriptive statistics were used to summarize the data. Results: In our study, 168 patients met the inclusion criteria. The average age of diagnosis was 66 years with a diverse ethnic composition, including White (35.7%), African American (26.8%), and Hispanic (15.5%) patients. Among the cohort, 126 out of 168 (75%) patients were seen by palliative care at least once, with 79 (62.7%) of them initially seen during one of the hospitalizations, and 47 (37.3%) were seen by palliative care outpatient for the first time. The median duration between pancreatic cancer diagnosis and first encounter with palliative care was 145 days (IQR 305 days). No significant differences were found in terms of age, race, sex, ethnicity or insurance type between patients who received palliative care and those who did not. The median time from consultation to death was 57 days and 36.5% patients received palliative care only within one month of their death. Patients who received palliative care were more likely to have a DNR/DNI code status (86.7% vs. 13.3%, p &lt; 0.001) and were more likely to be enrolled in hospice care (86.3% vs. 13.7%, p &lt; 0.001). Conclusions: Early involvement of specialist palliative care in management of patients with metastatic pancreatic cancer may lead to optimization of health care services with earlier hospice referrals and comfort directed care at the end of life. Further research is warranted to explore the impact of palliative care on patient outcomes, quality of life, and the potential benefits of aligning treatment decisions with patients' end-of-life preferences.

Oncology hospitalist impact on hospice utilization.

Unplanned hospitalizations among patients with advanced cancer are often sentinel events prompting goals of care discussions and hospice transitions. Late referrals to hospice, especially those at the end of life, are associated with decreased quality of life and higher total health care costs. Inpatient management of patients with solid tumor malignancies is increasingly shifting from oncologists to oncology hospitalists. However, little is known about the impact of oncology hospitalists on the timing of transition to hospice. To compare hospice discharge rate and time to hospice discharge on an inpatient oncology service led by internal medicine-trained hospitalists and a service led by oncologists. At Smilow Cancer Hospital, internal medicine-trained hospitalists were integrated into one of two inpatient medical oncology services allowing comparison between the new, hospitalist-led service (HS) and the traditional, oncologist-led service (TS). Discharges from July 26, 2021, through January 31, 2022, were identified from the electronic medical record. The odds ratio for discharge disposition by team was calculated by logistic regression using a multinomial distribution. Adjusted length of stay before discharge was assessed using multivariable linear regression. The HS discharged 47/400 (11.8%) patients to inpatient hospice, whereas the TS service discharged 18/313 (5.8%), yielding an adjusted odds ratio of 1.94 (95% CI, 1.07-3.51; p=.03). Adjusted average length of stay before inpatient hospice disposition was 6.83days (95% CI, 4.22-11.06) for the HS and 16.29days (95% CI, 7.73-34.29) for the TS (p=.003). Oncology hospitalists improve hospice utilization and time to inpatient hospice referral on an inpatient medical oncology service. Patients with advanced cancer are often admitted to the hospital near the end of life. These patients generally have a poor chance of long-term survival and may prefer comfort-focused care with hospice. In this study, oncology hospitalists discharged a higher proportion of patients to inpatient hospice with less time spent in the hospital before discharge.

Prognostic Risk Stratification and End-of-Life Care Outcomes in Patients With Metastatic Melanoma Treated With Immune Checkpoint Inhibitors.

The emergence of immune checkpoint inhibitors (ICIs) has improved survival outcomes in patients with metastatic melanoma, while potentially increasing the use of systemic therapy near the end of life (EOL). Yet, less is known on how to facilitate treatment decision making and identify patients who might benefit from early palliative care comanagement. We determined baseline clinical and laboratory factors that are associated with poor prognosis for patients with advanced melanoma treated with ICIs. We subsequently identified prognostic subgroups to evaluate association with EOL outcomes and determine if EOL care varied across prognostic strata. Our cohort included 398 patients with metastatic melanoma treated with ICIs. Factors associated with overall survival (OS) included: lactate dehydrogenase, neutrophil/lymphocyte ratio, performance status, prior therapies, liver metastases, and lung metastases. Patients were stratified by risk of death using risk scores developed from multivariable analyses. A total of 205 patients died: 45/133 (34%) low-risk, 63/133 (47%) medium-risk, and 97/132 (73%) of high-risk patients. Among those who died, higher risk patients were more likely to receive ICIs within 14, 30, and 90 days of death. We found no association between risk group and hospice referrals or location of death. Patients with metastatic melanoma at highest risk of death as defined by our model were more likely than lower-risk patients to receive ICIs near the EOL. Prognostic risk stratification may guide early palliative care interventions to appropriately utilize ICIs and optimize EOL care.

Evaluating the impact of the metastatic spinal cord compression coordinator in a regional cancer network: a prospective, non- randomized pilot study.

Extradural metastatic spinal cord compression (MSCC) is a debilitating and potentially irreversible complication of cancer. Delay in treatment could lead to irreversible neurological damage, adverse quality of life and a burden on health care resources. Lack of effective communication between teams has been identified as one of the reasons for delay in treatment. The MSCC coordinator (often a nurse, radiotherapy radiographer or a doctor) is responsible for coordinating the diagnosis and management of patients with MSCC. The role has been shown to streamline service, ensure timely decision-making and improved survival outcomes. However, available data are anecdotal or from limited series presented as abstracts in conferences. In this study, we assessed the impact (time to treatment) of the newly introduced role on the treatment pathway compared to similar period in the preceding year. This was a multi-centre, prospective, pilot study carried out in Kent, UK between 1st April to 30th June 2021. Patients were considered eligible if they had MRI-confirmed cauda equina or cord compression. The data prospectively collected include: (I) time from diagnostic imaging to radiotherapy treatment; (II) number of referrals to hospital palliative care (HPC), occupational/physiotherapy (OPH) and community hospice referrals (CHP). A comparative retrospective data for (I) was collected for the same time period in the preceding year. The study outcome assessed was reduction in time from radiological diagnosis of MSCC to receiving radiotherapy. Fifty-eight patients in 2020 and 24 patients in 2021 were included in the dataset. The MSCC coordinator role (introduced in 2021) led to reduction in the time from imaging to treatment (P=0.045). Compared to 2020, there was a shorter mean/median time to treatment, seeing more patients being treated within 24 hours. All hospitals except East Kent Hospitals saw more patients being treated within 24 hours. 7 referrals each made to HPC, OPH and CHP respectively. Introduction of MSCC coordinator role led to improved time from imaging to radiotherapy treatment. The new service led to engagement with rehabilitative and palliative services. Future work should be done to assess the long-term impact of this role on utilization of support services and patient recovery.

Palliative care and end of life care in decompensated cirrhosis.

Palliative care and end of life care in decompensated cirrhosis.

The impact on hospice quality after initiation of an internal palliative care program by a community oncology practice.

e18720 Background: Virginia Cancer Institute (VCI) participated in the Oncology Care Model (OCM) with an aim to improve cancer care quality. As part of OCM, VCI started a palliative care program (PC) in 2016 by partnering with a local palliative care provider. In September 2020, VCI overhauled PC moving away from outside provider (OPC) and created an internal program (IPC). Both programs managed care from VCI oncologist referrals to PC until patient’s hospice start or practice discharge. This study describes the methods or changes from OPC to IPC and the resulting difference in hospice quality measure performance. Methods: Under OPC, services were provided half-day per week in office from a PC nurse practitioner (NP). IPC changed to a PC NP employed by VCI who provided services 5 days per week with office, hospital and telemedicine options. IPC added multiple PC education, communication touchpoints with oncologists and practice staff. IPC provided reminders to VCI physician teams about the availability of in-house PC services and the benefits of early engagement. Along with the oncologists, IPC continued goals of care discussions with patients and family to ensure patients’ desires and needs were met. OPC hospice referrals from PC went to a single hospice group. IPC added a network of multiple hospice groups. Retrospective claims review of OCM performance periods (PP) 1-8 (Jul 2016 – Dec 2020) for OPC and OCM PP 9-10 (Jul 2020 – Dec 2021) for IPC was performed and excluded patients with incomplete hospice claims. Primary endpoint was difference between OPC and IPC in OCM-3 quality: proportion of OCM patients who died during their episode with 3 or more days hospice immediately prior to death. Secondary endpoint was the difference in proportions of OPC and IPC with any hospice length of stay. Z-test between 2 proportions was used to calculate significance. Results: There were 871 and 197 OCM-3 eligible patients reviewed from OPC and IPC respectively. OCM-3 quality performance was 48.1% OPC and 62.4% IPC, p &lt; 0.01. Any hospice performance was 65.8% OPC and 78.7% IPC, p &lt; 0.01. The OCM-3 goal throughout for maximum quality score was 60%. Performance improvement started in the first IPC period (PP9) and was greater in the second IPC period (PP10). Conclusions: Results showed a significant improvement in OCM performance measures between OPC and IPC over a short period of 10 months. After IPC, practice met the OCM-3 goal. The data is limited to latest available OCM reconciliation claims and may be refreshed when additional OCM data is released. Although specific cause and effect was not assessed, the authors attribute quality improvement to the implementation of an internal, full-time PC NP. This expanded PC access for patients and increased communication between patients and providers. We believe that, as a result, the quality of care delivery improved.

Trends in hospice referral timing and location among individuals dying of ovarian cancer: persistence of missed opportunities

ObjectiveTo evaluate trends, racial disparities, and opportunities to improve the timing and location of hospice referral for women dying of ovarian cancer.MethodsThis retrospective claims analysis included 4258 Medicare beneficiaries over...

Utilization of Palliative and Hospice Care Among Pancreatic Cancer Patients at an Academic Center

IntroductionPancreatic ductal adenocarcinoma has the lowest 5-y relative survival of all solid tumor malignancies. Palliative care can improve the quality of life of both patients and their caregivers. However, the utilization patterns of palliative care in patients with pancreatic cancer are unclear. MethodsPancreatic cancer patients who were diagnosed between October 2014 and December 2020 at the Ohio State University were identified. Palliative care and hospice utilization and referral patterns were assessed. ResultsOf the 1458 pancreatic cancer patients, 55% (n = 799) were male, median age at diagnosis was 65 y (interquartile range [IQR]: 58, 73), and most were Caucasian (n = 1302, 89%). Palliative care was utilized by 29% (n = 424) of the cohort, with the initial consultation obtained after an average of 6 ± 9 mo from diagnosis. Patients who received palliative care were younger (62 y, IQR: 55, 70 versus 67 y, IQR: 59, 73; P < 0.001) and more frequently members of racial and ethnic minorities (15% versus 9%; P < 0.001) versus those who did not receive palliative care. Among the 344 (24%) patients who received hospice care, 153 (44%) had no prior palliative care consultation. Patients referred to hospice care survived a median of 14 d (95% CI, 12-16) after hospice referral. ConclusionsOnly 3 out of 10 patients with pancreatic cancer received palliative care at an average of 6 mo from initial diagnosis. More than two out of every five patients referred to hospice had no previous palliative care consultation. Efforts to understand the impact of improved integration of palliative care into pancreatic cancer programs are needed.

Consider hospice in end-stage liver disease prognostic scale to open discussions regarding six-month mortality.

Hospice is underutilized in the management of patients with end-stage liver disease and may improve the patient experience at the end of life. This study aims to create a novel prognostic scale to accurately predict 6-month mortality to more comprehensively facilitate hospice referral. Sociodemographic, clinical, and laboratory variables associated with mortality from the United Network for Organ Sharing database were tested in univariate analysis followed by multivariate analyses with four predictor groups: Demographics, Diagnoses, Complexities, and Laboratory studies to develop the hospice in end-stage liver disease prognostic scale (HELP) scale (70% sample, N=13 516) followed with replication in a 30% (N=5792) internal validation sample. Only the predictor groups of Complexities and Laboratory studies met the c-statistic threshold of 0.70 for inclusion in the multivariate analyses. Backward elimination in the final logistic regression and validated weighted transformation procedure resulted in: HELP scale=(functional status × 11) + (ascites × 3) + (SBP × 3) + (HE × 4) + (dialysis × 5) + (TIPS × -3) + (albumin × -3) + (MELD-Na ≥ 21 × 20). HELP scale had a strong predictive value for six-month mortality with Area under the Receiver Operating Curve (AUROC) 0.816 and replicated in the validation sample. HELP scale is a novel prognostic score utilizing the strength of model of end-stage liver disease-sodium (MELD-Na), along with clinical factors, for a more nuanced assessment of six-month mortality. This scale can provide an individualized approach in opening discussions of hospice referral and may be better accepted by patients and providers given its contextualization of important clinical factors.

Hospital safety-net status and postdischarge outcomes: The impact of socioeconomic status and Medicare post-acute care types.

To examine the impact of socioeconomic status (SES) and postacute care (PAC) locations on the association between hospital safety-net status and 30-day postdischarge outcomes (readmission, hospice use,or death). Medicare Current Beneficiary Survey (MCBS) participants during 2006-2011 who were Medicare Fee-for-Service beneficiaries aged 65.5 years or older were included. The associations between hospital safety-net status and 30-day post-discharge outcomes were evaluated by comparing the models with and without PAC and SES adjustments. Safety-net hospital status was defined as being in the top 20% of hospitals ranked by hospital-level percent of total Medicare patient days. SES was measured using individual-level SES (dual eligibility, income,and education) and the Area Deprivation Index (ADI). This study identified 13,173 index hospitalizations for 6,825 patients; 1,428 hospitalizations (11.8%) were in safety-net hospitals. The averageunadjusted 30-day hospital readmission rate was 22.6% in safety-net hospitals versus 18.8% in nonsafety-net hospitals. Regardless of whether patient SES status was controlled or not, safety-net hospitals had higher estimated probabilities of 30-day readmission (ranging from 0.217 to 0.222 vs. 0.184 to 0.189), and lower probabilities for having neitherreadmission nor hospice/death (0.750-0.763 vs. 0.780-0.785); for models additionally adjusted for PAC types, safety-net patients had lower rates of hospice use or death (0.019-0.027 vs. 0.030-0.031). The results suggested that safety-net hospitals had lower hospice/death rates but higher readmission rates relative to outcomes at nonsafety-net hospitals. Readmission rate differences were similar regardless of patients' SES status. However, the rate of hospice referral or death rate was related to SES, which suggested that the outcomes were affected by SES and PAC types.

Hospice as “treatment” for BPSD: finding an ethical way forward

Patients with Behavioral and Psychological Symptoms of Dementia can be among the most challenging patients to treat. Even when their behaviors improve with treatment, just the history of their behaviors can make them difficult to place in a nursing home or memory care unit. Historically hospice has only been used as an option for patients who meet the Medicare criteria for hospice; however, prognostication of likelihood of death within 6 months is difficult to do, even in patients with advanced dementia. Other criteria such as the ADEPT criteria have been used, though prognostication is difficult even with these criteria. Quality of Life and suffering are not technically hospice criteria in the USA; furthermore, defining quality of life in advanced dementia is challenging and suffering in dementia patients has never really been operationalized, except in patients with overt signs of distress such as screaming.This session will present a case of a man with advanced dementia who did not meet the traditional criteria for hospice, as he was fully ambulatory, able to feed himself finger foods and even able to enjoy listening and dancing to his favorite music. He had only lost 2 pounds over the past year, even though his weight was 50lbs lower than it had been in his prime, when he lived in the community. He had no ongoing medical comorbidities that would shorten his life; he had pulled through 2 bouts of COVID without issue during his time on the unit. He had a significant history of aggression which, at the time of the hospice referral, mostly came out sporadically when resisting care or with redirection from wandering into the rooms of other patients. He had some other undesirable behaviors such as urinating on the floor. He had been previously kicked out of a couple of nursing homes because of aggressive behavior towards other residents. He had been cared for on a geripsychiatry unit for 10 months, as his history made him unplaceable in conventional nursing homes and the option of a state hospital placement was not available. The palliative care doctor and the director of a hospice with an academic affiliation decided to use his pacing as a sign of "suffering" and contended that the usual treatment for BPSD (which included antipsychotics and mood stabilizers) on the geripsychiatry unit was prolonging his life and hence his "suffering". The palliative care doctor referred to him as a "hothouse flower"; she presented hospice the best option to the family (who had barely visited him in the 10 months he was on the unit) and they enthusiastically espoused this course of treatment. He was referred to the main inpatient hospice where he received palliative sedation and expired within 2 weeks.This case will examine the process of this referral; attempt to clarify the underlying prejudices of some of the parties involved towards patients with dementia that may have driven some of the decision-making; clarify some of the ethical issues in the decision-making to use hospice for this problematic patient. The experience in the Netherlands where some geriatricians have published their experience with palliative sedation in BPSD and have even developed a workgroup with guidelines will be reviewed as well.

Supportive Care for Dementia: A Replicable Model to Reduce Neurobehavioral Symptoms, Caregiver Stress, and Hospitalizations, and Increase Hospice Referrals.

Objective: This report describes a hospice-supported no-fee program to support patients living with all levels of dementia and their caregivers. Background: Our medical system struggles to serve the rapidly increasing numbers of patients with dementia. Hospice of the Valley developed a low-cost six-month program to reduce caregiver stress and reduce neurobehavioral disturbances of patients living with dementia, reduce costs for insurers, and increase hospice referrals. Methods: Data were analyzed from 532 patients living with caregivers admitted over 22 months. Caregiver burden, behaviors, hospitalization, and hospice admissions were tracked. Results: Severity of neurobehavioral disturbances and burden to caregivers decreased significantly. Hospitalizations decreased during and after the program, resulting in cost savings for insurance programs. Twenty-five percent of participants were admitted to hospice. Discussion: The Supportive Care for Dementia program was welcomed by community physicians, leading to improved supportive care and increased hospice referrals. The program is replicable and has been adopted by one health plan and is being evaluated by others.

A QUALITY INITIATIVE TO INCREASE HOSPICE REFERRALS FOR STARS PATIENTS DURING THE SECOND COVID SURGE

Abstract Background CMS uses the Overall Hospital Quality Star Rating program to stratify hospitals based on specific quality criteria (e.g., 30-day readmissions of older adults with pneumonia). “STARS patients” experience more readmissions, longer LOS and often have more complex discharge plans. During the second surge of COVID we implemented a program to increase hospice referrals through early identification and implementation of goals of care (GOC) conversations. Methods Electronic Medical Records reviewed for STARS patients from pre- (1/2019-7/2020) and post (3/2021–2/2022) program implementation. Location: 2 community-based hospitals. Data collected: demographics, hospital outcomes, discharge disposition. Data compared with Student’s t tests and Chi square. Results 459 patients, 177 pre-program and 282 post-program were included. Groups were similar in age (83.0 vs 83.6), LACE score (13.0 vs 12.8), principal diagnoses (PNA: 41.5% vs 46.0%, HF/COPD/AMI: 58.5% vs 54.0%), and mortality (3.5 vs. 4.0%). LOS increased 4.9 days vs. 6.1 days (p &amp;lt; 0.01), readmission rates unchanged: 12.6% vs 13.0% (p=0.90). GOC conversations increased, 48.6% to 75.0% (p &amp;lt; 0.01), DNR from 24% to 44% (p &amp;lt; 0.01), and comfort measures from 0.5% to 5% (p &amp;lt; 0.01). Hospice referrals increased from 0.5% to 11.2% (p &amp;lt; 0.01). Discussion: Early identification of STARS patients increased GOC conversations, DNR, comfort measures and hospice referral. Patients across time periods were similar in age, LACE and admitting diagnoses. LOS increased by a day, likely reflecting time needed to arrange discharge disposition. Increased hospice at end-of-life is associated with better quality care and patient/family satisfaction. This program may be adapted to larger, academic medical centers within the health system.

HOW DOES THE INTERSECTION OF RACE AND GENDER AFFECT HOSPICE CARE AT THE END OF LIFE?

Abstract Research in the palliative and end-of-life-care field has shown that hospice care in the final months of life can improve outcomes such as pain, emotional well-being, and physical comfort. Yet, researchers often find significant disparities in the ability to access hospice care, with Black individuals being less likely to have hospice care at the end of life. The theory of intersectionality suggests that the combination of multiple vulnerable identities may add to the number of hardships and stressors that an individual experiences across the lifespan. To test the theory, this study aimed to access whether gender moderated the relationship between race and the receipt of hospice care at the end of life. Data were derived from Round 3 to Round 10 of the National Health and Aging Trends Study, and two multivariate regression models were used to assess the relationship between the race/gender interaction and hospice care at the end of life (Model 1: main effects, Model 2: interaction term). Results showed that the effect of race on hospice care was indeed dependent on gender, with Black women being the least likely to have hospice care at the end of life. This points to the combined disadvantages resulting from membership in two vulnerable groups (i.e., being a woman and being Black), including fewer hospice facilities in Black-populated areas, race and gender discrimination in hospice referrals, and other factors that combine to reduce hospice access for Black women. Implications for research, practice, and policy are provided.

HOSPICE UTILIZATION AND PLACE OF DEATH BY DEMENTIA DIAGNOSIS AND RACE/ETHNICITY

Abstract Timing of hospice referral is critical to patient’s and family’s quality of life and satisfaction with hospice care. This study examined racial/ethnic variation in hospice use and factors associated with death at home among Medicare beneficiaries aged 50 years and older who died in 2018 (n=1,998,282). Hospice use was most frequent among non-Hispanic white beneficiaries (55.8%) followed by Hispanic (46.2%), Asian American (44.5%), Black (42.7%), and American Indian (42.1%) beneficiaries. Among decedents diagnosed with dementia, initiation of hospice prior to the last day of life was significantly associated with death at home among all racial/ethnic groups: non-Hispanic white (OR=2.62), Black (OR=2.04), Hispanic (OR=2.17), Asian American (OR=2.54), and American Indian (OR=2.76). Among decedents not diagnosed with dementia, initiation of hospice prior to the last day of life was less strongly associated with death at home: white (OR=1.33), Black (OR=0.83), Hispanic (OR=1.32), Asian American (OR=1.69), and American Indian (OR=1.56).

Palliative care for patients with glioma: A recent scientometric analysis of the Web of Science in 2022.

Patients with glioma present with complex palliative care needs throughout their disease trajectory. A scientometric analysis is effective and widely used to summarize the most influential studies within a certain field. We present the first scientometric analysis of palliative care for patients with glioma. Based on a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) principle, we conducted a generalized search for articles on palliative care for glioma in the Web of Science database and evaluated the top 100 most frequently cited articles among 2,542 articles. The number of citations for the top 100 cited articles on palliative care for glioma ranged from 10 to 223. We have a narrative conclusion, as follows: most of these articles were published in oncology-specific journals (n = 53) and palliative-specific journals (n = 22). The United States, Australia, and the Netherlands were the top three countries contributing most of the articles (n = 59). Most of the research methods were quantitative analyses, qualitative analyses, and systematic reviews and meta-analyses (n = 70). In quantitative studies, 66 scales were used, and the top three scales used included the following: the Distress Thermometer, Functional Assessment of Cancer Therapy-Brain Index (FACT-Br), and Karnofsky Performance Scale (KPS). The articles were classified into six major categories based on research subjects, including patients (n = 44), caregivers (n = 16), patients and caregivers (n = 20), literature (n = 19), and healthcare providers (n = 1). Articles were classified into seven major categories based on research themes: quality of life (n = 11); end-of-life symptoms and care (n = 16); palliative and supportive care needs (n = 35); advance care planning and decision making (n = 4); psychological, social, and spiritual needs (n = 12); hospice utilization and referral (n = 3); and others (n = 19). The studies of the primary topic are correlated with the number of citations. The results of the analysis indicated that patients diagnosed with glioma present a high variety of palliative care needs, including physical, psychological, social, and spiritual needs. The caregiver's burden and needs are important as well. The proportion of quantitative analyses, qualitative analyses, and systematic reviews and meta-analyses is relatively high, but the number of randomized controlled trials (RCTs) was low. End-of-life care and supportive care needs appeared frequently. Thus, palliative care is an urgent need to be addressed in glioma management. The appropriate scales should be selected for patients with glioma and meet their palliative needs.

Implementing a Standardized Workflow Process to Increase the Palliative Care to Hospice Admission Rate.

Palliative care is a precursor for hospice care, an underutilized Medicare benefit that has been shown to improve quality of life, decrease health care costs, and provide expert symptom relief at the end of life. Palliative patients transitioning to hospice services were experiencing delays within the admission process. To determine whether standardizing the workflow process with chart completion leads to increases in the hospice admission rate for palliative care patients transitioning to hospice care. This quality improvement project adapted Kurt Lewin's change theory and the Plan-Do-Study-Act (PDSA) cycle for implementation. Preintervention patient data were collected from May 2021 through August 2021, and postintervention data were collected from September 2021 through December 2021. Standardization of the workflow process included assigning an urgency level to the hospice referral and deactivation (close) of the electronic medical record (EMR) chart, signaling completion of the workflow process. The palliative care to hospice admission rate increased by 11.5% in the postintervention group. The EMR chart deactivation rate increased by 55.3%, which was statistically significant ( P ≤ .001). The standardized workflow process increased the number of palliative care to hospice admissions and improved the effectiveness of transitioning palliative care patients to hospice services.