Hospice Use Research Articles

Hospice Use and Pain Management in Elderly Nursing Home Residents With Cancer

ContextPain management is suboptimal in nursing homes. ObjectivesTo estimate the extent to which receipt of hospice in nursing homes (NHs) increases the receipt of pain management for residents with cancer at the end of life. MethodsStudy participants included Medicare beneficiaries with cancer who were NH residents in the last 90 days of life in 2011–2012 (n = 78,160). Residents in pain on hospice were matched to like residents without hospice by facility, type of pain assessment (self-report/staff assessment), and weeks until death (9064 matched strata, 16,968 unique residents). Minimum Data Set 3.0 provided information on residents' pain prevalence and receipt of pain management (scheduled analgesics, as needed [pro re nata {PRN}] medication, nonpharmacologic interventions). We developed conditional logistic models to estimate the association between hospice use and pain management, stratified by self-reported and staff-assessed pain. ResultsWe found that pain prevalence was higher in residents using hospice versus those without hospice (e.g., residents who self-reported pain: hospice: 59.9%, 95% CIs = 59.3%–60.5%; nonhospice: 50.0%, 95% CI = 49.4%–50.6%). In matched analyses, untreated pain was uncommon (self-reported pain: 2.9% and 5.6% in hospice users and nonusers, respectively). Hospice use was associated with receipt of scheduled analgesics (self-reported: adjusted odds ratio = 1.85, 95% CI = 1.73–1.971) and PRN medication (self-reported: adjusted odds ratio = 1.31, 95% CI = 1.20–1.43). Pain prevalence and the association between hospice and pain management were similar in residents with staff-assessed pain. ConclusionUntreated pain at the end of life among residents with cancer in NHs is unusual. Hospice is associated with increased pain management among those with documented pain.

Hospice Utilization and Its Effect on Acute Care Needs at the End of Life in Medicare Beneficiaries With Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is a poor-prognosis cancer with a high symptom burden. Multidisciplinary HCC care is complex and unique in cancer medicine. We sought to determine whether the distinct process affects hospice use and how hospice affects end-of-life acute care utilization. Patients dying after HCC diagnosed from 2004 to 2011 were identified within SEER-Medicare. Hospice use and associated factors were described using logistic regression. Coarse exact and propensity score matching created groups of hospice and nonhospice comparators balanced on clinical characteristics. Health care use from first hospice claim to death and the matched duration in the nonhospice group were compared. Of 7,992 decedent patients with HCC, 63% used hospice before death, with a median duration of 18 days (interquartile range, 5-51 days). Initial treatment with surgery and ablation (odds ratio [OR], 0.63; 95% CI, 0.53 to 0.74) or chemoembolization/radioembolization (OR, 0.71; 95% CI, 0.62 to 0.80) was associated with decreased odds of subsequent hospice use compared with untreated patients. Hospice use was more likely in those consulting hematology/oncology (OR, 1.33; 95% CI, 1.13 to 1.56) but not in those consulting gastroenterology (OR, 0.79; 95% CI, 0.65 to 0.95). Hospice patients had lower rates of hospitalization (7.9% v 47.8%; risk ratio [RR], 0.16; 95% CI, 0.14 to 0.19), intensive care unit stay (2.8% v 25.3%; RR, 0.11; 95% CI, 0.09 to 0.14), and in-hospital death (3.5% v 58.4%; RR, 0.06; 95% CI, 0.05 to 0.07). Processes of care influence which patients with HCC are referred to hospice. Hospice use has a marked effect on acute care use at the end of life in patients with HCC. Efforts to incorporate cancer-focused palliative care might improve the quality of end-of-life care in HCC.

Family Perspectives on Hospice Care Experiences of Patients with Cancer.

Purpose To determine whether hospice use by patients with cancer is associated with their families' perceptions of patients' symptoms, goal attainment, and quality of end-of-life (EOL) care. Methods We interviewed 2,307 families of deceased patients with advanced lung or colorectal cancer who were enrolled in the Cancer Care Outcomes Research and Surveillance study (a multiregional, prospective, observational study) and died by 2011. We used propensity-score matching to compare family-reported outcomes for patients who did and did not receive hospice care, including the presence and relief of common symptoms (ie, pain, dyspnea), concordance with patients' wishes for EOL care and place of death, and quality of EOL care. We also examined associations between hospice length of stay and these outcomes among hospice enrollees. Results In a propensity-score-matched sample of 1,970 individuals, families of patients enrolled in hospice reported more pain in their patient compared with those not enrolled in hospice. However, families of patients enrolled in hospice more often reported that patients received "just the right amount" of pain medicine (80% v 73%; adjusted difference, 7 percentage points; 95% confidence interval [CI], 1 to 12 percentage points) and help with dyspnea (78% v 70%; adjusted difference, 8 percentage points; 95% CI, 2 to 13 percentage points). Families of patients enrolled in hospice also more often reported that patients' EOL wishes were followed (80% v 74%; adjusted difference, 6 percentage points; 95% CI, 2 to 11 percentage points) and "excellent" quality EOL care (57% v 42%; adjusted difference, 15 percentage points; 95% CI, 11 to 20). Families of patients who received > 30 days of hospice care reported the highest quality EOL outcomes. Conclusion Hospice care is associated with better symptom relief, patient-goal attainment, and quality of EOL care. Encouraging earlier and increased hospice enrollment may improve EOL experiences for patients with cancer and their families.

The Incidence and Cost of Hospice Use Among Elderly Patients with Diffuse Large B-Cell Lymphoma: A SEER-Medicare Analysis

Introduction:Data are limited on the use of hospice services for diffuse large B cell Lymphoma (DLBCL). As DLBCL is treated in both academic and community settings, there may be variations in hospice enrollment due to both patient and practitioner characteristics. We aimed to identify predictors for hospice enrollment for DLBCL patients, and to compare total costs of care and components of cost among hospice and non-hospice DLBCL patients in the 30 days prior to death.Methods:Using the SEER-Medicare database from 2002-2012, we identified DLBCL patients 65 years and older using ICD-O3 codes. Patients were excluded if they did not die, died within 30 days of diagnosis, or had a secondary cancer diagnosis. We investigated predictors of hospice enrollment within the last 30 days of life including sex, race, age, marital status, residence, modified Charlson Comorbidity Index (CCI), income, time from diagnosis to death, practice type, region, and chemotherapy use. Using generalized estimating equation using a log link and gamma distribution, we evaluated adjusted and unadjusted costs for the last 30 days of care, aggregated into 5-day periods among hospice and non-hospice users, separating costs into inpatient, outpatient, hospice, office visits, and diagnostic testing. We tested the robustness of our finding using a time-varying propensity score weighted model.Results:We identified 12,644 DLBCL patients. Hospice users were older than non-users (mean age: 80 vs. 78 years, p<0.001), more often white (92.9 vs 91%, p=0.02), less likely to be married (45.1 vs 53.7, p<0.001) and were more likely to be female (61.2% vs. 52.1%, p<0.001). Patients diagnosed at stage 1 were less likely to enroll in hospice than those with more advanced stage (26.7 vs. 30.9, p=0.004). There were no significant differences in enrollment by urbanicity, neighborhood poverty level, and CCI. Non-hospice patients were more likely than hospice users to have received transfusions (p<0.001) and chemotherapy (p<0.001) in the last 30 days of life. There was no difference in proportion being treated in academic vs community settings for hospice and non-hospice users.In the last 30 days prior to death, we found that costs continually increased for non-hospice users from $2,063 for days 26-30 prior to death to $3,068 for the last five days of life (p<0.001). However, hospice users’ costs decreased over this time period from $1,752 to $1,326 (p=0.002) (Figure). Our results were consistent after adjusting for age, CCI, Ann Arbor stage, race, marital status, urbanicity, and census tract poverty level ($2,041 days 26-30 vs. $3,109 days 0-5 for non-hospice users, p<0.001; $1,800 days 26-30 vs. $1,348 days 0-5 for non-hospice users, p=0.001). For non-hospice patients, inpatient admissions drove costs ($2,289) and for hospice patients, hospice costs drove costs ($443). Non-hospice users had higher costs in all categories of care (Table). Our propensity score weighted models provided similar results.Conclusion:Using data from SEER-Medicare, we found differences in patient characteristics associated with hospice use among older adults with DLBCL, specifically age, race, marital status, and sex. Those who received transfusions or chemotherapy in the last 30 days of life were less likely to enroll in hospice. Community vs. academic settings was not associated with hospice enrollment. We also identified differences in healthcare utilization in the last 30 days of life among hospice and non-hospice patients. Total health care costs were significantly higher over the last 30 days of life in non-hospice patients, and the primary cost driver is inpatient admissions. Further analyses will help to identify those patients who did not receive hospice services, but received palliative care. Earlier hospice intervention may reduce costs of care for older patients with DLBCL in the last 30 days of life. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Barriers to Quality End-of-Life Care for Latinos

Hospice is an option that serves the care needs of terminally ill patients. However, promoting awareness of pursuing end-of-life (EOL) care among Hispanics is challenging. Hispanics are the fastest growing ethnic minority group in the United States but the most unlikely to use hospice services for EOL. This project was intended to identify health care providers' (HCPs') self-perceived barriers/solutions to improve use of hospice among Latino patients in both Hispanic-predominant and white-predominant communities. Focus groups were conducted at 2 hospice agencies to compare views on Hispanic EOL care. Two HCP groups from VITAS hospice in Texas (n = 9, 12) and 1 in Missouri (n = 24) participated. Qualitative analysis was performed. Across groups, all HCPs had similar distributions of professions (predominantly nursing). Despite the differences in ethnicity and few Hispanic patients in Missouri, common EOL barriers were identified, including language, religion, and family culture. Potential solutions identified included education in Spanish to families, the use of community religious leaders, and use of media (“telenovelas = soap operas”) to bring the concept of Hospice to Hispanic homes. From the perspective of HCPs, this study identifies barriers and solutions with potential health care implications to improve hospice care among growing Hispanic communities in a culturally appropriate manner.

Predictors of Transition to Hospice Care Among Hospitalized Older Adults With a Diagnosis of Dementia in Texas: A Population-Based Study.

BackgroundDecedent older adults with dementia are increasingly less likely to die in a hospital, though escalation of care to a hospital setting, often including critical care, remains common. Although hospice is increasingly reported as the site of death in these patients, the factors associated with transition to hospice care during end-of-life (EOL) hospitalizations of older adults with dementia and the extent of preceding escalation of care to an intensive care unit (ICU) setting among those discharged to hospice have not been examined.MethodsWe identified hospitalizations aged ≥ 65 years with a diagnosis of dementia in Texas between 2001 and 2010. Potential factors associated with discharge to hospice were evaluated using multivariate logistic regression modeling, and occurrence of hospice discharge preceded by ICU admission was examined.ResultsThere were 889,008 elderly hospitalizations with a diagnosis of dementia during study period, with 40,669 (4.6%) discharged to hospice. Discharges to hospice increased from 908 (1.5%) to 7,398 (6.3%) between 2001 and 2010 and involved prior admission to ICU in 45.2% by 2010. Non-dementia comorbidities were generally associated with increased odds of hospice discharge, as were development of organ failure, the number of failing organs, or use of mechanical ventilation. However, discharge to hospice was less likely among non-white minorities (lowest among blacks: adjusted odds ratio (aOR): 0.67; 95% confidence interval (CI): 0.65 - 0.70) and those with non-commercial primary insurance or the uninsured (lowest among those with Medicaid: aOR (95% CI): 0.41 (0.37 - 0.46)).ConclusionsThis study identified potentially modifiable factors associated with disparities in transition to hospice care during EOL hospitalizations of older adults with dementia, which persisted across comorbidity and severity of illness measures. The prevalent discharge to hospice involving prior critical care suggests that key discussions about goals-of-care likely took place following further escalation of care to ICU. Together these findings can inform system- and clinician-level interventions to facilitate timely and consistent use of hospice to meet patients’ goals of care.

The estimated hospital-wide financial impact of a comprehensive inpatient palliative care (PC) program.

173 Background: Inpatient PC improves quality of care, patient and family satisfaction, and lowers costs. PC consultation during a cancer hospital stay led to a 14 (if by day 6) to 24% (by day 2) reduction in direct cost, and especially when people had comorbidities. (May, JCO 2015; Health Affairs 2016). We attempted to discern the financial impact of both a PC inpatient unit (PCU) and PC consultations on patients in other inpatient units for a large academic medical center, the Johns Hopkins Hospital (JHH), as we prepared to expand the PCU from 6 to11 beds and increased inpatient PC consultation capacity. Methods: We estimated the savings for an 11 bed PCU based on cost per day from FY 2015 with a 6 bed unit ($444 lower costs per PCU day compared to inpatient stay prior to transfer to the PCU). We then calculated the cost savings for an 11 bed unit operating at 80% occupancy. We estimated the direct cost savings of consultations by adjusting the $/discharge saved (Morrison, Arch Int Med 2008) to 2014 $ (by multiplying the $/discharge saved by 1.4 to adjust for medical inflation). Results: The PCU inpatient stays resulted in projected lower costs of $6.7M over 5 years ($444/day x 3009 days/year, or $~1.3M yearly). IP revenue and margins were small (data not shown). For PC consults of 785 alive discharges ($2197/case) and 97 decedent discharges ($6357/case), total estimated savings in direct costs per case are $2,530,000/year. The PCU allows for additional benefits not calculated in this analysis, including inpatient backfill opportunities, more appropriate ICU bed use, savings from increased referral to hospice (hospice referrals increased 340% in 3 years), and reduced readmission rates from increased PC and hospice use. Conclusions: In addition to improving quality of care and patient satisfaction, the combined IP and consult PC programs contribute to substantially lower charges and costs per day. Backfill revenue, the opportunity for increased revenue from improved patient satisfaction (HCAHPS) scores, and reduced readmission rates will increase this financial impact. [Table: see text]

The Effect of Pediatric Palliative Care Policy on Hospice Utilization Among California Medicaid Beneficiaries

ContextCalifornia implemented pediatric palliative care legislations that allowed children to receive curative and supportive care from diagnosis of a life-threatening serious illness in 2010. Palliative care policies may improve access to hospice care as children near end of life. ObjectivesThe aim of this study was to examine the effect of the palliative care policy on hospice utilization for children and their families was investigated. MethodsUsing 2007 and 2010 California Medicaid data, a difference-in-difference analysis was conducted to analyze hospice use (i.e., hospice enrollment, hospice length of stay) changes for children who resided in pediatric policy counties relative to those who did not. The sample of children in California who died with a life-threatening serious illness in 2007 and 2010 equaled 979 children. ResultsMore than 10% of children enrolled in hospice care with an average of less than 3 days of hospice care. The palliative care policy did not have any effect on hospice enrollment. However, the policy was positively associated with increasing days in hospice care (incidence rate ratio = 5.61, P < 0.05). The rate of hospice length of stay increased by a factor of 5.61 for children in palliative care counties compared with children unaffected by the policy. ConclusionThe pediatric palliative care policy was associated with longer lengths of stay in hospice once the children were enrolled. Policies promoting palliative care are critical to ensuring access to hospice care for children.

Place of Death of Individuals with Terminal Cancer: New Insights from Medicare Hospice Place-of-Service Codes.

To use place-of-service (POS) codes in the Medicare hospice claims files to document where elderly hospice users with cancer die. Retrospective cohort study. Surveillance, Epidemiology, and End Results (SEER) cancer registry areas. Elderly Medicare beneficiaries who died of lung, breast, colorectal, or pancreatic cancer in 2007 and 2008 (N = 46,037). Use of hospice, place of service at death (home, nursing home, hospital, inpatient hospice, other), length of stay in hospice. Two-thirds of the beneficiaries used hospice. Younger, male, black, Asian, and unmarried beneficiaries and those enrolled in fee-for-service Medicare or from areas with lower income were less likely to use hospice. Hospice enrollment also varied significantly according to SEER registry. Thirty percent of the hospice users were not receiving home-based care at the time of death, and 17% were enrolled for less than 3 days. Factors associated with hospice death in the home mirrored those associated with hospice use. Individuals dying in hospitals (odds ratio (OR) = 5.13, 95% confidence interval (CI) = 4.63-5.69), inpatient hospice (OR = 1.86, 95% CI = 1.70-2.02), and nursing homes (OR = 1.19, 95% CI = 1.10-1.28) had greater odds of a short hospice stay (≤7 days) than those dying at home, after controlling for all other measured factors, whereas those dying in nursing homes had greater odds of long stays (>180 days) (OR = 1.46, 95% CI = 1.28-1.67). New hospice POS codes are useful for understanding place of death for hospice users. Hospice deaths cannot be assumed to happen at home.

Trends in hospice discharge, documented inpatient palliative care services and inpatient mortality in ovarian carcinoma

ObjectiveTo investigate the trends in discharge to hospice, documented inpatient palliative care services, and inpatient mortality in metastatic ovarian cancer (mOvCa) patients. MethodsPatients≥18years with mOvCa and a non-elective admission between January 1, 2006 and December 31, 2011 were identified from the National Inpatient Sample (NIS). The primary outcome of interest was the temporal trend in the annual proportion of hospitalizations for mOvCa where discharge destination was hospice. Secondary outcomes included temporal trend of inpatient mortality and documented palliative care services. Multivariable logistic regression models were used to ascertain independent factors predictive of hospice discharge and documented palliative services across the clusters of hospitals. ResultsA total of 106,203 non-elective hospitalizations were identified. The rate of hospice discharge increased from 9.2% in 2004 to 11.1% in 2011 (ptrend<0.001). Similarly, the rate of documented palliative care services increased from 2.7% in 2004 to 10.4% in 2011 (ptrend<0.001). The inpatient mortality decreased from 9.6% in 2004 to 7.4% in 2011 (ptrend<0.001). In a subset of hospitalizations with extreme risk of dying, 22% were discharged to hospice and 11% received documented palliative care services. One fifth of the patients who died in the hospital received documented palliative care services. ConclusionsThe use of hospice as a discharge destination and documented palliative care services is relatively low but appears to be increasing over time for mOvCa patients. Monitoring this data is vital to plan educational programs regarding palliative care approaches in this at-risk population.

Exploring the association of hospice care on patient experience and outcomes of care

ObjectiveTo examine the association of the use of hospice care on patient experience and outcomes of care. Promoting high-value, safe and effective care is an international healthcare imperative. However, the...

End-of-Life Care in Nursing Homes: From Care Processes to Quality.

Nursing homes (NHs) are an important setting for the provision of palliative and end-of-life (EOL) care. Excessive reliance on hospitalizations at EOL and infrequent enrollment in hospice are key quality concerns in this setting. We examined the association between communication-among NH providers and between providers and residents/family members-and two EOL quality measures (QMs): in-hospital deaths and hospice use. We developed two measures of communication by using a survey tool implemented in a random sample of U.S. NHs in 2011-12. Using secondary data (Minimum Data Set, Medicare, and hospice claims), we developed two risk-adjusted quality metrics for in-hospital death and hospice use. In the 1201 NHs, which completed the survey, we identified 54,526 residents, age 65+, who died in 2011. Psychometric assessment of the two communication measures included principal factor and internal consistency reliability analyses. Random-effect logistic and weighted least-square regression models were estimated to develop facility-level risk-adjusted QMs, and to assess the effect of communication measures on the quality metrics. Better communication with residents/family members was statistically significantly (p = 0.015) associated with fewer in-hospital deaths. However, better communication among providers was significantly (p = 0.006) associated with lower use of hospice. Investing in NHs to improve communication between providers and residents/family may lead to fewer in-hospital deaths. Improved communication between providers appears to reduce, rather than increase, NH-to-hospice referrals. The actual impact of improved provider communication on residents' EOL care quality needs to be better understood.

Care in the Final Month of Life among Adolescent and Young Adult Cancer Patients in Kaiser Permanente Southern California.

Little is known about the care that adolescent and young adult (AYA) patients with cancer receive at the end of life (EOL). To examine care in the last month of life among AYA patients with cancer. Medical record review of the last 30 days of life. One hundred eleven AYA patients aged 15-39 years at death with either stage I-III cancer and evidence of cancer recurrence or stage IV cancer at diagnosis. Patients received care in Kaiser Permanente Southern California, an integrated healthcare delivery system, and died from 2007 to 2010. Use of intensive measures, including chemotherapy in the last 14 days of life and emergency room visits, hospitalizations, and intensive care unit admissions in the last 30 days; documented care preferences; symptom prevalence and treatment; advance care planning; hospice use; and location of death. One hundred seven patients (96%) had documented care preferences in the last month of life. At first documentation, 72% of patients wished for life-prolonging care, 20% wished for care focused on comfort, and 8% were undecided. Forty-seven percent of patients had documented changes in preferences in the last month, with 40% wishing for life-prolonging care when preferences were last noted before death, 56% preferring comfort, and 4% undecided. Seventy-eight percent of patients received at least one form of intensive EOL care, including 75% of those who preferred comfort measures at last documentation. Many AYA patients enter the last month of life wishing for life-prolonging care. While most ultimately wish for comfort, intensive care is prevalent even among such patients.

Associations Between End-of-Life Cancer Care Patterns and Medicare Expenditures.

The purpose of this study was to examine the extent to which patterns of intensive end-of-life care explain geographic variation in end-of-life care expenditures among cancer decedents. Using the SEER-Medicare database, we identified 90,465 decedents who were diagnosed with cancer in 2004-2011. Measures of intensive end-of-life care included chemotherapy received within 14 days of death; more than 1 emergency department visit, more than 1 hospitalization, or 1 or more intensive care unit (ICU) admissions within 30 days of death; in-hospital death; and hospice enrollment less than 3 days before death. Using hierarchical generalized linear models, we estimated risk-adjusted expenditures in the last month of life for each hospital referral region and identified key contributors to variation in expenditures. The mean expenditure per cancer decedent in the last month of life was $10,800, ranging from $8,300 to $15,400 in the lowest and highest expenditure quintile areas, respectively. There was considerable variation in the percentage of decedents receiving intensive end-of-life care intervention, with 41.7% of decedents receiving intensive care in the lowest quintile of expenditures versus 57.9% in the highest quintile. Regional patterns of late chemotherapy or late hospice use explained only approximately 1% of the expenditure difference between the highest and lowest quintile areas. In contrast, the proportion of decedents who had ICU admissions within 30 days of death was a major driver of variation, explaining 37.6% of the expenditure difference. Promoting appropriate end-of-life care has the potential to reduce geographic variation in end-of-life care expenditures.

Pediatric Palliative Care Program versus Usual Care and Healthcare Resource Utilization in British Columbia: A Matched-Pairs Cohort Study.

Evidence on the impact of pediatric palliative care programs (PPCP) on resource utilization is scarce and requires broader measures to include utilization beyond the hospital setting. This research aims to provide a Canadian comparative analysis between children in a PPCP with those under usual care, including hospice use to inpatient resource use measurement. We conducted a retrospective matched-pairs (disease and age at death) cohort comparison of children who died in hospice versus hospital (never enrolled in a PPCP), from 2008 to 2012. Utilization was retrieved from administrative databases and chart review. The main outcomes were number of admissions and length of stay (LOS). Eleven pairs were found. PPCP users were more likely to have advanced directives (100% vs. 27%). After controlling for disease and age, we found no significant difference in number of admissions; however, PPCP users had an increase in admissions post-referral compared to pre-referral (median 3.08 admissions), driven by the need for critical care. We did not find a significant difference in LOS, but observed longer admissions among PPCP users pre- (1.91 days/month) and post-referral (3.66 days/month) compared to usual care. Over 60% of inpatient utilization shifted to the hospice post-referral. The terminal pediatric population referred to PPCP may systematically differ from those under usual care even before enrollment, presenting with higher inpatient utilization in critical care nearing death. A significant portion of inpatient utilization shifted to the hospice, with implications for resource reallocation and enhancements in PPCP referrals.

Interventions for Reducing Hospital Readmission Rates: The Role of Hospice and Palliative Care.

Despite evidence that enrollment with hospice services has the potential to reduce hospital readmission rates, previous research has not examined exactly how hospitals may promote the appropriate use of hospice and palliative care for their discharged patients. Therefore, we sought to explore the strategies used by hospitals to increase the use of hospice and palliative care for patients at risk of readmission. We conducted a secondary analysis of qualitative data from a study of hospitals that were participating in the State Action on Avoidable Readmissions (STAAR) initiative, a quality improvement collaborative. We used data attained from 46 in-depth interviews conducted during 10 hospital site visits using a standard discussion guide and protocol. We used a grounded theory approach using the constant comparative method to generate recurrent and unifying themes. We found that a positive effect for hospitals participating in the STAAR initiative was enhanced engagement in efforts to promote greater use of hospice and palliative care as a possible method of reducing unplanned readmissions, the central goal of the STAAR initiative. Hospital staff described strategies to increase the use of hospice and palliative care that included (1) designing and implementing tracking systems to identify patients most at risk of being readmitted, (2) providing education about hospice and palliative care to family, internal and external clinical groups, and (3) establishing closer links to posthospital settings. National efforts to reduce rehospitalizations may result in improved integration of hospice and palliative care for patients who are at risk of readmission.

Are Trends in Hospitalization Prior to Hospice Use Associated With Hospice Episode Characteristics?

This study expands current knowledge of factors associated with initiation of hospice care by examining prehospice patterns of medical care leading to Medicare hospice use and the relationships to hospice episode characteristics. Data from the Atherosclerosis Risk in Communities (ARIC) study cohort offer the ability to control for measures that are not available in Medicare claims data, including marital status, nursing home residency, and education. For 1248 ARIC participants who used hospice (2006-2012), participant level trends in the number of hospital days per 30-day period over the year prior to hospice initiation were generated using a fixed-effects model. Logistic regression was used to estimate the associations between increasing hospital use over the year prior to hospice enrollment with key patient characteristics (diagnosis, age, and comorbidity) and episode characteristics (short hospice stay ending in death, long hospice stay, and live discharge). Participants with severe comorbidity (measured as a Charlson comorbidity index score greater than 5) had higher odds of increasing hospital use prior to hospice (odds ratio [OR] = 3.28, confidence interval [CI] = 2.25-4.78). Increasing hospital use did not vary by diagnosis but was associated with reduced odds of a live hospice discharge (OR = 0.55, CI = 0.34-0.88) or long stay in hospice (OR = 0.44, CI = 0.24-0.79) and increased odds of a short stay in hospice (OR = 1.92, CI = 1.36-2.71). The evidence that care patterns prior to hospice use are associated with hospice outcomes could facilitate development of interventions to improve timely hospice referral.

Pediatric Primary Care Involvement in End-of-Life Care for Children.

To examine the relationship between pediatric primary care involvement and hospice and home health care use at end of life. California Medicaid data were used to estimate the relationship between pediatric primary care involvement and use of hospice and home health care using generalized estimating equations. Of the 2037 children who died between 2007 and 2010, 11% used hospice and 23% used home health. Among all children, primary care was not related to hospice use and was associated with home health use, usual source of care (OR = 1.83, P < .05), comprehensive care (OR = 1.60, P < .05), and continuous care (low: OR = 1.49, P < .05; moderate: OR = 2.57, P < .05; high: OR = 2.12, P < .05). Primary care for children aged 15 to 20 years was related to hospice use, usual source of care (OR = 4.06, P < .05) and continuous care (low: OR = 4.92, P < .05; moderate OR = 4.09, P < .05; high OR = 3.92, P < .05). Primary care for children under 5 years was associated with home health use, usual source of care (OR = 2.59, P < .05), comprehensive care (OR = 2.49, P < .05), and continuous care (low: OR = 2.22, P < .05; moderate: OR = 3.64, P < .05; high: OR = 3.62, P < .05). For children aged 6 to 14 years, this association was seen with continuous care (moderate: OR = 2.38, P < .05; high: OR = 2.13, P < .05). Home health for children aged 15 to 20 years was related to continuous care (moderate: OR = 2.32, P < .05). Primary care involvement affected hospice use among older age-groups and home health use among younger age-groups. These findings underscore the need for clinical knowledge about end-of-life care for children of all ages among primary care providers.

Home care for children with multiple complex chronic conditions at the end of life: The choice of hospice versus home health

ABSTRACTFamilies desire to bring their children home at end of life, and this creates a variety of unique care needs at home. This study analyzed the child and family factors associated with hospice versus home health care use in the last year of life among children with multiple complex chronic conditions. Using the Andersen Behavioral Healthcare Utilization Model, the predisposing, enabling, and need factors of the child and family were shown to be significant predictors of hospice and home health care use. Hospice and home health care have advantages, and families may wish to use the service that best fits their needs.

End-of-Life Care Intensity and Hospice Use: A Regional-level Analysis.

Despite increased hospice use over the last decade, end-of-life care intensity continues to increase. To understand this puzzle, we sought to examine regional variation in intensive end-of-life care and determine its associations with hospice use patterns. Using Medicare claims for decedents aged 66 years and above in 2011, we assessed end-of-life care intensity in the last 6 months of life across hospital referral regions (HRRs) as measured by proportion of decedents per HRR experiencing hospitalization, emergency department use, intensive care unit (ICU) admission, and number of days spent in hospital (hospital-days) and ICU (ICU-days). Using hierarchical generalized linear models and adjusting for patient characteristics, we examined whether these measures were associated with overall hospice use, very short (≤7 d), medium (8-179 d), or very long (≥180 d) hospice enrollment, focusing on very short stay. End-of-life care intensity and hospice use patterns varied substantially across HRRs. Regional-level end-of-life care intensity was positively correlated with very short hospice enrollment. Comparing HRRs in the highest versus the lowest quintiles of intensity in end-of-life care, regions with more intensive care had higher rates of very short hospice enrollment, with adjusted odds ratios (AOR) 1.14 [99% confidence interval (CI), 1.04-1.25] for hospitalization; AOR, 1.23 (CI, 1.12-1.36) for emergency department use; AOR, 1.25 (CI, 1.14-1.38) for ICU admission; AOR, 1.10 (CI, 1.00-1.21) for hospital-days; and AOR, 1.20 (CI, 1.08-1.32) for ICU-days. At the regional level, increased end-of-life care intensity was consistently associated with very short hospice use.