Receiving Hospice Services Research Articles

Neuropathic symptoms, physical and emotional well-being, and quality of life at the end of life.

The purpose of this cross-sectional, descriptive study was to assess differences in neuropathic symptoms, physical and emotional well-being, and quality of life in cancer patients at the end of life compared to those without neuropathic symptoms. Neuropathic symptoms were defined as numbness and tingling in the hands and/or feet. A secondary analysis of data from two hospices in Central Florida was performed. Adults (n = 717) with a cancer diagnosis, an identified family caregiver, and who were receiving hospice services, were eligible. The prevalence of numbness/tingling in the hands or feet was 40% in this sample of hospice patients with cancer. Participants with neuropathic symptoms of numbness/tingling had a significantly higher prevalence of pain (76.7% vs. 67.0%; p = .006), difficulty with urination (29.4% vs. 20.3%; p = .007), shortness of breath (64.9% vs. 54.1%; p = .005), dizziness/lightheadedness (46.0% vs. 28.2%; p < .001), sweats (35.5% vs. 20.3%; p < .001), worrying (50.7% vs. 37.3%; p = .001), feeling irritable (38.5% vs. 28.7%; p = .008), feeling sad (48.2% vs. 37.8%; p = .008), and difficulty concentrating (46.2% vs. 32.5%; p < .001). They also reported significantly higher overall symptom intensity and symptom distress scores (p = < .001), higher pain severity (p = .001) and pain distress (p = .002), and decreased quality of life (p = .002) compared to those without numbness/tingling. Neuropathic symptoms are emotionally distressing at the end of life and associatedwith higher symptom burden and diminished quality of life.

PC-FACS

PC-FACS

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.

Predictors of Late Palliative Care Referral in Children With Cancer

ContextEarly integration of palliative care (PC) in the management of children with high-risk cancer is widely endorsed by patients, families, clinicians, and national organizations. However, optimal timing for PC consultation is not standardized, and variables that influence timing of PC integration for children with cancer remain unknown. ObjectivesTo investigate associations between demographic, disease, treatment, and end-of-life attributes and timing of PC consultation for children with high-risk cancer enrolled on a PC service. MethodsA comprehensive standardized tool was used to abstract data from the medical records of 321 patients treated at a large academic pediatric cancer center, who died between 2011 and 2015. ResultsGender, race, ethnicity, enrollment on a Phase I protocol, number of high-acuity hospitalizations, and receipt of cardiopulmonary resuscitation were not associated with timing of PC involvement. Patients with hematologic malignancy, those who received cancer-directed therapy during the last month of life, and those with advance directives documented one week or less before death had higher odds of late PC referral (malignancy: odds ratio [OR] 3.24, P = 0.001; therapy: OR 4.65, P < 0.001; directive: OR 4.81, P < 0.0001). Patients who received hospice services had lower odds of late PC referral <30 days before death (OR 0.31, P < 0.001). ConclusionHematologic malignancy, cancer-directed therapy at the end of life, and delayed documentation of advance directives are associated with late PC involvement in children who died of cancer. Identification of these variables affords opportunities to study targeted interventions to enhance access to earlier PC resources and services for children with high-risk cancer and their families.

Ways of Knowing and Caring Used by Nurses in Community Hospice Agencies.

Providing nursing care for an individual who is terminally ill is a complex endeavor. Understanding the different ways nurses who work in hospice agencies use knowing about and caring for persons receiving services becomes important because the actions of nurses are influenced by the nurses' perceptions. Hearing the narrative of nurses providing end-of-life care through phenomenological research can inform nursing education and institutions' methods to support the development of skills and characteristics to improve palliative and end-of-life nursing care. The purpose of this research was to question nurses who work in hospice agencies concerning their lived experiences related to knowing about and caring for individuals who were receiving hospice services. Four themes were identified related to the concepts of knowing and caring. These are difficult-to-measure concepts but add value to the profession and document how nurses contribute to patient care. In addition, the concepts are meaningful to patients and families receiving hospice services. The research provided a method of making the work of these nurses visible and gave more knowledge about nurses who provide end-of-life care.

Barriers to Hospice Care in Trauma Patients: The Disparities in End-of-Life Care.

End-of-life and palliative care are important aspects of trauma care and are not well defined. This analysis evaluates the racial and socioeconomic disparities in terms of utilization of hospice services for critically ill trauma patients. Trauma patients ≥15 years old from 2012 to 2015 were queried from the National Trauma Databank. Chi-square and multivariate logistic regression analyses for disposition to hospice were performed after controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was calculated for all patients discharged to hospice. Chi-square analysis of 2 966 444 patient's transition to hospice found patients with cardiac disease, bleeding and psychiatric disorders, chemotherapy, cancer, diabetes, cirrhosis, respiratory disease, renal failure, cirrhosis, and cerebrovascular accident (CVA) affected transfer ( P < .0001). Logistic regression analysis after controlling for covariates showed uninsured patients were discharged to hospice significantly less than insured patients (odds ratio [OR]: 0.71; P < .0001). Asian, African American, and Hispanic patients all received less hospice care than Caucasian patients (OR: 0.65, 0.60, 0.73; P < .0001). Negative binomial regression analysis with margins for LOS showed Medicare patients were transferred to hospice 1.2 days sooner than insured patients while uninsured patients remained in the hospital 1.6 days longer ( P < .001). When compare to Caucasians, African Americans patients stayed 3.7 days longer in the hospital and Hispanics 2.4 days longer prior to transfer to hospice ( P < .0001). In all patients with polytrauma, African Americans stayed 4.9 days longer and Hispanics 2.3 days longer as compared to Caucasians ( P < .0001). Race and ethnicity are independent predictors of a trauma patient's transition to hospice care and significantly affect LOS. Our data demonstrate prominent racial and socioeconomic disparities exist, with uninsured and minority patients being less likely to receive hospice services and having a delay in transition to hospice care when compared to their insured Caucasian counterparts.

Variation in guideline-concordant care for elderly patients with metastatic breast cancer in the United States.

Prior studies have identified shortcomings in the quality of care for early-stage breast cancer. Guidelines recommend systemic therapy for metastatic breast cancer (MBC), but few studies have examined guideline concordance for these patients. We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify patients aged ≥66 diagnosed in 2010-2011 with de novo MBC who were continuously enrolled in fee-for-service Medicare. We described initial care (within 6months of diagnosis) for hormone receptor (HR)-positive/human epidermal receptor-2 (HER2)-negative, HER2-positive, and triple-negative (TN) tumors. We identified factors independently associated with receiving no initial systemic therapy, and compared hospice and hospital utilization for treated versus untreated patients. Among 446 patients, 65% were HR-positive, 21% were HER2-positive, and 14% were TN. Most patients (76.9%) received initial systemic treatment. Among treated HR-positive patients, 15% received chemotherapy as initial treatment; among treated HER2-positive patients, 34% did not receive HER2-targeted initial therapy. Factors independently associated with receiving no initial systemic therapy included older age (ORage continuous/year=1.08, 95% CI 1.04-1.11), being not married (ORnot married vs. married=2.87, 95% CI 1.42-5.81), and subtype (ORTN vs. HR+=4.95, 95% CI 2.53-9.71). Of patients who did not receive initial systemic therapy, 41.1% did not receive hospice services. In this population-based MBC cohort, almost one quarter did not receive initial systemic therapy and a substantial proportion of treated patients did not receive guideline-concordant first-line therapy. Further research should explore underuse of chemotherapy and HER2-targeted therapies, investigate whether patterns of care are consistent with patient preferences, and identify opportunities to optimize hospice utilization for patients not receiving treatment.

Variations in Hospice Utilization and Length of Stay for Medicare Patients With Melanoma

ContextTimely hospice referral is an indicator of high-quality end-of-life care for cancer patients. Variations in patient characteristics associated with hospice utilization and length of stay have been demonstrated in studies of other malignancies but not melanoma. ObjectivesWe sought to understand hospice utilization and patient characteristics associated with variability in use for the older melanoma population. MethodsWe used the Surveillance, Epidemiology, and End Results–Medicare database to identify 13,393 melanoma patients aged 65+ years at time of diagnosis between 2000 and 2009, who died by 12/31/10. The primary outcome was enrollment in hospice with secondary outcome of hospice duration. Patient characteristics associated with variations in hospice enrollment were examined. ResultsAmong 13,393 patients who died with melanoma, 5298 (40%) received hospice care. Of these, 17% were enrolled in hospice for three days or less, while 13% had ≥90 days of hospice care. Despite improvements over time in the proportion of patients who received hospice and those who received at least 90 days of hospice care, late hospice enrollments did not change. Multivariable analysis revealed that patients of older age, with distant disease at time of diagnosis, and residing in rural areas or in census tracts with higher rates of high school completion were more likely to enroll in hospice. ConclusionRates of hospice enrollment increased over time but remained under accepted quality benchmarks with variations evident in those who receive hospice services. Efforts to increase access to earlier hospice care for all patients dying with melanoma are essential.

Unexpected Survivors: Children With Life-Limiting Conditions of Uncertain Prognosis.

Prognostication of survival is difficult in children with life-limiting illnesses because of the rarity of these conditions and technological advances improving survival. The objective of this article is to describe the characteristics of children with life-limiting illnesses who survived longer than the expectations of health-care providers. This is a retrospective cohort study conducted in a tertiary-care children's hospital in North Carolina. "Unexpected survivors," defined as children who survived despite a prognosis of imminent death or significantly longer than prognosticated by health-care providers, were identified from among 349 children enrolled in a pediatric palliative care program between March 2008 and October 2012. Children's clinical courses were followed until September 2015 or their death. Eighteen (5%) children were identified as unexpected survivors; 17 (10 girls and 7 boys) were included. Congenital anomalies were the most common diagnoses. Neonatal intensive care unit was the most frequent setting of prognostication. Thirteen children used some form of medical technology at the time of prognostication. Eleven children received hospice services. Eight died during the observation period but survived significantly longer than expected (median survival time 1.5 years), and 9 survived beyond the observation period (median survival time 5.9 years). Unexpected survivors are a small group of children with life-limiting conditions. Clinicians should be aware of the possibility of prognostic inaccuracy, able to communicate prognostic uncertainty to parents, and engage supportive services when prognosticating poor survival. Prospective studies are needed to understand outcomes of children with life-limiting illnesses of uncertain prognosis.

Small Study Calls for Change in SNF, Medicare Hospice Benefit

Small Study Calls for Change in SNF, Medicare Hospice Benefit

End-of-Life Care for Patients with Potentially Resectable Pancreatic Cancer Who Received Radiation Therapy

Pancreatic adenocarcinoma (PDAC) is a highly lethal malignancy, and patients with potentially resectable PDAC often receive radiation therapy (RT) to improve outcomes. However, even among patients who receive RT and potentially curative surgery, most develop recurrent disease and ultimately die of their PDAC. Currently, end-of-life care for these patients is understudied. We hypothesized that a substantial proportion of patients with PDAC who received RT experience early mortality (death within 1 year after completing RT) and that the use of palliative care and hospice services are underutilized in this population. We performed a retrospective study of patients with PDAC who received RT from October 1998 to December 2010 using a cohort of patients who underwent surgery followed by adjuvant standard fractionation RT (N=159) and a cohort of patients treated with neoadjuvant proton RT in 5 fractions followed by surgical resection (N=48). We reviewed electronic medical records to obtain baseline demographic and clinical characteristics (including patient-reported pain scores obtained at routine patient visits, scored 0-10), death dates, and receipt of palliative care and hospice services. We used logistic regression to identify factors associated with early mortality after RT and receipt of palliative care and hospice services, adjusted for age and type of RT received. Of 207 patients, 56 (27%) died within 1 year of completing RT and 161 (78%) died overall. Of the patients who died, 43% received palliative care consultation: 33% within 30 days of death and 10% within 7 days of death. Over half (58%) of those who died received hospice services: 57% within 30 days of death and 26% within 7 days of death. Logistic regression demonstrated that post-RT pain scores were associated with early mortality (OR 1.2, p=0.047). Female sex (OR 2.3, p=0.042) and white race (OR 9.5, p=0.044) were associated with receipt of palliative care consultation. Female sex (OR 3.1, p=0.006) was associated with receipt of hospice services. Despite receiving RT, mortality rates among patients with potentially resectable PDAC remain high, and over one-fourth of patients in our cohort died within 1 year after completing RT. Notably, we found that post-RT pain scores were associated with greater odds of experiencing early mortality, thus highlighting the importance of incorporating patient-reported symptom burden into the routine care of these patients. We also found that nearly half of patients who died received palliative care consultation and over half received hospice services. Importantly, we identified that female sex and patient race were associated with the use of palliative care and hospice services. Our results merit confirmation, and we hope our findings will motivate ongoing efforts to improve the end-of-life care for patients with PDAC.

Quality Hospice Care in Adult Family Homes: Barriers and Facilitators

ObjectivesOlder adults in need of residential services are increasingly spending their final days in small, domestic-style care settings such as adult family homes. In this study, we sought to identify processes that facilitated the provision of quality hospice care to seriously ill residents of adult family homes and their family members. DesignWe conducted a secondary analysis of qualitative data collected as part of a randomized clinical trial of a problem-solving intervention for family members of hospice patients. SettingThe original trial was conducted in partnership with 2 large, community-based hospice agencies in the state of Washington. ParticipantsData from 73 family members of residents of adult family homes receiving hospice services were included in the analysis. MeasurementsData were collected via semi-structured individual interviews, which were audio-recorded and transcribed prior to analysis. ResultsFamily members described quality hospice care in the adult family home as care that is consistent with residents and families' values and that results in comfort and social connectedness for residents while promoting peace of mind and decreasing burden for residents' families. They identified numerous processes that facilitated the provision of quality care including personalizing care, sharing information and expertise, working together to resolve conflicts, and prioritizing residents and families' values over existing or competing philosophies of care. ConclusionThe adult family home setting can amplify both the benefits and challenges associated with receipt of hospice. When choosing an adult family home, older adults and their families should strongly consider selecting a home with a track record of positive collaborations with hospice agencies if the need for end-of-life care is anticipated.

A qualitative study of the emotional and spiritual needs of Hispanic families in hospice.

As the older U.S. population becomes more ethnically diverse, there will be an increased need for culturally sensitive hospice care services. Hispanics often experience multiple barriers to quality end-of-life care services. To address the underlying disparities in the cultural, emotional, and spiritual aspects of hospice care, the objective of the present qualitative study was to examine the emotional and spiritual needs of Hispanic patients' families while in hospice. Semistructured in-person interviews were conducted with 29 Hispanic patients' families regarding their perceived experience of the hospice-based emotional and spiritual support received. Demographic information was collected on both the family member and the patient. Interviews were digitally recorded, transcribed, and analyzed using thematic content analysis. Participant narratives fell into five main themes: (1) the influence of Hispanic culture in the relationship with hospice care providers; (2) types of social support received from hospice; (3) barriers to receiving support; (4) lack of health literacy regarding hospice care; and (5) cultural preferences for religious/spiritual support in hospice. Our results provide insight into the specific emotional and spiritual needs of Hispanic families receiving hospice services. Our findings highlight that cultural values play an important role in the hospice care experiences of Hispanic families.

National Policies Fostering Hospice Care Increased Hospice Utilization and Reduced the Invasiveness of End-of-Life Care for Cancer Patients.

In 2011, two national policies aiming to foster hospice services for terminal cancer patients took effect in Taiwan. The single-payer National Health Insurance of Taiwan started to reimburse full hospice services. The national hospital accreditation program, which graded all hospitals, incorporated hospice utilization in its evaluation. We assessed the impact of these national policies. A cohort of 249,394 patients aged ≥18 years who died of cancer between 2008 and 2013 were identified from the National Death Registry. We retrieved utilization data of medical services and compared the health care utilization in the final month of life before and after the implementation of the new policies. After the policy changes, hospice utilization increased from 20.8% to 36.2%. In a multivariate analysis adjusting for patient demographics, cancer features, and hospital characteristics, hospice utilization significantly increased after 2011 (adjusted odds ratio [AOR] 2.35, p < .001), accompanied by a decrease in intensive care unit (ICU) admissions, invasive mechanical ventilation (IMV), and cardiopulmonary resuscitation (CPR; AORs 0.87, 0.75, and 0.80, respectively; all p < .001). The patients who received hospice services were significantly less likely to receive ICU admissions, IMV, and CPR (AORs 0.20, 0.12, and 0.10, respectively; all p < .001). Hospice utilization was associated with an adjusted net savings of U.S. $696.90 (25.2%, p < .001) per patient in the final month of life. The national policy changes fostering hospice care significantly increased hospice utilization, decreased invasive end-of-life care, and reduced the medical costs of terminal cancer patients. National policies fostering hospice care significantly increased hospice utilization, decreased invasive end-of-life care, and reduced the medical costs of terminal cancer patients.

A Survey of Hospice and Palliative Nurses Association Nurse Educators’ Teaching Practices and Attitudes Toward Driving Safety in Hospice and Palliative Care Patients

In 2014, the National Hospice and Palliative Care organization estimated that 1.6 to 1.7 million Americans received hospice services, an increase of nearly 20% from the year 2010. Approximately 20% to 25% of hospice patients have the functional ability to drive. The increasing number of patients served by hospice and palliative services makes the issue of driving safety more important than ever. Because nurses practice at the frontline of care, they have an integral role in determining whether patients have the ability to drive safely. Our objective was to examine the teaching practices and attitudes of Hospice and Palliative Nurses Association (HPNA)–certified nurse educators regarding patient driving safety. An anonymous, cross-sectional email survey was sent to the 276 HPNA-certified nurse educators. One hundred twenty-six nurse educators (46%) responded. A large majority (90%) either strongly agree or agree that teaching nurses how to determine whether a patient is at risk for impaired driving is important. A minority, however, reported educating nurses on how to (1) determine whether a patient is at risk for impaired driving (18%), (2) counsel patients about impaired driving (21%), and (3) report potentially impaired drivers to the proper authorities (21%). Most nurse educators do not feel confident in their ability to teach nurses on the topic of impaired driving (38%) but are receptive to further education (87%). There is a need for further education of HPNA nurse educators in the area of patient driving safety.

Can research at the end of life be a useful tool to advance HIV cure?

OPINION Can research at the end of life be a useful tool to advance HIV cure? Sara Gianella a , Jeff Taylor b , Timothy R. Brown c , Andy Kaytes b , Cristian L. Achim a , David J. Moore a , Susan J. Little a , Ronald J. Ellis a and Davey M. Smith a,d AIDS 2017, 31:1–4 Keywords: end of life, eradication, HIV cure, last gift, legacy, peri-mortem research model, research Modern antiretroviral therapy (ART) has saved millions of years of life [1], but it cannot eradicate latently infected cells [2,3]. The replication-competent provirus that remains during ART represents the major barrier to curing HIV [4]. Most of this latent reservoir resides in solid tissues and not in circulating blood, and we have yet to fully define the sanctuary sites of HIV persistence [5]. Timothy Ray Brown (known by many as the ‘Berlin Patient’) may be the closest to an HIV cure after being treated with an allogeneic hematopoietic stem cell transplant from a donor who was homozygous for the CCR5D32 deletion [6]. Unfortunately, this remarkable success has not been reproduced, and robust viral replication resumes almost universally following treat- ment interruption [7–9]. Even if strategies currently in development succeed in purging HIV from circulating CD4 þ T cells, residual virus can remain in the central nervous system (CNS), gut-associated lymphoid tissue (GALT), genital tract, adipose tissue, and others [9–12]. Thus, cure efforts must tackle the eradication of HIV reservoirs in anatomic compartments and sanctuaries throughout the body. The earliest stages of HIV infection are characterized by high levels of viral replication and little immune response [13,14]. This window of uncontrolled replication allows the virus to seed reservoirs throughout the body, as early as within 2 weeks of HIV infection [15], and to persist indefinitely throughout the lifespan of HIV-infected individuals [10]. These proviral reservoirs continue to expand and diversify until viral replication is successfully suppressed with ART. Despite extensive investigations, we still do not fully understand the dynamics of the total body HIV reservoir and how sub-reservoirs in various compart- ments relate to one another. For example, it remains unclear what factors govern the size and the activity of replication-competent HIV DNA in the CNS compared to the genital tract and blood. Most studies that have explored nonblood reservoirs among persons living with HIV infection have been limited to small samples of cerebrospinal fluid (CSF), genital secretion, gut, and shallow lymph nodes [10,16]. Studies using macaque models with simian immunodeficiency viruses (SIVs) have been enlightening for reservoirs in different tissues [17–23], but while SIV shares a high degree of structural and sequence identity to HIV, studies of SIV will not suffice to test eradication strategies for humans. For example, the Merck adenovirus type 5 (Ad5) trivalent HIV-1 vaccine trial (STEP trial) did not show efficacy in preventing HIV infection or slowing disease progression [24], despite promising results in various macaques’ trials [25–27]. As the field tackles the ambitious goal of eradicating HIV from the human body, we will need to test the effectiveness of cure interventions in living persons. a University of California, San Diego, La Jolla, b Community Advisory Board (CAB) AntiViral Research Center (AVRC), c Las Vegas, Nevada, and d Veterans Affairs San Diego Healthcare System, San Diego, California, USA. Correspondence to Sara Gianella, University of California San Diego, 9500 Gilman Drive, MC 0679, La Jolla, CA 92093-0679, USA. Tel: +1 858 642 1620; fax: +1 858 552 7445; e-mail: gianella@ucsd.edu Received: 18 August 2016; revised: 23 September 2016; accepted: 27 September 2016. DOI:10.1097/QAD.0000000000001300 ISSN 0269-9370 Copyright Q 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Dementia Caregivers and Live Discharge from Hospice: What Happens When Hospice Leaves?

ABSTRACTHospice offers holistic support for individuals living with terminal illness and their caregivers. Some individuals receiving hospice services experience a slower decline in health as than expected, resulting in a ‘live discharge’ from hospice. A live discharge affects both patient and caregiver(s).The current study (N=24) explored the experiences of caregivers of adults with dementia who experienced a live discharge from hospice. Findings emphasize the comprehensive services covered under the Medicare Hospice benefit and those lost after a live discharge. Implications for social workers supporting caregivers are discussed, including the need to view the patient-caregiver unit during a live discharge.

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.

Characteristics Associated with In-Hospital Death among Commercially Insured Decedents with Cancer.

A majority of patients with poor-prognosis cancer express a preference for in-home death; however, in-hospital deaths are common. We sought to identify characteristics associated with in-hospital death. Case series. Commercially insured patients with cancer who died between July 2010 and December 2013 and who had at least two outpatient visits at a tertiary cancer center during the last six months of life. Patient characteristics, healthcare utilization, and in-hospital death (primary outcome) were ascertained from institutional records and healthcare claims. Bivariate and multivariable analyses were used to evaluate the association of in-hospital death with patient characteristics and end-of-life outcome measures. We identified 904 decedents, with a median age of 59 years at death. In-hospital death was observed in 254 patients (28%), including 110 (12%) who died in an intensive care unit. Hematologic malignancy was associated with a 2.57 times increased risk of in-hospital death (95% confidence interval [CI] 1.91-3.45, p < 0.001), and nonenrollment in hospice was associated with a 14.5 times increased risk of in-hospital death (95% CI 9.81-21.4, p < 0.001). Time from cancer diagnosis to death was also associated with in-hospital death (p = 0.003), with the greatest risk among patients dying within six months of cancer diagnosis. All significant associations persisted in multivariable analyses that were adjusted for baseline characteristics. In-hospital deaths are common among commercially insured cancer patients. Patients with hematologic malignancy and patients who die without receiving hospice services have a substantially higher incidence of in-hospital death.

A Phenomenological Study of Experiences of Family Care Givers for Their Terminal Cancer Patient Receiving Hospice Services at the Hospital

A Phenomenological Study of Experiences of Family Care Givers for Their Terminal Cancer Patient Receiving Hospice Services at the Hospital