Lung, breast, and colorectal cancer: the relationship between extent of disease and age at diagnosis

We examined the relationship between age and extent of disease at initial diagnosis as part of a population-based, prospective study documenting the patterns of care received by over 1500 newly diagnosed lung, breast, and colorectal cancer patients identified in nine Rhode Island hospitals. For each cancer site examined, no age by extent of disease relationship was observed; however, analysis by sex among lung cancer patients indicated an inverse age relationship for men. The absence of an age effect for breast cancer patients is in contrast to earlier research findings that identify a positive association between extent of disease and age at diagnosis. Past results may reflect age-related differences in patient and physician screening behavior characteristic of earlier time periods.

Predictors of bereavement depression and its health services consequences

As a crisis event and major life transition, bereavement is believed to precipitate or exacerbate physical and psychologic dysfunction. Yet, despite an ever-growing body of research, the causal relationship between bereavement and subsequent morbidity remains unsettled. Using a large sample, prospective measurements, and multivariate analyses, a literature-based model of the determinants of clinical depression after bereavement was tested. Results show that consanguinity, patient age, poor prior physical and mental health, family tension, and survivor dissatisfaction with their caretaking abilities during the terminal phase were the most important determinants of risk of depression after bereavement. Among spouses, bereavement depression was significantly associated with poor prior physical and mental health and dissatisfaction with caretaking abilities. Analyses of the consequences of bereavement in terms of health-care utilization found strong effects of depression on physician utilization. In light of the aging of the United States population, and thus the growth of the bereaved population, the results suggest the importance of preventive medicine to avert the costs to the health-care system of depression-related somatization following bereavement.

Clinical symptoms and length of survival in patients with terminal cancer

Planning terminal care for patients with malignant neoplasms is difficult, in part, because accurate measures of prognosis have not been defined. Using data from the National Hospice Study, we examined the correlation of 14 easily assessable clinical symptoms with survival in patients with terminal cancer. Performance status was the most important clinical factor in estimating survival time, but five other symptoms had independent predictive value as well (shortness of breath, problems eating or anorexia, trouble swallowing, dry mouth, and weight loss). We generated four parametric accelerated time survival models to estimate survival in patients with combinations of these symptoms and validated the log-normal model on the entire data set. This model was unaffected by patient age, sex, primary tumor type, or site. Our findings illustrate the value of biologically "soft" clinical data in predicting survival in patients with terminal cancer. The prevalence of similar symptoms among patients with cancer of various primary and metastatic sites also supports the concept of a common final clinical pathway in patients with advanced malignant neoplasms.

Day hospital as an alternative to inpatient care for cancer patients: a random assignment trial

A stratified, random-assignment trial of 442 cancer patients was conducted to evaluate medical, psychosocial, and financial outcomes of day hospital treatment as an alternative to inpatient care for certain cancer patients. Eligible patients required: a 4- to 8-hour treatment plan, including chemotherapy and other long-term intravenous (i.v.) treatment; a stable cardiovascular status; mental competence; no skilled overnight nursing; and a helper to assist with home care. Patients were ineligible if standard outpatient treatment was possible. No statistically significant (p less than 0.05) differences were found between the Adult Day Hospital (ADH) and Inpatient care in medical or psychosocial outcomes over the 60-day study period. The major difference was in medical costs--approximately one-third lower for ADH patients (p less than 0.001) than for the Inpatient group. The study demonstrates that day hospital care of medical oncology patients is clinically equivalent to Inpatient care, causes no negative psychosocial effects, and costs less than Inpatient care. Findings support the trend toward dehospitalization of medical treatment.

Physicians' use of health resources for terminal cancer patients: clinical setting versus physician specialty

A large proportion of all Medicare reimbursements (22%) are made for terminally ill patients. Alternative methods of care for such patients (for example, hospice care) may be more appropriate and less costly. The role of physician characteristics in determining use of resources for terminal patients is compared with that of care setting (type of facility), using data from the National Hospice Study. Multiple logistic regression reveals a stronger relationship between care setting and resource utilization than between physician "aggressiveness" and utilization. Physician specialty has little effect on utilization. These findings suggest that care setting may influence physician practice behavior. This may be due to self-selection of particular types of physicians or patients, or to a characteristic of the facility itself.

Cancer patients' quality of life over the disease course: lessons from the real world

We examined the correlates of the Quality of Life Index (QLI) in three samples of cancer patients: newly diagnosed (N = 397), recipients of chemotherapy (N = 194), and terminal (N = 2046). The relative importance of physical, emotional, social, and disease symptom characteristics in predicting the QLI was compared across samples. Despite differences in data collection approaches (telephone, personal interview, or paper and pencil) and differences in patient characteristics, the QLI was a robust construct with its central organizing principle being physical functioning. In all samples, functioning, symptoms, depression, and social support were significant predictors of the QLI, while age and cancer type were only minimally related. The QLI significantly differentiated between patients at different disease phases and measured more than physiological functioning. However analyses suggested that the dominant factor constraining the range of human psychosocial functioning was physical condition.

Nausea and vomiting in terminal cancer patients

Using data from the National Hospice Study, nausea and vomiting in terminal cancer patients and physician response to these symptoms were studied. Nausea and vomiting developed in 62% of terminal cancer patients with prevalence rates of at least 40% during the last six weeks of life. Stomach and breast cancer were significantly more likely to be associated with nausea and vomiting; lung and brain primary sites were significantly less likely to have this association. Although women and younger patients reported higher rates, no relationship could be demonstrated between these symptoms and the Karnofsky level or chemotherapy during the last six weeks of life. In the subsample for whom medication use was known, 32% of nauseated patients received antiemetic prescriptions. Physicians were less likely to prescribe antiemetics for elderly patients and those with serious mental impairment. When prescribed, 72% of nauseated patients consumed antiemetics.

Staff burnout in a hospice setting

Burnout is a job-related state characterized by emotional and physical exhaustion which can be caused by intense involvement over an extended period of time with people who are experiencing psychological and/or physical problems. People working in the health care professions have been identified as being particularly at risk for experiencing burnout. Based on hospice staff survey data collected as a part of the National Hospice Study (NHS), this paper describes multivariate analyses of selected demographic, occupational, and organizational predictors of burnout. Findings indicated that younger, better-educated staff are more prone to burnout, as are staff who work on a full-time basis in direct contact with patients. None of the hospice organizational factors tested were significantly related to burnout. Further research is necessary to determine whether or not such factors as staff support systems are effective in mitigating burnout among staff in the health care field.

Secondary morbidity among the recently bereaved

Discussions of the health consequences of bereavement have appeared with increasing frequency in the literature in recent years. Capitalizing on one of the largest samples of bereaved subjects to date, the authors analyzed National Hospice Study bereavement interview data regarding the rate of medical care use and short-term secondary morbidity. Results suggest that physician visit rates were somewhat higher but hospitalization rates lower among the recently bereaved than age- and sex-adjusted national norms. Multivariate analyses revealed that previous health problems and having been married to the deceased were consistently the strongest predictors of morbidity and health care use.

Dyspnea in terminally ill cancer patients

To determine the epidemiology of dyspnea in terminal cancer patients, we examined data from the National Hospice Study, which followed up patients during their last six weeks of life. The incidence of dyspnea in these patients was 70.2 percent, with prevalence rates generally exceeding 50 percent at any of three measurements. In addition to lung or pleural involvement by the tumor, the presence of underlying lung disease or cardiac and low performance on the Karnofsky scale were significantly associated with dyspnea. Lung, colorectal, and breast carcinomas were the most common tumor sites in our dyspneic patients and accounted for almost 60 percent of cancer diagnoses in these patients. In 23.9 percent of dyspneic terminal cancer patients, neither lung or pleural involvement nor underlying lung or heart disease could be identified as risk factors.

An examination of the relationship of reimbursement and organizational structure to the use of hospice volunteers

This article examines the use of volunteers in hospice based on a national study of hospice programs. The data collected as part of the study make it possible to address several questions related to the prevalence and role of volunteers. Does the prevalence of volunteers decrease with the availability of reimbursement for hospice services? Is reimbursement related to a shift in the types of activities performed by volunteers? Is the level of volunteer involvement and the mix of volunteer activities related to type of hospice organization? Although it was hypothesized that volunteer activities would shift to non-patient-related tasks with the availability of reimbursement, this was not found to be the case. The availability of Medicare reimbursement for hospice services was not related to a decrease in the ratio of volunteers to paid staff. Freestanding hospices utilized volunteers to a greater degree than institution-affiliated hospices.

An examination of the effect of reimbursement and organizational structure on the allocation of hospice staff time

The unique needs of the terminally ill patient may require more planning and service coordination than those of the non-terminal patient. The hospice interdisciplinary team was a response to these additional needs. This paper examines the pattern of patient care and administrative activities of paid hospice staff by hospice organizational type and demonstration status in the National Hospice Study. Data gathered over a one year period revealed that demonstration hospices, in which all allowable costs were Medicare reimbursed, spent significantly more time in general and patient related administrative activities than non-demonstration hospices, which operated within existing Medicare cost limits. Staff in demonstration home care-based hospices reported significantly longer home visits than staff in non-demonstration hospices. In both groups, home care-based hospice visits were of longer duration than those home visits conducted by staff of hospital-based hospices.

An alternative in terminal care: results of the National Hospice Study

Hospice is a program of supportive services for terminally ill patients and their families, provided either at home or in designated inpatient settings, which is purported to improve patient and family quality of life at lower cost than conventional terminal care. The National Hospice Study was a multi-site, quasi-experimental study to compare the experiences of terminal cancer patients and their families in hospices with those of similar patients and families receiving conventional terminal care. The results indicate that, although care is different in hospices, e.g. lesser utilization of aggressive interventional therapy and diagnostic testing, patients' quality of life is similar in the hospice and conventional care systems with the exception of pain and symptom control, which may be better in the inpatient hospice setting. Hospice patients are more likely to die at home and their families are satisfied with that outcome. Otherwise, no consistent superiority of family outcome was associated with the hospice approach. The cost of hospice care is less than that of conventional terminal care for patients in hospices without inpatient facilities, but the cost of hospice appears to be equivalent to conventional care for patients in hospices having beds.

Simulating the impact of case-mix adjusted hospice rates

The Medicare hospice benefit prospectively reimburses hospices based on the inpatient status of the patient, whether or not the patient is at home, and whether the patient is receiving round-the-clock nursing. Using national Hospice Study data, two case-mix adjusters based on patient functioning and living arrangement were found to be significantly related to per diem cost. These were tested by simulating their impact on hospice revenues. Increasing per diem reimbursements 35 percent for nonambulatory patients living alone only increases hospice revenues by 4 percent; hospices with sicker patients benefit the most.

The effect of treatment setting and patient characteristics on pain in terminal cancer patients: a report from the National Hospice Study

Debilitating pain is the symptom most often associated with cancer by the general public. The National Hospice Study (NHS) evaluated pain control among terminal cancer patients served in hospital based (HB) and home based (HC) hospices, and in conventional care settings (CC) such as outpatient clinics and oncology units. Pain was reported by the patient when able to respond and by the patients' primary care person (PCP) during repeated interviews until death. Patient and PCP pain reports were correlated at 0.43. PCPs reported that around 16% of patients were pain free in the last weeks of life while 18% were in persistent pain. Statistically adjusting for differences in the CC, HB, and HC samples, HB patients were less likely to report having persistent pain than either CC or HC patients, although there were no differences in the proportion of patients who were pain free. Age was negatively correlated with the level of pain. As expected, brain and bone metastases were related to pain in opposite directions, with more pain among those with bone involvement and less among those with brain involvement. Conclusions about whether HB hospices really are superior at pain control must be made cautiously in view of the relationship between age and pain and the greater age of hospice patients in our study.

Cost savings in hospice: final results of the National Hospice Study

Medicare inpatient and home care costs over the last year of life of terminal cancer patients served in two types of hospices and in conventional care (CC) were compared as a part of the National Hospice Study (NHS). Both home care (HC) and hospital-based (HB) hospice patients had lower costs in the last month of life than did CC patients. HC patients substituted home care for inpatient care, yielding cost savings for lengths of hospice stay of up to 1 year. Although HB patients added home care to relatively high levels of inpatient care, their ancillary costs per inpatient day were significantly lower than those of CC patients. Thus, HB costs over the last year of life were also somewhat less than those of CC. The size of the savings associated with hospice care is sensitive to the type of hospice and the length of stay distribution of patients served; patients served longer have significantly higher costs in the last year of life.

Relationship between age at diagnosis and treatments received by cancer patients

Increases in cancer incidence and mortality reflect the larger numbers of elderly in the population. Using a mortality sample of 1891 biopsy-confirmed cancer patients, analyses reveal older breast, prostate, and cervical-uterine cancer victims were more likely to be diagnosed with metastases. Logistic regression analyses of subsamples of breast (N = 224), lung (N = 513), and colorectal (N = 299) cancer patients indicate that age is significantly inversely related to receipt of both subsequent chemotherapy and radiation therapy, controlling for stage of disease and presence of co-morbid disease. Exceptions to this relationship are the use of radiation therapy among nonmetastatic lung cancer patients and all breast cancer patients. The implications of these findings for current cancer control programs are discussed.

Patient predictors of hospice choice. Hospital versus home care programs

Research findings indicate cost savings associated with home care hospices, while hospital-based hospices can be as expensive as conventional care. Based on National Hospice Study data, this article identifies the characteristics of patients admitted to hospital-based and home care hospices in those areas of the country where a choice of hospice model was possible. Multivariate logistic regression indicates that the significant discriminating factors between the two patient populations relate to the availability of supportive care at home and the severity of nursing care problems at the time of hospice entry. Reinforcing selected pre-existing differences, an examination of prehospice had longer episodes of care than was the case for home care hospice patients.

The use of transfusion in terminal cancer patients. Hospice versus conventional care setting

This study examines the usage of blood component products by terminal cancer patients in hospice and conventional care settings. Our results show that patients in conventional care settings are five times more likely to be transfused than are patients in hospital-based hospices and ten times more likely to be transfused than are patients in home-care hospices (p = 0.003). Since the outcome of care was comparable for the three types of care settings, the transfusion of blood component products to terminal cancer patients may be overused in conventional care settings.

The cost of residential care homes serving elderly adults

Given increasing expenditures for long-term nursing home care costs, the residential care home (RCH) provides a viable alternative for elderly Americans requiring daily supervision but not extensive care. Purposive and random sampling procedures were used to select 181 RCHs serving the elderly in five states in order to analyze their expenditures. Home operator interviews yielded facility and patient descriptors as well as expenditure data. Analyses of these data revealed total expenditures per resident month to be $330 in 1980 dollars. Based on multivariate analyses, measures of resident case mix were significantly related to food costs but not to staffing costs. Findings suggest that small homes commit more resources to resident care since operator labor is not an expenditure.

Terminally ill patients' and families' responses to participation in a research study

Evaluations of the effect of interventions on the terminally ill focus on outcomes such as patient satisfaction and quality of life. Due to the theoretical nature of these measures, researchers must rely on patients and family members as primary data sources. Family members of terminally ill patients wee queried concerning their motives for participation in the National Hospice Study and their reactions to an intensive interview schedule. Of those contacted, 94% agreed to the interview. The most frequently cited reasons for participating in the study were the desire to help other families facing a serious illness and the desire to help the hospice movement. Responses indicated a real enthusiasm for study participation in spite of the stressful nature of the terminally ill patient's situation.

The Karnofsky Performance Status Scale. An examination of its reliability and validity in a research setting

The Karnofsky Performance Status Scale (KPS) is widely used to quantify the functional status of cancer patients. However, limited data exist documenting its reliability and validity. The KPS is used in the National Hospice Study (NHS) as both a study eligibility criterion and an outcome measure. As part of intensive training, interviewers were instructed in and tested on guidelines for determining the KPS levels of patients. After 4 months of field experience, interviewers were again tested based on narrative patient descriptions. The interrator reliability of 47 NHS interviewers was found to be 0.97. The construct validity of the KPS was analyzed, and the KPS was found to be strongly related (P less than 0.001) to two other independent measures of patient functioning. Finally, the relationship of the KPS to longevity (r = 0.30) in a population of terminal cancer patients documents its predictive validity. These findings suggest the utility of the KPS as a valuable research tool when employed by trained observers.

The Karnofsky Performance Status Scale. An examination of its reliability and validity in a research setting

The Karnofsky Performance Status Scale (KPS) is widely used to quantify the functional status of cancer patients. However, limited data exist documenting its reliability and validity. The KPS is used in the National Hospice Study (NHS) as both a study eligibility criterion and an outcome measure. As part of intensive training, interviewers were instructed in and tested on guidelines for determining the KPS levels of patients. After 4 months of field experience, interviewers were again tested based on narrative patient descriptions. The interrator reliability of 47 NHS interviewers was found to be 0.97. The construct validity of the KPS was analyzed, and the KPS was found to be strongly related (P less than 0.001) to two other independent measures of patient functioning. Finally, the relationship of the KPS to longevity (r = 0.30) in a population of terminal cancer patients documents its predictive validity. These findings suggest the utility of the KPS as a valuable research tool when employed by trained observers.

Psychiatric history as a barrier to residential care

Bias against individuals with a history of psychiatric hospitalization can block their access to residential care homes and thus impede deinstitutionalization efforts. After surveying home operators in nine residential care programs in five states, the authors found that providers tend to accept a physically impaired client over one with behavioral problems or a history of psychiatric hospitalization. The authors also point out that actual admission practices may not reflect facility policies. For example, more than 30 percent of the operators said they admitted persons with behavioral problems or psychiatric histories, yet no such persons resided in their homes. The authors suggest strategies such as provider education and financial incentives to combat the operator's bias against former mental patients.

Burnout among hospice staff

Is burnout common among health care personnel dealing with situations of great emotional intensity? This study surveyed personnel in 40 hospices to examine the components of burnout among those who work with the terminally ill. Although the overall burnout among staff was found to be relatively low, a higher than average measure of burnout was recorded among employees with high educational levels, long tenure, and full-time status.

Roles ascribed to volunteers. An examination of different types of hospice organizations

Volunteers have been the hallmark of the hospice movement since its U.S. inception in 1973. As part of the National Hospice Study, volunteer hours and activities were reported monthly in forth participating hospices nationwide. Most volunteers were white females with at least a high school education. The attitude of paid staff toward volunteers was overwhelmingly positive. Overall, the level of volunteer involvement is approximately 1.5 hours per patient each day he or she spends in the hospice program. This breaks down to nearly .80 hours of direct patient care and .70 hours devoted to other activities. While the most prevalent use of volunteers is in the provision of direct patient care in freestanding hospices, volunteers also spend a large proportion of their time in the performance of administrative activities.

Discharged rehabilitation patients: impact of follow-up surveillance by a friendly visitor

The period after hospital discharge is the most critical for rehabilitation patients returning to a community setting. A friendly visitor surveillance program using nonprofessional volunteers was designed to monitor treatment regimen compliance by alerting medical professionals of impending crises among discharged rehabilitation patients. A randomized experimental design was used to evaluate the impact of 1 year of program exposure on rehospitalization, service use, and psychosocial outcomes experienced by 142 patients. Patients were randomized into 3 groups: friendly visitors (FV) and biannual nursing visits; biannual nursing (RN) visits only; and controls (CON). Over 1/3 of the sample was rehospitalized at least once during the 1-year impact period, yet no differences were found across experimental groups nor patients' diagnostic category. No meaningful pattern of significant differences between the groups was observed at the p less than 0.1 probability level in any of the other outcome areas. The need to alert the medical system of impending patient problems occurred rarely, suggesting that existing informal support systems and regular use of medical services may be sufficient to monitor rehabilitation patients' progress.

National hospice study analysis plan

Since the founding of the first hospice in the United States in 1974, the number of health care organizations providing hospice services has grown rapidly. In 1978, the U.S. General Accounting Office identified 59 operational hospices [1]. A survey undertaken by the National Hospice Organization (NHO) in 1980 found 235 operational programs and many more actively planning to deliver services. By the summer of 1981, the Joint Commission on the Accreditation of Hospitals (JCAH), in studying the feasibility of a voluntary hospice accreditation program, had 650 responses to a national survey [2]. Finally, the 1981 NHO directory identifies 464 operational "provider programs" as well as 33 functioning state-level hospice organizations with an additional 353 programs in various stages of establishing hospice programs of care [3]. The growth of the movement and the public recognition it has received have catalyzed advocacy of Federal support for hospice services. In 1979, the Congress responded by mandating a study to delineate the implications of inclusion of hospice services in the Medicare program. The Health Care Financing Administration (HCFA) then selected 26 hospices (from an applicant pool of 233) to participate in a two-year experimental program. These demonstration sites receive reimbursement for services provided Medicare beneficiaries not otherwise available under current regulations. The special reimbursement provisions went into effect on October 1, 1980. (See Appendix A: Description of the Hospice Reimbursement Program.) In the spring of 1980, the Robert Wood Johnson Foundation and the John A. Hartford Foundation joined with the Health Care Financing Administration (HCFA) to solicit proposals for a national evaluation of hospice care as a basis for future Federal fiscal policy and legislation. Brown University was selected as the evaluation center by competitive process and the grant was awarded on September 30, 1980. The evaluation employs a quasi-experimental design in which the impact of hospice care (with and without reimbursement) on quality of life and costs are compared to non-hospice (conventional) terminal care. Eight hundred patients and families in 24 comparison sites located in three regional areas (Southern New England, Northern Midwest and Southern California) are expected to participate. Primary data collection began on August 1, 1981. Analyses of differential outcome are performed using standard linear multiple regression and logistic multiple regression with separate models for each comparison group. Effects are tested by separately estimating the specific response variable for the prototype (average) hospice patient for each model.