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Aldridge MD, Hunt LJ, Halloran Z, Harrison KL. Private Equity Acquisitions Of Hospices Are Increasing; Ownership Remains Opaque. Health Aff (Millwood) 2024; 43:1306-1310. [PMID: 39226494 DOI: 10.1377/hlthaff.2023.01671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Private equity ownership across the US health care system is rapidly increasing, yet ownership structures are complex and opaque. We used an economic data set tracking mergers and acquisitions linked to Medicare data to identify private equity hospice acquisitions. Given the influence of for-profit ownership on hospice quality, transparent data on private equity investment are fundamental to ensuring high-quality end-of-life care.
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Affiliation(s)
- Melissa D Aldridge
- Melissa D. Aldridge , Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center, Bronx, New York
| | - Lauren J Hunt
- Lauren J. Hunt, University of California San Francisco, San Francisco, California
| | - Zelle Halloran
- Zelle Halloran, University of Washington, Seattle, Washington
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2
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Hunt LJ, Morrison RS. The Growing Influence of the Financial Sector in Serious Illness Care in the United States. J Palliat Med 2024. [PMID: 39167541 DOI: 10.1089/jpm.2024.0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024] Open
Affiliation(s)
- Lauren J Hunt
- Philip R. Lee Institute for Health Policy Studies, Global Brain Health Institute, University of California, San Francisco, California, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters VA Medical Center, Bronx, New York, USA
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3
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Anwar A, Amin MK, Anwar S, Shahzad M. Bridge the Gap: Addressing Rural End-of-Life Care Disparities and Access to Hospice Services. J Pain Symptom Manage 2024:S0885-3924(24)00853-4. [PMID: 39002712 DOI: 10.1016/j.jpainsymman.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/30/2024] [Accepted: 07/03/2024] [Indexed: 07/15/2024]
Abstract
Rural hospices face many obstacles in delivering palliative and end-of-life care in the United States. We aimed to identify these barriers and their potential solutions. Following a systematic approach, a comprehensive literature search using relevant keywords was conducted on online databases. Additionally, we conducted a manual search to include policy documents and white papers. Key challenges reported in the literature included limited geographic barriers and access issues, limited economic support, regulatory hindrances, and difficulty training and retaining palliative care staff. This contributes to inequitable access to hospice care in rural settings. We propose several potential solutions to overcome these hurdles and improve access. Advanced practice providers should be considered to serve as physician heads in rural hospices, which would expand resources in areas with physician shortages. A single per diem payment model should be implemented for rural hospices, regardless of the level of care provided, to help offset the higher cost of care. The Critical Access Hospital program and offering cost-based reimbursement for swing-bed stays could improve access to postacute care, including hospice services. Telehealth can improve the timeliness of care and reduce travel costs for patients and providers. Another solution to consider is simulation-based training to enhance the education of healthcare providers. In conclusion, there is a critical gap in end-of-life care access in rural communities. A multifaceted approach including policy changes, financial support, and technological innovations is essential to improve hospice care access in rural populations.
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Affiliation(s)
- Asif Anwar
- Northwestern University (A.A.), Evanston, Illinois, USA
| | - Muhammad Kashif Amin
- Department of Internal Medicine, University of Kansas Medical Center (M.K.A.), Kansas City, Kansas, USA
| | | | - Moazzam Shahzad
- H. Lee Moffitt Cancer Center (M.S.), Tampa, Florida, USA; Division of Hematology and Oncology, University of South Florida (M.S.), Tampa, Florida, USA.
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4
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Gaines AG, Cagle JG. Associations Between Certificate of Need Policies and Hospice Quality Outcomes. Am J Hosp Palliat Care 2024; 41:471-478. [PMID: 37256687 DOI: 10.1177/10499091231180613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Certificate of need (CON) laws are state-based regulations requiring approval of new healthcare entities and capital expenditures. Varying by state, these regulations impact hospices in 14 states and DC, with several states re-examining provisions. AIM This cross-sectional study examined the association of CON status on hospice quality outcomes using the hospice item set metric (HIS). DESIGN Data from the February 2022 Medicare Hospice Provider and General Information reports of 4870 US hospices were used to compare group means of the 8 HIS measures across CON status. Multiple regression analysis was used to predict HIS outcomes by CON status while controlling for ownership and size. RESULTS Approximately 86% of hospices are in states without a hospice CON provision. The unadjusted mean HIS scores for all measures were higher in CON states (M range 94.40-99.59) than Non-CON (M range 90.50-99.53) with significant differences in all except treatment preferences. In the adjusted model, linear regression analyses showed hospice CON states had significantly higher HIS ratings than those from Non-CON states for beliefs and values addressed (β = .05, P = .009), pain assessment (β = .05, P = .009), dyspnea treatment (β = .08, P < .001) and the composite measure (β = .09, P < .001). Treatment preferences, pain screening, dyspnea screening, and opioid bowel treatment were not statistically significant (P > .05). CONCLUSION The study suggests that CON regulations may have a modest, but beneficial impact on hospice-reported quality outcomes, particularly for small and medium-sized hospices. Further research is needed to explore other factors that contribute to HIS outcomes.
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Affiliation(s)
- Arlen G Gaines
- Doctoral Program in Palliative Care, Department of Pharmacy Practice and Science, University of Maryland, Baltimore, MD, USA
| | - John G Cagle
- Department of Social Work, University of Maryland, Baltimore, MD, USA
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Hotchkiss JT, Ridderman E, Hotchkiss BT. How do enrollees feel about support in Big Hospices? - The caregiver experience of emotional, spiritual, and bereavement support by profit status among large US providers. Palliat Support Care 2024:1-21. [PMID: 38587043 DOI: 10.1017/s1478951524000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
OBJECTIVES Recent findings narrate profiteering detrimentally impacting hospice care quality. However, no study has examined the caregiver experience of emotional and spiritual support expressed online. The purpose was to evaluate the hospice caregiver's experience of emotional, spiritual, and bereavement support and whether the care was respectful and compassionate to the care unit. METHODS Retrospective mixed methods of sentiment and quantitative analysis. Sources were online caregiver reviews (n = 4,279), Consumer Assessment of Healthcare Providers and Systems (CAHPS) data on the 50 largest US hospices. RESULTS Caring and compassionate professionals were lauded in nonprofit (+.57) and for-profit settings (+.46). The nonprofit experience was in the excellent range (+42) for emotional, spiritual, and bereavement support but fell to dissatisfying (-.15) among for-profits. A respectful experience (16%) was much less commonly expressed than a compassionate one (38%). Distribution of CAHPS "Treating patient with respect" (M = 89.62, SD = 2.63) and "Emotional and spiritual support" (M = 89.80, SD = 2.04) limited inter-hospice comparisons. SIGNIFICANCE OF RESULTS Compassionate professionals were thanked and praised regardless of profit status. Sadly, anger was expressed toward large, for-profits more fixated on census than emotional, spiritual, and bereavement support; thankfully nonprofits were more supportive. CAHPS items for "Treating patient with respect" and "Emotional, spiritual support" offer limited discriminating value since low CAHPS performers always had relatively high scores on these 2, yet otherwise low scores on the remaining 6. Online reviews on the same topics provide a more substantive and realistic appraisal - distinguishing high from low performers. A higher bar than mere respect is needed for the tender experience of death, dying, and grieving. Compassion is an especially relevant addition to CAHPS since caregivers named compassionate staff as a distinguishing factor. Parity for mental health at end of life is a vital research topic. Future research should also explore the caregiver expectations set on admission.
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Affiliation(s)
- Jason T Hotchkiss
- Department of Professional and Graduate Studies, Cornerstone University, Grand Rapids, MI, USA
| | - Emily Ridderman
- Department of Professional and Graduate Studies, Cornerstone University, Grand Rapids, MI, USA
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Teno JM, Belanger E, Khan G. Quality of Data on Profit Status Reported Care Compare. J Pain Symptom Manage 2024; 67:e161-e162. [PMID: 37949254 DOI: 10.1016/j.jpainsymman.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Joan M Teno
- Adjunct Professor of Health Services, Policy, and Practice, Brown University School of Public Health (J.M.T.), Providence, RI; Associate Professor of Health Services, Policy, and Practice, Brown University School of Public Health (E.B.), Providence, RI; MPH Candidate, Brown University School of Public Health (G.K.), Providence, RI.
| | - Emmanuelle Belanger
- Adjunct Professor of Health Services, Policy, and Practice, Brown University School of Public Health (J.M.T.), Providence, RI; Associate Professor of Health Services, Policy, and Practice, Brown University School of Public Health (E.B.), Providence, RI; MPH Candidate, Brown University School of Public Health (G.K.), Providence, RI
| | - Gulmeena Khan
- Adjunct Professor of Health Services, Policy, and Practice, Brown University School of Public Health (J.M.T.), Providence, RI; Associate Professor of Health Services, Policy, and Practice, Brown University School of Public Health (E.B.), Providence, RI; MPH Candidate, Brown University School of Public Health (G.K.), Providence, RI
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7
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de Havenon A, Skolarus LE, Mac Grory B, Bangad A, Sheth KN, Burke JF, Creutzfeldt CJ. National- and State-Level Trends in Medicare Hospice Beneficiaries for Stroke During 2013 to 2019 in the United States. Stroke 2024; 55:131-138. [PMID: 38063013 PMCID: PMC10752263 DOI: 10.1161/strokeaha.123.045021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/10/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Stroke is the fifth leading cause of death in the United States, one of the leading contributors to Medicare cost, including through Medicare hospice benefits, and the rate of stroke mortality has been increasing since 2013. We hypothesized that hospice utilization among Medicare beneficiaries with stroke has increased over time and that the increase is associated with trends in stroke death rate. METHODS Using Medicare Part A claims data and Centers for Disease Control mortality data at a national and state level from 2013 to 2019, we report the proportion and count of Medicare hospice beneficiaries with stroke as well as the stroke death rate (per 100 000) in Medicare-eligible individuals aged ≥65 years. RESULTS From 2013 to 2019, the number of Medicare hospice beneficiaries with stroke as their primary diagnosis increased 104.1% from 78 812 to 160 884. The number of stroke deaths in the United States in individuals aged ≥65 years also increased from 109 602 in 2013 to 129 193 in 2019 (17.9% increase). In 2013, stroke was the sixth most common primary diagnosis for Medicare hospice, while in 2019 it was the third most common, surpassed only by cancer and dementia. The correlation between the change from 2013 to 2019 in state-level Medicare hospice for stroke and stroke death rate for Medicare-eligible adults was significant (Spearman ρ=0.5; P<0.001). In a mixed-effects model, the variance in the state-level proportion of Medicare hospice for stroke explained by the state-level stroke death rate was 48.2%. CONCLUSIONS From 2013 to 2019, the number of Medicare hospice beneficiaries with a primary diagnosis of stroke more than doubled and stroke jumped from the sixth most common indication for hospice to the third most common. While increases in stroke mortality in the Medicare-eligible population accounts for some of the increase of Medicare hospice beneficiaries, over half the variance remains unexplained and requires additional research.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, Center for Brain & Mind Health, Yale University, New Haven, CT (A.d.H., A.B., K.N.S.)
| | - Lesli E Skolarus
- Department of Neurology, Northwestern University, Chicago, IL (L.E.S.)
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, NC (B.M.G.)
| | - Aaron Bangad
- Department of Neurology, Center for Brain & Mind Health, Yale University, New Haven, CT (A.d.H., A.B., K.N.S.)
| | - Kevin N Sheth
- Department of Neurology, Center for Brain & Mind Health, Yale University, New Haven, CT (A.d.H., A.B., K.N.S.)
| | - James F Burke
- Department of Neurology, Ohio State University, Columbus (J.F.B.)
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Wladkowski SP, Enguídanos S. Alzheimer's Disease and Related Dementias: Caregiver Perspectives on Hospice Re-Enrollment Following a Hospice Live Discharge. J Palliat Med 2023; 26:1374-1379. [PMID: 37155702 DOI: 10.1089/jpm.2023.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: The number of individuals dying of Alzheimer's disease and related dementias (ADRDs) is steadily increasing and they represent the largest group of hospice enrollees. In 2020, 15.4% of hospice patients across the United States were discharged alive from hospice care, with 5.6% decertified due to being "no longer terminally ill." A live discharge from hospice care can disrupt care continuity, increase hospitalizations and emergency room visits, and reduce the quality of life for patients and families. Furthermore, this discontinuity may impede re-enrollment into hospice services and receipt of community bereavement services. Objectives: The aim of this study is to explore the perspectives of caregivers of adults with ADRDs around hospice re-enrollment following a live discharge from hospice. Design: We conducted semistructured interviews of caregivers of adults with ADRDs who experienced a live discharge from hospice (n = 24). Thematic analysis was used to analyze data. Results: Three-quarters of participants (n = 16) would consider re-enrolling their loved one in hospice. However, some believed they would have to wait for a medical crisis (n = 6) to re-enroll, while others (n = 10) questioned the appropriateness of hospice for patients with ADRDs if they cannot remain in hospice care until death. Conclusions: A live discharge for ADRD patients impacts caregivers' decisions on whether they will choose to re-enroll a patient who has been discharged alive from hospice. Further research and support of caregivers through the discharge process are necessary to ensure that patients and their caregivers remain connected to hospice agencies postdischarge.
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Affiliation(s)
| | - Susan Enguídanos
- USC Leonard Davis School of Gerontology, Los Angeles, California, USA
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Odejide OO, Aldridge MD. Access to High-Quality Hospice Care in a For-Profit World. Oncologist 2023; 28:743-745. [PMID: 37487057 PMCID: PMC10485296 DOI: 10.1093/oncolo/oyad205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/20/2023] [Indexed: 07/26/2023] Open
Abstract
Evidence supporting the relief of suffering and improved end-of-life care provided by hospice is in contrast with recent media reports of cases of poor-quality care driven by profit-motivated hospices. This commentary presents a brief history of hospice and potential solutions to address the current challenges affecting access to high-quality hospice care.
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Affiliation(s)
- Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J. Peters Veterans Affairs Medical Center, Bronx, NYUSA
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10
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Aldridge MD, Hunt LJ, Harrison KL, McKendrick K, Li L, Morrison RS. Health Care Costs Associated With Hospice Use For People With Dementia In The US. Health Aff (Millwood) 2023; 42:1250-1259. [PMID: 37669483 DOI: 10.1377/hlthaff.2023.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Policy makers in the US are increasingly concerned that greater use of the Medicare hospice benefit by people with dementia is driving up costs. Yet this perspective fails to incorporate potential cost savings associated with hospice. We estimated the association between hospice use by people with dementia and health care costs, using Medicare Current Beneficiary Survey data from the period 2002-19. For community-dwelling people with dementia, Medicare costs were lower for those who used hospice than for those who did not, whether hospice enrollment was in the last three days ($2,200) or last three months ($7,200) of life, primarily through lower inpatient care costs in the last days of life. In nursing homes, total and Medicare costs were lower for hospice users with dementia who enrolled within a month of death than for those who did not use hospice. Total costs for the entire last year of life for those who used any days of hospice in the last year compared with no hospice did not differ, although Medicare costs were higher and Medicaid costs lower for those in nursing homes. Medicare policies that reduce hospice access and incentivize hospice disenrollment may actually increase Medicare costs, given that hospice cost savings generally derive from a person's last days or weeks of life.
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Affiliation(s)
- Melissa D Aldridge
- Melissa D. Aldridge , Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center, Bronx, New York
| | - Lauren J Hunt
- Lauren J. Hunt, University of California San Francisco, San Francisco, California
| | | | | | - Lihua Li
- Lihua Li, Icahn School of Medicine at Mount Sinai
| | - R Sean Morrison
- R. Sean Morrison, Icahn School of Medicine at Mount Sinai and James J. Peters Bronx Veterans Affairs Medical Center
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Hunt LJ, Gan S, Smith AK, Aldridge MD, Boscardin WJ, Harrison KL, James JE, Lee AK, Yaffe K. Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia. J Palliat Med 2023; 26:1100-1108. [PMID: 37010377 PMCID: PMC10440673 DOI: 10.1089/jpm.2023.0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 04/04/2023] Open
Abstract
Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Alexander K. Smith
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Krista L. Harrison
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer E. James
- Institute for Health and Aging, University of California, San Francisco, San Francisco, California, USA
| | - Alexandra K. Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
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Cross SH, Kavalieratos D. Public Health and Palliative Care. Clin Geriatr Med 2023; 39:395-406. [PMID: 37385691 PMCID: PMC10571066 DOI: 10.1016/j.cger.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Meeting the needs of people at the end of life (EOL) is a public health (PH) concern, yet a PH approach has not been widely applied to EOL care. The design of hospice in the United States, with its focus on cost containment, has resulted in disparities in EOL care use and quality. Individuals with non-cancer diagnoses, minoritized individuals, individuals of lower socioeconomic status, and those who do not yet qualify for hospice are particularly disadvantaged by the existing hospice policy. New models of palliative care (both hospice and non-hospice) are needed to equitably address the burden of suffering from a serious illness.
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Affiliation(s)
- Sarah H Cross
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA
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Gerlach LB, Zhang L, Strominger J, Kim HM, Teno J, Bynum JPW, Maust DT. Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing. J Am Geriatr Soc 2023; 71:2571-2578. [PMID: 36971013 PMCID: PMC10522794 DOI: 10.1111/jgs.18344] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing. METHODS Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics. RESULTS In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic- prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6-0.7, Hispanic RR 0.4, 95% CI 0.3-0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6-0.8, Hispanic RR 0.4, 95% CI 0.3-0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2-1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5-2.7) and antipsychotics (RR 2.7, 95% CI 2.6-2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3-2.4; antipsychotic: RR 2.3, 95% CI 2.2-2.4). Prescribing rates varied widely across Census regions. CONCLUSIONS Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.
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Affiliation(s)
- Lauren B. Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Lan Zhang
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Joan Teno
- Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Julie P. W. Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Donovan T. Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Colenda CC. Commentary on "Dementia Care at the End of Life: It's Time to Embrace Palliative Care". Am J Geriatr Psychiatry 2023; 31:304-306. [PMID: 36549994 DOI: 10.1016/j.jagp.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
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Anhang Price R, Parast L, Elliott MN, Tolpadi AA, Bradley MA, Schlang D, Teno JM. Association of Hospice Profit Status With Family Caregivers' Reported Care Experiences. JAMA Intern Med 2023; 183:311-318. [PMID: 36848095 PMCID: PMC9972244 DOI: 10.1001/jamainternmed.2022.7076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/24/2022] [Indexed: 03/01/2023]
Abstract
Importance Expansive growth in the US hospice market has been driven almost exclusively by an increase in for-profit hospices. Prior research found that, in contrast to not-for-profit hospices, for-profit hospices focus on delivering care to patients in nursing homes, provide fewer nursing visits, and use less skilled staff. However, prior studies have not reported on the associations of these differences in care patterns with hospice care quality. Patient- and family-centeredness is a core element of hospice care quality that is measured through surveys of care experiences. Objective To examine whether differences in profit status are associated with family caregivers' reports of hospice care experiences and assess factors that may be associated with observed differences in care experiences by profit status. Design, Setting, and Participants Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from 653 208 caregiver respondents, reflecting care received from 3107 hospices between April 2017 and March 2019, were used for a cross-sectional examination of hospice care experiences by profit status. Data analysis was performed from January 2020 to November 2022. Main Outcomes and Measures Outcomes were case-mix-adjusted and mode-adjusted top-box scores for 8 measures of hospice care experiences, including communication, timely care, symptom management, and emotional and religious support, as well as a summary score averaging across measures. Linear regression examined the association between profit status and hospice-level scores, adjusting for other organizational and structural hospice characteristics. Results There were 906 not-for-profit and 1761 for-profit hospices with mean (SD) time in operation of 25.7 (7.8) years and 13.8 (8.0) years, respectively. Mean (SD) decedent age at death was 82.8 (2.3) years, similar for not-for-profit and for-profit hospices. The mean proportion of patients who were Black, Hispanic, and White was 4.9%, 0.9%, and 91.4% for not-for-profit hospices and 9.0%, 2.2%, and 85.4% for for-profit hospices, respectively. Family caregivers reported worse care experiences at for-profit hospices than at not-for-profit hospices for all measures. Significant differences in average hospice performance by profit status remained after adjusting for hospice characteristics. However, for-profit hospice performance varied, with 548 of 1761 (31.1%) for-profit hospices scoring 3 or more points below the national hospice average of overall performance and 386 of 1761 (21.9%) scoring 3 or more points above the average. In contrast, only 113 of 906 (12.5%) not-for-profit hospices scored 3 or more points below the average, and 305 of 906 (33.7%) scored 3 or more points above the average. Conclusions and Relevance In this cross-sectional study of CAHPS Hospice Survey data, caregivers of patients receiving hospice care reported substantially worse care experiences in for-profit than in not-for-profit hospices; however, there was variation in reported experiences among both types of hospices. Public reporting of hospice quality is important.
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Gianattasio KZ, Power MC, Lupu D, Prather C, Moghtaderi A. Medicare Hospice Policy Changes and Beneficiaries' Rate of Live Discharge and Length-of-Stay. J Pain Symptom Manage 2023; 65:162-172. [PMID: 36526252 PMCID: PMC9928899 DOI: 10.1016/j.jpainsymman.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/18/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
CONTEXT The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of long hospice stays, and the 2016 two-tier payment system decreased daily reimbursement rates after 60 days of enrollment. Both aimed to reduce long stays. OBJECTIVES Examine how live discharge rates and length of stay changed in relation to the policies. METHODS We computed monthly hospice-level percent live discharges and length of stay using 2008-2019 Medicare hospice claims. We compared prepolicies trends and postpolicies trends overall, within Alzheimer's disease and related dementias (ADRD) patients, within lung cancer patients, and stratified by hospice ownership (for-profit vs. nonprofit/government-owned). RESULTS We included 10,539,912 and 10,453,025 episodes of care in the analytical samples for live discharge and length of stay analyses, respectively. Overall percent live discharges declined during the prepolicies period (-0.13 percentage-points per month, 95% CI: -0.14, -0.12), but exhibited no significant change during the postpolicies period. Trends were driven primarily by for-profits, with similar patterns within ADRD and lung cancer patients. Overall, mean length of stay increased over time, with greater rate of increase during the postpolicies period (0.41 days per month, 95% CI: 0.39, 0.42) compared to the prepolicies period (0.12 days per month, 95% CI: 0.10, 0.14). Length-of-stay increased faster among ADRD patients, but changed minimally for lung cancer patients. CONCLUSION Live discharge rates declined significantly during the prepolicies period, but plateaued after implementation of the policies, driven by changes in for-profits. However, the policies did not reduce length of stay, which increased at faster rates, suggesting that postpolicies excess live discharges were not restricted to long-stay patients.
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Affiliation(s)
- Kan Z Gianattasio
- Department of Health Policy and Management (K.Z.G., A.M.), George Washington University Milken Institute School of Public Health, Washington, DC; Department of Health Care Evaluation (K.Z.G.), NORC at the University of Chicago, Bethesda, Maryland.
| | - Melinda C Power
- Department of Epidemiology (M.C.P.), George Washington University Milken Institute School of Public Health, Washington, DC
| | - Dale Lupu
- George Washington University School of Nursing (D.L.), Washington, DC
| | - Christina Prather
- Division of Geriatrics and Palliative Medicine (C.P.), George Washington School of Medicine and Health Sciences, Washington, DC
| | - Ali Moghtaderi
- Department of Health Policy and Management (K.Z.G., A.M.), George Washington University Milken Institute School of Public Health, Washington, DC
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17
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Differences Between For-profit and Non-profit Hospice Agencies in the US Medicare Population. J Gen Intern Med 2022; 37:2582-2583. [PMID: 34236604 PMCID: PMC9360281 DOI: 10.1007/s11606-021-06982-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
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18
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Ankuda CK, Moreno J, Teno JM, Aldridge MD. Transitions from Home Health to Hospice: The Role of Agency Affiliation. J Palliat Med 2022; 25:873-879. [PMID: 34964665 PMCID: PMC9360178 DOI: 10.1089/jpm.2021.0390] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 01/31/2023] Open
Abstract
Background: Home health agencies (HHAs) are often affiliated with hospice agencies and commonly care for patients with serious illness within the Medicare program. HHAs may therefore provide a potential opportunity to facilitate timely referral to hospice when appropriate. Objectives: To determine if patients cared for by HHAs affiliated with hospice agencies experience differential hospice use and care patterns. Design: Nationally representative cohort study. Setting/Subjects: 1431 decedents in the 2002 to 2017 Medicare Current Beneficiary Survey who received home health in the last year of life in the United States. Measurements: Primary independent variable was HHA hospice affiliation. Primary dependent variable was hospice enrollment; secondary dependent variables were hospice live discharge and length of stay. Results: The 27.3% of decedents cared for by a HHA affiliated with a hospice had greater education levels and wealth and were more likely to live in the Midwest and Northeast. In adjusted models, HHA-hospice affiliated decedents had greater odds of enrolling in hospice compared to those cared for by HHAs not affiliated with a hospice, corresponding to a hospice enrollment rate of 51.0% for those cared for by HHAs affiliated with hospices versus 39.7% for HHAs not affiliated (p = 0.004). There were no differences in hospice length of stay or live discharge rate by hospice affiliation. Conclusion: Medicare beneficiaries cared for by HHAs affiliated with hospices are more likely to enroll in hospice at the end of life. This has implications for improving hospice access through home health incentives and models of care.
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Affiliation(s)
- Claire K. Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Melissa D. Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters Bronx Veterans Affairs Medical Center, Bronx, New York, USA
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19
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Reckrey JM, Ornstein KA, McKendrick K, Tsui EK, Morrison RS, Aldridge M. Receipt of Hospice Aide Visits Among Medicare Beneficiaries Receiving Home Hospice Care. J Pain Symptom Manage 2022; 63:503-511. [PMID: 34954065 PMCID: PMC8930441 DOI: 10.1016/j.jpainsymman.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Hospice aides provide essential direct care to hospice patients, yet there is minimal research examining hospice aide visits. OBJECTIVES describe the prevalence and frequency of hospice aide visits, and 2) evaluate patient, community, and hospice characteristics associated with these visits. METHODS Longitudinal cohort study of Medicare Current Beneficiary Survey (MCBS) participants who died between 2010-2018 and received routine hospice care in the 6 months prior to death (n = 674). We characterized prevalence and frequency of hospice aide visits over time and used generalized linear modelling to identify factors associated with visits. RESULTS 64% of hospice enrollees received hospice aide visits and average visit frequency (1.3 per week) remained stable throughout enrollment. The only patient characteristic associated with receipt of hospice aide visits was primary hospice diagnosis (respiratory diagnosis vs. dementia: OR 0.372, P = 0.040). Those living in community-based residential housing and those cared for by hospices with aides employed as staff were more likely to receive any hospice aide visits (OR 2.331, P = 0.047 and OR 4.612, P = 0.002, respectively.) CONCLUSION: Hospice aide visits are a common component of hospice care, but visit frequency does not increase as death approaches. Receipt of hospice aide visits was primarily associated with community and hospice agency (rather than patient) characteristics. Future work is needed to ensure that hospice aides are integrated in the hospice interdisciplinary team and that access to hospice aide visits is meaningfully driven by patient and family needs, rather than the practice norms and business models of individual hospice agencies.
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Affiliation(s)
- Jennifer M Reckrey
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York.
| | - Katherine A Ornstein
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York
| | - Karen McKendrick
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York
| | - Emma K Tsui
- CUNY Graduate School of Health and Health Policy (E.K..T.), New York, New York
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York; James J. Peters VA Medical Center (R.S.M., M.A.), Bronx, New York, USA
| | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai (J.M.R., K.A.O., K.M., R.S.M., M.A.), New York, New York; James J. Peters VA Medical Center (R.S.M., M.A.), Bronx, New York, USA
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20
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Aldridge MD, Hunt L, Husain M, Li L, Kelley A. Impact of Comorbid Dementia on Patterns of Hospice Use. J Palliat Med 2022; 25:396-404. [PMID: 34665050 PMCID: PMC8968839 DOI: 10.1089/jpm.2021.0055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: The evidence base for understanding hospice use among persons with dementia is almost exclusively based on individuals with a primary terminal diagnosis of dementia. Little is known about whether comorbid dementia influences hospice use patterns. Objective: To estimate the prevalence of comorbid dementia among hospice enrollees and its association with hospice use patterns. Design: Pooled cross-sectional analysis of the nationally representative Health and Retirement Study (HRS) linked to Medicare claims. Subjects: Fee-for-service Medicare beneficiaries in the United States who enrolled with hospice and died between 2004 and 2016. Measurements: Dementia was assessed using a validated survey-based algorithm. Hospice use patterns were enrollment less than or equal to three days, enrollment greater than six months, hospice disenrollment, and hospice disenrollment after six months. Results: Of 3123 decedents, 465 (14.9%) had a primary hospice diagnosis of dementia and 943 (30.2%) had comorbid dementia and died of another illness. In fully adjusted models, comorbid dementia was associated with increased odds of hospice enrollment greater than six months (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI]: 1.11-2.09) and hospice disenrollment following six months of hospice (AOR = 2.55, 95% CI: 1.43-4.553). Having a primary diagnosis of dementia was associated with increased odds of hospice enrollment greater than six months (AOR = 2.62, 95% CI: 1.86-3.68), hospice disenrollment (AOR = 1.82, 95% CI: 1.32-2.51), and hospice disenrollment following six months of hospice (AOR = 4.31, 95% CI: 2.37-7.82). Conclusion: Approximately 45% of the hospice population has primary or comorbid dementia and are at increased risk for long hospice enrollment periods and hospice disenrollment. Consideration of the high prevalence of comorbid dementia should be inherent in hospice staff training, quality metrics, and Medicare Hospice Benefit policies.
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Affiliation(s)
- Melissa D. Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters Bronx VA Medical Center, New York, New York, USA.,Address correspondence to: Melissa D. Aldridge, PhD, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Lauren Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Mohammed Husain
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lihua Li
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters Bronx VA Medical Center, New York, New York, USA
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21
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Aldridge MD, Moreno J, McKendrick K, Li L, Brody A, May P. Association Between Hospice Enrollment and Total Health Care Costs for Insurers and Families, 2002-2018. JAMA HEALTH FORUM 2022; 3:e215104. [PMID: 35977281 PMCID: PMC8903119 DOI: 10.1001/jamahealthforum.2021.5104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/07/2021] [Indexed: 12/19/2022] Open
Abstract
Importance Use of hospice has been demonstrated to be cost saving to the Medicare program and yet the extent to which hospice saves money across all payers, including whether it shifts costs to families, is unknown. Objective To estimate the association between hospice use and total health care costs including family out-of-pocket health care spending. Design Setting and Participants This retrospective cohort study of health care spending in the last 6 months of life used data from the nationally representative Medicare Current Beneficiary Survey (MCBS) between the years 2002 and 2018. Participants were MCBS participants who resided in the community and died between 2002 and 2018. Exposures Covariate balancing propensity scores were used to compare participants who used hospice (n = 2113) and those who did not (n = 3351), stratified by duration of hospice use. Main Outcomes and Measures Total health care expenditures were measured across payers (family out-of-pocket, Medicare, Medicare Advantage, Medicaid, private insurance, private health maintenance organizations, Veteran's Administration, and other) and by expenditure type (inpatient care, outpatient care, medical visits, skilled nursing, home health, hospice, durable medical equipment, and prescription drugs). Results The study population included 5464 decedents (mean age 78.7 years; 48% female) and 38% enrolled with hospice. Total health care expenditures were lower for those who used hospice compared with propensity score weighted non-hospice control participants for the last 3 days of life ($2813 lower; 95% CI, $2396-$3230); last week of life ($6806 lower; 95% CI, $6261-$7350); last 2 weeks of life ($8785 lower; 95% CI, $7971-$9600); last month of life ($11 747 lower; 95% CI, $10 072-$13 422); and last 3 months of life ($10 908 lower; 95% CI, $7283-$14 533). Family out-of-pocket expenditures were lower for hospice enrollees in the last 3 days of life ($71; 95% CI, $43-$100); last week of life ($216; 95% CI, $175-$256); last 2 weeks of life ($265; 95% CI, $149-$382); and last month of life ($670; 95% CI, $530-$811) compared with those who did not use hospice. Health care savings were associated with reductions in inpatient care. Conclusions and Relevance In this population-based cohort study of community-dwelling Medicare beneficiaries, hospice enrollment was associated with lower total health care costs for the last 3 days to 3 months of life. Importantly, we found no evidence of cost shifting from Medicare to families related to hospice enrollment. The magnitude of lower out-of-pocket spending to families who enrolled with hospice is meaningful to many Americans, particularly those with lower socioeconomic status.
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Affiliation(s)
- Melissa D. Aldridge
- Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters Bronx VA Medical Center, Bronx, New York
| | - Jaison Moreno
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Lihua Li
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ab Brody
- NYU Rory Meyers College of Nursing, New York, New York
- NYU Grossman School of Medicine, New York, New York
| | - Peter May
- Trinity College Dublin, Dublin, Ireland
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22
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Affiliation(s)
- Melissa D Aldridge
- Brookdale Dept of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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23
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Braun RT, Stevenson DG, Unruh MA. Acquisitions of Hospice Agencies by Private Equity Firms and Publicly Traded Corporations. JAMA Intern Med 2021; 181:1113-1114. [PMID: 33938919 PMCID: PMC8094028 DOI: 10.1001/jamainternmed.2020.6262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This case series examines the increase in acquisitions of hospice agencies by private equity firms and publicly traded corporations from 2011 to 2019.
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Affiliation(s)
- Robert Tyler Braun
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - David G Stevenson
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee.,The Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
| | - Mark Aaron Unruh
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
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24
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Osakwe ZT, Arora BK, Peterson ML, Obioha CU, Fleur-Calixte RS. Factors Associated With Home-Hospice Utilization. Home Healthc Now 2021; 39:39-47. [PMID: 33417361 DOI: 10.1097/nhh.0000000000000937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Utilization of hospice for end-of-life care is known to be lower among racial and ethnic minority groups than among White populations when controlling for other socioeconomic factors. Certain patient, provider, and community characteristics may influence home-hospice use. We sought to identify patient, provider, and community factors associated with home-hospice use. Our final analytic sample included 1,208,700 hospice patients who received home-hospice from 2,148 Medicare-certified hospice providers in 2016. We found that an increase in the proportion of hospice patients with a primary diagnosis of dementia decreased the odds that home-hospice was provided (OR = 1.42, 95% CI = 1.36-1.48). Patients who received hospice care from a provider with a higher proportion of dually enrolled patients were less likely to receive home-hospice (OR = 1.42, 95% CI = 1.36-1.48) and hospices located in ZIP-codes with higher proportion of Hispanic resident were less likely to provide home-hospice (OR = 1.00, 95% CI = 0.99-0.99). Additional research is needed to clarify the mechanisms underlying these associations.
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25
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Dressler G, Garrett SB, Hunt LJ, Thompson N, Mahoney K, Sudore RL, Ritchie CS, Harrison KL. "It's Case by Case, and It's a Struggle": A Qualitative Study of Hospice Practices, Perspectives, and Ethical Dilemmas When Caring for Hospice Enrollees with Full-Code Status or Intensive Treatment Preferences. J Palliat Med 2020; 24:496-504. [PMID: 33237830 DOI: 10.1089/jpm.2020.0215] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: Characterize hospice staff practices and perspectives on discussing end-of-life care preferences with patients/families, including those desiring intensive treatment and/or full code. Background: Patients in the United States can elect hospice while remaining full code or seeking intensive interventions, for example, blood transfusions, or chemotherapy. These preferences conflict with professional norms, hospice philosophy, and Medicare hospice payment policies. Little is known about how hospice staff manage patient/family preferences for full-code status and intensive treatments. Methods: We recruited employees of four nonprofit US hospices with varying clinical and hospice experience for semi-structured, in-depth interviews. Open-ended questions explored participants' practices and perceptions of discussing end-of-life care preferences in hospice, with specific probes about intensive treatment or remaining full code. Interdisciplinary researchers coded and analyzed data using the constant comparative method. Results: Participants included 25% executive leaders, 14% quality improvement administrative staff, 61% clinicians (23 nurses, 21 social workers, 7 physicians, and 2 chaplains). Participants reported challenges in engaging patients/families about end-of-life care preferences. Preferences for intensive treatment or full-code status presented an ethical dilemma for some participants. Participants described strategies to navigate such preferences, including educating about treatment options, and expressed diverse reactions, including accepting or attempting to shift enrollee preferences. Discussion: This study illuminates a rarely studied aspect of hospice care: how hospice staff engage with enrollees choosing full code and/or intensive treatments. Such patient preferences can produce ethical dilemmas for hospice staff. Enhanced communication training and guidelines, updated organizational and federal policies, and ethics consult services may mitigate these dilemmas.
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Affiliation(s)
- Gabrielle Dressler
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Sarah B Garrett
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Lauren J Hunt
- Department of Physiological Nursing, University of California, San Francisco, California, USA
| | - Nicole Thompson
- Osher Center for Integrative Medicine, University of California, San Francisco, San Francisco, California, USA
| | | | - Rebecca L Sudore
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Krista L Harrison
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
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26
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Rahman AN, Enguidanos S. In Search of Hospice Information: Consumer Information Available on Hospice Compare and Yelp. Palliat Med Rep 2020; 1:18-24. [PMID: 34223451 PMCID: PMC8241328 DOI: 10.1089/pmr.2020.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 11/24/2022] Open
Abstract
Background: The hospice industry has expanded in recent years with limited oversight and few consumer-facing resources to assist consumers in selecting hospice agencies to care for their family members. Objectives: To better understand the availability of consumer-facing hospice information and how hospices are evaluated by these websites, this study examined two websites with national reach—the Centers for Medicare and Medicaid Services' Hospice Compare (HC) website and Yelp.com. We described Yelp hospice ratings and caregiver-reported ratings on HC and compared conceptually related HC ratings to each other. Methods: We collected hospice ratings from Yelp and hospice- and caregiver-reported quality indicators (QIs) from HC for all California hospices. We conducted descriptive statistics for all variables and conducted chi-square to examine differences in proportions for categorical variables. We conducted Pearson's correlation coefficient (r) to test the strength of the association between the hospice-reported pain assessment QI and the caregiver-reported indicators on HC. Results: Among our sample of 1040 California hospices, HC reported QIs for 200 (19.2%) hospices for the caregiver-reported QIs ranging to 448 (43.1%) hospices for the hospice-reported QIs. Just 236 hospices (22.7%) had a Yelp review. Hospice ratings on both Yelp and HC were fairly high. For-profit hospices were less likely to show HC QIs or to be rated on Yelp. Caregiver-reported HC ratings for pain and symptom management were significantly lower than conceptually related HC hospice-reported QIs. Conclusions: More research is needed to understand the lack of hospice representation on HC and investigate the usefulness of hospice-reported HC measures.
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Affiliation(s)
- Anna N Rahman
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
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27
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Mathews J, Zimmermann C. Palliative care services at cancer centres — room for improvement. Nat Rev Clin Oncol 2020; 17:339-340. [DOI: 10.1038/s41571-020-0374-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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28
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Anhang Price R, Tolpadi A, Schlang D, Bradley MA, Parast L, Teno JM, Elliott MN. Characteristics of Hospices Providing High-Quality Care. J Palliat Med 2020; 23:1639-1643. [PMID: 32155376 DOI: 10.1089/jpm.2019.0505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: The hospice market has changed substantially, shifting from predominately not-for-profit independent entities to for-profit national chains. Little is known about how hospice organizational characteristics are associated with quality of hospice care. Objective: To examine the association between hospice characteristics and care processes and performance on measures of hospice care quality. Design: Logistic regression models assessed the association between hospice characteristics and processes and hospices being in the top quartile of quality measure performance. Setting/Subjects: U.S. hospices with publicly reported measure scores in 2015-2017. Measurements: Summaries of hospice-level performance on Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey measures (including communication, timely care, symptom management, emotional and spiritual support, respect, training families, overall rating, and willingness to recommend) and Hospice Item Set (HIS) measures (including pain screening and assessment, dyspnea screening and treatment, bowel regimen for patients on opioids, discussion of treatment preferences, and beliefs/values addressed). Results: Of the 2746 hospices that met public reporting requirements, 5.6% were in the top quartile of both CAHPS and HIS performance. Characteristics associated with being in the top quartile for CAHPS included being a nonprofit and nonchain or government hospice, smaller size (<200 patients per year), and serving a rural area. Characteristics associated with being in the top quartile for HIS included being in a for-profit chain, larger size (91+ patients per year), and having <40% of patients in a nursing home. Providing professional staff visits in the last two days of life to a higher proportion of patients was associated with hospices being in the top quartile of HIS and in the top quartile of CAHPS. Conclusions: Hospice characteristics associated with strong performance on HIS measures differ from those associated with strong performance on CAHPS measures. Providing professional staff visits in the last two days of life is associated with high performance on both quality domains.
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Affiliation(s)
| | | | | | | | | | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Brereton EJ, Matlock DD, Fitzgerald M, Venechuk G, Knoepke C, Allen LA, Tate CE. Content Analysis of Negative Online Reviews of Hospice Agencies in the United States. JAMA Netw Open 2020; 3:e1921130. [PMID: 32049299 PMCID: PMC8409083 DOI: 10.1001/jamanetworkopen.2019.21130] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE As online reviews of health care become increasingly integral to patient decision-making, understanding their content can help health care practices identify and address patient concerns. OBJECTIVE To identify the most frequently cited complaints in negative (ie, 1-star) online reviews of hospice agencies across the United States. DESIGN, SETTING, AND PARTICIPANTS This qualitative study conducted a thematic analysis of online reviews of US hospice agencies posted between August 2011 and July 2019. The sample was selected from a Hospice Analytics database. For each state, 1 for-profit (n = 50) and 1 nonprofit (n = 50) hospice agency were randomly selected from the category of extra-large hospice agencies (ie, serving >200 patients/d) in the database. Data analysis was conducted from January 2019 to April 2019. MAIN OUTCOMES AND MEASURES Reviews were analyzed to identify the most prevalent concerns expressed by reviewers. RESULTS Of 100 hospice agencies in the study sample, 67 (67.0%) had 1-star reviews; 33 (49.3%) were for-profit facilities and 34 (50.7%) were nonprofit facilities. Of 137 unique reviews, 68 (49.6%) were for for-profit facilities and 69 (50.4%) were for nonprofit facilities. A total of 5 themes emerged during the coding and analytic process, as follows: discordant expectations, suboptimal communication, quality of care, misperceptions about the role of hospice, and the meaning of a good death. The first 3 themes were categorized as actionable criticisms, which are variables hospice organizations could change. The remaining 2 themes were categorized as unactionable criticisms, which are factors that would require larger systematic changes to address. For both for-profit and nonprofit hospice agencies, quality of care was the most frequently commented-on theme (117 of 212 comments [55.2%]). For-profit hospice agencies received more communication-related comments overall (34 of 130 [26.2%] vs 9 of 82 [11.0%]), while nonprofit hospice agencies received more comments about the role of hospice (23 of 33 [69.7%] vs 19 of 31 [61.3%]) and the quality of death (16 [48.5%] vs 12 [38.7%]). CONCLUSIONS AND RELEVANCE Regarding actionable criticisms, hospice agencies could examine their current practices, given that reviewers described these issues as negatively affecting the already difficult experience of losing a loved one. The findings indicated that patients and their families, friends, and caregivers require in-depth instruction and guidance on what they can expect from hospice staff, hospice services, and the dying process. Several criticisms identified in this study may be mitigated through operationalized, explicit conversations about these topics during hospice enrollment.
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Affiliation(s)
- Elinor J Brereton
- Adult and Child Consortium for Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora
- Division of Geriatrics, University of Colorado School of Medicine, Aurora
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver
| | - Monica Fitzgerald
- Adult and Child Consortium for Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora
| | - Grace Venechuk
- Adult and Child Consortium for Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora
| | - Chris Knoepke
- Adult and Child Consortium for Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Larry A Allen
- Adult and Child Consortium for Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Channing E Tate
- Adult and Child Consortium for Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora
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Rahman AN, Rahman M. Home-Based Palliative Care: Toward a Balanced Care Design. J Palliat Med 2019; 22:1274-1280. [DOI: 10.1089/jpm.2019.0031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Anna Nolen Rahman
- University of Southern California, Leonard Davis School of Gerontology, Los Angeles, California
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31
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Abstract
This review proposes that the end of life is a uniquely contemporary life course stage. Epidemiologic, technological, and cultural shifts over the past two centuries have created a context in which dying has shifted from a sudden and unexpected event to a protracted, anticipated transition following an incurable chronic illness. The emergence of an end-of-life stage lasting for months or even years has heightened public interest in enhancing patient well-being, autonomy, and the receipt of medical care that accords with patient and family members' wishes. We describe key components of end-of-life well-being and highlight socioeconomic and race disparities therein, drawing on fundamental cause theory. We describe two practices that are critical to end-of-life well-being (advance care planning and hospice) and identify limitations that may undermine their effectiveness. We conclude with recommendations for future sociological research that could inform practices to enhance patient and family well-being at the end of life.
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Affiliation(s)
- Deborah Carr
- Department of Sociology, Boston University, Boston, Massachusetts 02215, USA
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Hughes MC, Vernon E. Closing the Gap in Hospice Utilization for the Minority Medicare Population. Gerontol Geriatr Med 2019; 5:2333721419855667. [PMID: 31276019 PMCID: PMC6598325 DOI: 10.1177/2333721419855667] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 03/10/2019] [Accepted: 04/04/2019] [Indexed: 12/19/2022] Open
Abstract
Background: Medicare spends about 20% more on the last year of life for Black and Hispanic people than White people. With lower hospice utilization rates, racial/ethnic minorities receive fewer hospice-related benefits such as lesser symptoms, lower costs, and improved quality of life. For-profit hospices have higher dropout rates than nonprofit hospices, yet target racial/ethnic minority communities more through community outreach. This analysis examined the relationship between hospice utilization and for-profit hospice status and conducted an economic analysis of racial/ethnic minority utilization. Method: Cross-sectional analysis of 2014 Centers for Medicare & Medicaid Services (CMS), U.S. Census, and Hospice Analytics data. Measures included Medicare racial/ethnic minority hospice utilization, for-profit hospice status, estimated cost savings, and several demographic and socioeconomic variables. Results: The prevalence of for-profit hospices was associated with significantly increased hospice utilization among racial/ethnic minorities. With savings of about $2,105 per Medicare hospice enrollee, closing the gap between the White and racial/ethnic minority populations would result in nearly $270 million in annual cost savings. Discussion: Significant disparities in hospice use related to hospice for-profit status exist among the racial/ethnic minority Medicare population. CMS and state policymakers should consider lower racial/ethnic minority hospice utilization and foster better community outreach at all hospices to decrease patient costs and improve quality of life.
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Affiliation(s)
- M Courtney Hughes
- Northern Illinois University, DeKalb, USA.,Relias Institute, Morrisville, NC, USA
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Systematic review of the hospice performance literature. Health Care Manage Rev 2019; 45:E23-E34. [PMID: 31233425 DOI: 10.1097/hmr.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospice is the key provider of end-of-life care to patients. As the number of U.S. hospice agencies has rapidly increased, the performance has been scrutinized more deeply. PURPOSE To foster understanding of how hospice performance is measured and what factors are associated with performance, we conducted a systematic review of empirical research on hospice performance in the United States. METHODS Both structure-process-outcome and structure-conduct-performance frameworks were applied to categorize and summarize the hospice performance literature. A total of 36 studies were included in the systematic review. RESULTS Hospice agencies adopted different strategies (e.g., service provision strategy and staffing strategy) to improve performance. Two strategic approaches (innovation and volunteer usage) were associated with better outcomes. Hospice organizational factors, market environment, and patient characteristics were related to hospice strategic conduct and performance. Majority of hospice performance studies have examined the relationship between hospice structure and strategic conduct/process, with fewer studies focusing on structure performance and even fewer concentrating on strategy performance. PRACTICE IMPLICATIONS Patient, organizational, and market factors are associated with hospice strategic conduct and performance. The majority of the literature considered the impact of hospice organizational characteristics, whereas only a few studies included patient and market factors. The summarization of factors that may influence hospice performance provides insight to different stakeholders.
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AbuDagga A, Weech-Maldonado R, Tian F. Organizational characteristics associated with the provision of cultural competency training in home and hospice care agencies. Health Care Manage Rev 2019; 43:328-337. [PMID: 27984407 PMCID: PMC5472501 DOI: 10.1097/hmr.0000000000000144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the increasing interest in community-based health care, little information exists on cultural competency training (CCT) and its predictors in this setting. PURPOSE We examined the associations between six organizational characteristics and the provision of CCT in home health care and hospice agencies. METHODOLOGY We used cross-sectional data from the agency component of the 2007 National Home and Hospice Care Survey. The CCT provision composite was composed of three items: whether the agency provides mandatory cultural training to understand cultural differences/beliefs that may affect delivery of services to (a) all administrators, clerical, and management staff; (b) all direct service providers; and (c) all volunteers. Organizational characteristics were volume, ownership status, chain membership, teaching status, Joint Commission accreditation status, and formal contracts. PRINCIPAL FINDINGS The weighted sample (n = 14,469) had a mean CCT provision score of 1.75 (range = 0-3). Our ordinal logistic regression model showed that Joint Commission accreditation increased CCT provision odds in the home health (odds ratio [OR] = 2.07, 95% confidence interval [CI] [1.01, 4.24]) and hospice (OR = 4.40, 95% CI [2.07, 9.38]) settings. Teaching status increased CCT provision odds (OR = 2.71, 95% CI [1.19, 6.17]) in the home health setting. Formal contracts increased CCT provision odds (OR = 4.03, 95% CI [1.80, 9.00]), whereas not-for-profit ownership decreased CCT provision odds (OR = 0.19; 95% CI [0.07, 0.50]) in the hospice setting. PRACTICE IMPLICATIONS Home health care and hospice agencies need to increase their CCT practices to overcome health disparities in an increasingly diverse and aging population.
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Affiliation(s)
- Azza AbuDagga
- Azza AbuDagga, PhD, MHA, is Health Services Researcher, Health Research Group, Public Citizen, Washington, DC. E-mail: . Robert Weech-Maldonado, PhD, MBA, is Professor and L.R. Jordan Endowed Chair, Department of Health Services Administration, University of Alabama at Birmingham. Fang Tian, PhD, MS, is Research Manager, Government and Academic Research, HealthCore, Inc., Alexandria, Virginia
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Bagcivan G, Bakitas M, Palmore J, Kvale E, Nichols AC, Howell SL, Dionne-Odom JN, Mancarella GA, Osisami O, Hicks J, Huang CHS, Tucker R. Looking Back, Moving Forward: A Retrospective Review of Care Trends in an Academic Palliative and Supportive Care Program from 2004 to 2016. J Palliat Med 2019; 22:970-976. [PMID: 30855204 DOI: 10.1089/jpm.2018.0410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To examine a rural-serving HBPC program's 12-year experience and historical trends to inform future program direction and expansion. Background: There is limited information about longitudinal trends in mature hospital-based palliative care (HBPC) programs serving racially diverse rural populations. Methods: This is a retrospective cross-sectional study of operational and patient-reported outcomes from the University of Alabama at Birmingham (UAB) Center for Palliative and Supportive Care (CPSC) inpatient (n=11,786) and outpatient (n=315) databases from October 2004 to March 2016. Results: Inpatients were a mean age of 63.7 years, male (50.1%), white (62.3%), general medicine referred (19.5%), primarily for goals of care (84.4%); 47.1% had "do not resuscitate/do not intubate" status and 46.9% were transferred to the Palliative Care and Comfort Unit (PCCU) after consultation. Median time from admission to consultation was three days, median PCCU length of stay (LOS) was four days, and median hospital LOS was nine days. Increased emergency department and cardiology referrals were notable in later years. Outpatients' mean age was 53.02 years, 63.5% were female, 76.8% were white, and 75.6% had a cancer diagnosis. Fatigue, pain, and disturbed sleep were the most common symptoms at the time of the visit; 34.6% reported mild-to-moderate depressive symptoms. Of patients reporting pain (64.8%), one-third had 50% or less relief from pain treatment. Discussion: The CPSC, which serves a racially diverse rural population, has demonstrated robust growth. We are poised to scale and spread our lessons learned to underserved communities.
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Affiliation(s)
- Gulcan Bagcivan
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama.,2Koc University School of Nursing, İstanbul, Turkey
| | - Marie Bakitas
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama.,3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jackie Palmore
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth Kvale
- 5Division of Geriatrics and Palliative Care, Department of Medicine, University of Texas, Austin, Texas
| | - Ashley C Nichols
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen L Howell
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - J Nicholas Dionne-Odom
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama.,3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gisella A Mancarella
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Oladele Osisami
- 1School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Jennifer Hicks
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chao-Hui Sylvia Huang
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rodney Tucker
- 3Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, Alabama.,4Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Wang SY, Hsu SH, Aldridge MD, Cherlin E, Bradley E. Racial Differences in Health Care Transitions and Hospice Use at the End of Life. J Palliat Med 2019; 22:619-627. [PMID: 30615546 DOI: 10.1089/jpm.2018.0436] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Although the fragmentation of end-of-life care has been well documented, previous research has not examined racial and ethnic differences in transitions in care and hospice use at the end of life. Design and Subjects: Retrospective cohort study among 649,477 Medicare beneficiaries who died between July 2011 and December 2011. Measurements: Sankey diagrams and heatmaps to visualize the health care transitions across race/ethnic groups. Among hospice enrollees, we examined racial/ethnic differences in hospice use patterns, including length of hospice enrollment and disenrollment rate. Results: The mean number of care transitions within the last six months of life was 2.9 transitions (standard deviation [SD] = 2.7) for whites, 3.4 transitions (SD = 3.2) for African Americans, 2.8 transitions (SD = 3.0) for Hispanics, and 2.4 transitions (SD = 2.7) for Asian Americans. After adjusting for age and sex, having at least four transitions was significantly more common for African Americans (39.2%; 95% confidence interval [CI]: 38.8-39.6%) compared with whites (32.5%, 95% CI: 32.3-32.6%), and less common among Hispanics (31.2%, 95% CI: 30.4-32.0%), and Asian Americans (26.5%, 95% CI: 25.5-27.5%). Having no care transition was significantly more common for Asian Americans (33.0%, 95% CI: 32.0-34.1%) and Hispanics (28.8%, 95% CI: 28.0-29.6%), compared with African Americans (19.2%, 95% CI: 18.9-19.5%) and whites (18.9%, 95% CI: 18.8-19.0%). Among hospice users, whites, African Americans, and Hispanics had similar length of hospice enrollment, which was significantly longer than that of Asian Americans. Nonwhite patients were significantly more likely than white patients to experience hospice disenrollment. Conclusions: Racial/ethnic differences in patterns of end-of-life care are marked. Future studies to understand why such patterns exist are warranted.
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Affiliation(s)
- Shi-Yi Wang
- 1 Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut.,2 Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Sylvia H Hsu
- 1 Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut.,3 Schulich School of Business, York University, Toronto, Ontario, Canada
| | - Melissa D Aldridge
- 4 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,5 Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
| | - Emily Cherlin
- 6 Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
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Factors Associated With Hospices' Nonparticipation in Medicare's Hospice Compare Public Reporting Program. Med Care 2018; 57:28-35. [PMID: 30489545 DOI: 10.1097/mlr.0000000000001016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To enhance the quality of hospice care and to facilitate consumers' choices, the Centers for Medicare and Medicaid Services (CMS) began the Hospice Quality Reporting Program, in which CMS posted the quality measures of participating hospices on its reporting website, Hospice Compare. Little is known about the participation rate and the types of nonparticipating hospices. OBJECTIVE To examine the factors associated with hospices' nonparticipation in Hospice Compare. RESEARCH DESIGN We analyzed data from the CMS 2016 Hospice Compare. "Nonparticipants" were those who did not submit any quality measure. With the data of the Provider of Service file, the Healthcare Cost Report Information System, and the Area Health Resources File, multivariate logistic regressions estimated the association between nonparticipants and hospice and market characteristics, including ownership, size, nurse staffing ratio, and market competition intensity. RESULTS Among the 4123 certified hospices subject to penalty from nonparticipation, 259 did not participate in Hospice Compare. California, New Mexico, Texas, and Wyoming had participation rates lower than 80%. Hospices that were for-profit, had no accreditation, had few nurses per patient day, provided no inpatient care, and were located in competitive markets were less likely to participate than other hospices. CONCLUSIONS Hospice Compare successfully motivated hospice in participating in the quality report program in most of states. For-profit hospices, hospices with less quality, and hospices located in competitive markets were less likely to participate. Further research is warranted to examine the quality of these nonparticipants, especially in the 4 states with a lower participation rate.
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Ghesquiere A, Bagaajav A, Metzendorf M, Bookbinder M, Gardner DS. Hospice Bereavement Service Delivery to Family Members and Friends With Bereavement-Related Mental Health Symptoms. Am J Hosp Palliat Care 2018; 36:370-378. [PMID: 30428680 DOI: 10.1177/1049909118812025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES: A sizable minority of those who lose a loved one in hospice will experience symptoms of bereavement-related mental health disorders. Though hospices offer services to bereaved informal caregivers (family members or friends) of patients, little is known about services offered or interest in them. Therefore, we sought to assess services offered by hospice staff and interest expressed by bereaved informal caregivers with symptoms of depression, anxiety, or complicated grief (CG). METHODS: De-identified electronic bereavement care charts of 3561 informal caregivers who lost someone in a large urban metropolitan hospice from October 1, 2015, to June 30, 2016, were reviewed. RESULTS: Of bereaved informal caregivers in the sample, 9.4% (n = 333) were positive for symptoms of depression, anxiety, or CG. The symptom-positive family members/friends were more likely than other family members/friends to be offered mailings, one-to-one counseling, telephone calls, and reference material. However, interest in most services by symptom-positive caregivers was low, with only 6% interested in one-to-one counseling and 7% interested in outside referral. DISCUSSION: The findings suggest that hospices offer a range of services to family members or friends with symptoms of anxiety, depression, and CG, but that there can be a gap between what is offered and in the interest levels of the bereaved. Engagement with symptomatic family members and friends could be enhanced in future work.
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Affiliation(s)
- Angela Ghesquiere
- 1 Brookdale Center for Healthy Aging, Hunter College of the City University of New York, New York, NY, USA
| | - Ariunsanaa Bagaajav
- 2 Silberman School of Social Work, Hunter College of the City University of New York, New York, NY, USA
| | - Marguerite Metzendorf
- 3 Bereavement and Creative Art Services, MJHS Hospice and Palliative Care, New York, NY, USA
| | | | - Daniel S Gardner
- 2 Silberman School of Social Work, Hunter College of the City University of New York, New York, NY, USA
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Stevenson D, Sinclair N. Complaints About Hospice Care in the United States, 2005–2015. J Palliat Med 2018; 21:1580-1587. [DOI: 10.1089/jpm.2018.0125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- David Stevenson
- Department of Health Policy, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Nicholas Sinclair
- Department of Health Policy, Vanderbilt School of Medicine, Nashville, Tennessee
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Dolin R, Holmes GM, Stearns SC, Kirk DA, Hanson LC, Taylor DH, Silberman P. A Positive Association Between Hospice Profit Margin And The Rate At Which Patients Are Discharged Before Death. Health Aff (Millwood) 2018; 36:1291-1298. [PMID: 28679817 DOI: 10.1377/hlthaff.2017.0113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death-a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program.
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Affiliation(s)
- Rachel Dolin
- Rachel Dolin is a fellow at the David A. Winston Health Policy Fellowship, in Washington, D.C. Previously, she was a National Science Foundation Graduate Research Fellow in the Department of Health Policy and Management, Gillings School of Global Public Health, at the University of North Carolina at Chapel Hill (UNC)
| | - G Mark Holmes
- G. Mark Holmes is an associate professor in the Department of Health Policy and Management, Gillings School of Global Public Health, and director of the Cecil G. Sheps Center for Health Services Research, both at UNC
| | - Sally C Stearns
- Sally C. Stearns is a professor in the Department of Health Policy and Management, Gillings School of Global Public Health, UNC
| | - Denise A Kirk
- Denise A. Kirk is an applications analyst in the North Carolina Rural Health Research Program at the Cecil G. Sheps Center for Health Services Research, UNC
| | - Laura C Hanson
- Laura C. Hanson is a professor of medicine in the Division of Geriatric Medicine, associate director of the Geriatric Fellowship Program, and director of the Palliative Care Program, all at UNC
| | - Donald H Taylor
- Donald H. Taylor Jr. is a professor in the Sanford School of Public Policy, Duke University, in Durham, North Carolina
| | - Pam Silberman
- Pam Silberman is a professor of the practice and director of the Executive Doctoral Program in Health Leadership, Department of Health Policy and Management, Gillings School of Global Public Health, and associate director for policy analysis at the Cecil G. Sheps Center for Health Services Research, all at UNC
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Abstract
The Affordable Care Act (ACA) expanded access to high-quality end-of-life care for Americans with serious illness, including cancer. Before the ACA was enacted in 2010, nearly 715,000 patients died in hospitals annually, despite evidence that most Americans prefer to die at home. Moreover, fewer than half of Medicare beneficiaries used hospice before death, despite evidence that hospice services improve cancer patients' quality of life near death and caregivers' bereavement outcomes. The ACA-stipulated programs and subsequent efforts were designed to address these deficiencies in access to high-quality end-of-life care. However, important gaps in coverage persist. In this article, we highlight the impact of the ACA on end-of-life care for individuals with and without cancer.
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Affiliation(s)
- Ravi B. Parikh
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alexi A. Wright
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
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Dolin R, Silberman P, Kirk DA, Stearns SC, Hanson LC, Taylor DH, Holmes GM. Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps? J Pain Symptom Manage 2018; 55:775-784. [PMID: 29180057 DOI: 10.1016/j.jpainsymman.2017.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/15/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year. OBJECTIVE The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases. METHODS We analyzed monthly hospice outcomes using 2012-2013 Medicare claims. RESULTS Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges. CONCLUSION Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care.
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Affiliation(s)
| | - Pam Silberman
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Denise A Kirk
- The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Laura C Hanson
- Palliative Care Program, Division of Geriatric Medicine, Center for Aging and Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - G Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Marmo S, Berkman C. Social Workers' Perceptions of Job Satisfaction, Interdisciplinary Collaboration, and Organizational Leadership. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2018; 14:8-27. [PMID: 29488858 DOI: 10.1080/15524256.2018.1437590] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
To address job satisfaction, and therefore employment retention, of hospice social workers, this study examined how relationships with other members of the interdisciplinary hospice team and perceptions of hospice leadership may be associated with job satisfaction of hospice social workers. The sample of 203 hospice social workers was recruited by e-mailing invitations to hospice social workers identified by hospice directors in three states, use of online social media sites accessed by hospice social workers, and snowball sampling. Study measures included professional experience, hospice characteristics, interdisciplinary collaboration, perception of servant leadership, and intrinsic and extrinsic job satisfaction. Variables significant in the model for intrinsic satisfaction were perception of servant leadership, interdisciplinary collaboration, and feeling valued by the hospice physician. Variables significant in the model for extrinsic satisfaction were perception of servant leadership, interdisciplinary collaboration, feeling valued by the hospice physician, and number of social workers at the hospice. Interdisciplinary collaboration was more important for intrinsic job satisfaction and leadership style was more important for extrinsic job satisfaction. Profit status of the hospice, experience of the social worker, caseload size, and other variables were not significant in either model. These results support previous findings that leadership style of the hospice director and relationships with hospice colleagues are important for hospice social workers' job satisfaction. Such low-cost modifications to the hospice work environment, albeit not simple, may improve job satisfaction of hospice social workers.
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Affiliation(s)
- Suzanne Marmo
- a Department of Social Work , Sacred Heart University , Fairfield , Connecticut , USA
| | - Cathy Berkman
- b Graduate School of Social Service , Fordham University , New York , New York , USA
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Rizzuto J, Aldridge MD. Racial Disparities in Hospice Outcomes: A Race or Hospice-Level Effect? J Am Geriatr Soc 2017; 66:407-413. [PMID: 29250770 DOI: 10.1111/jgs.15228] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To determine whether there is racial variation in hospice enrollees in rates of hospitalization and hospice disenrollment and, if so, whether systematic differences in hospice provider patterns explain the variation. DESIGN Longitudinal cohort study. SETTING Hospice. PARTICIPANTS Medicare beneficiaries (N = 145,038) enrolled in a national random sample of hospices (N = 577) from the National Hospice Survey and followed until death (2009-10). MEASUREMENTS We used Medicare claims data to identify hospital admissions, emergency department (ED) visits, and hospice disenrollment after hospice enrollment. We used a series of hierarchical models including hospice-level random effects to compare outcomes of blacks and whites. RESULTS In unadjusted models, black hospice enrollees were significantly more likely than white enrollees to be admitted to the hospital (14.9% vs 8.7%, odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.74-1.95), visit the ED (19.8% vs 13.5%, OR = 1.58, 95% CI = 1.50-1.66), and disenroll from hospice (18.1% vs 13.0%, OR = 1.48, 95% CI = 1.40-1.56). These results were largely unchanged after accounting for participant clinical and demographic covariates and hospice-level random effects. In adjusted models, blacks were at higher risk of hospital admission (OR = 1.75, 95% CI = 1.64-1.86), ED visits (OR = 1.61, 95% CI = 1.52-1.70), and hospice disenrollment (OR = 1.54, 95% CI = 1.45-1.63). CONCLUSION Racial differences in intensity of care at the end of life are not attributable to hospice-level variation in intensity of care. Differences in patterns of care between black and white hospice enrollees persist within the same hospice.
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45
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De Vleminck A, Morrison RS, Meier DE, Aldridge MD. Hospice Care for Patients With Dementia in the United States: A Longitudinal Cohort Study. J Am Med Dir Assoc 2017; 19:633-638. [PMID: 29153752 DOI: 10.1016/j.jamda.2017.10.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/02/2017] [Accepted: 10/05/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients with dementia form an increasing proportion of those entering hospice care. Little is known about the types of hospices serving patients with dementia and the patterns of hospice use, including timing of hospice disenrollment between patients with and without dementia. OBJECTIVES To characterize the hospices that serve patients with dementia, to compare patterns of hospice disenrollment for patients with dementia and without dementia, and to evaluate patient-level and hospice-level characteristics associated with hospice disenrollment. METHODS We used data from a longitudinal cohort study (2008-2011) of Medicare beneficiaries (n = 149,814) newly enrolled in a national random sample of hospices (n = 577) from the National Hospice Survey and followed until death (84% response rate). RESULTS A total of 7328 patients (4.9%) had a primary diagnosis of dementia. Hospices caring for patients with dementia were more likely to be for-profit, larger sized, provide care for more than 5 years, and serve a large (>30%) percentage of nursing home patients. Patients with dementia were less likely to disenroll from hospice in conjunction with an acute hospitalization or emergency department visit and more likely to disenroll from hospice after long enrollment periods (more than 165 days) as compared with patients without dementia. No significant difference was found between patients with and without dementia for disenrollment after shorter enrollment periods (less than 165 days). In the multivariable analyses, patients were more likely to be disenrolled after 165 days if they were served by smaller hospices and hospices that served a small percentage of nursing home patients. CONCLUSION Patients with dementia are significantly more likely to be disenrolled from hospice following a long enrollment period compared with patients without dementia. As the number of individuals with dementia choosing hospice care continues to grow, it is critical to address potential barriers to the provision of quality palliative care for this population near the end of life.
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Affiliation(s)
- Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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Mroz TM, Meadow A, Colantuoni E, Leff B, Wolff JL. Home Health Agency Characteristics and Quality Outcomes for Medicare Beneficiaries With Rehabilitation-Sensitive Conditions. Arch Phys Med Rehabil 2017; 99:1090-1098.e4. [PMID: 28943160 DOI: 10.1016/j.apmr.2017.08.483] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/15/2017] [Accepted: 08/24/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine associations between organizational characteristics of home health agencies (eg, profit status, rehabilitation therapy staffing model, size, and rurality) and quality outcomes in Medicare beneficiaries with rehabilitation-sensitive conditions, conditions for which occupational, physical, and/or speech therapy have the potential to improve functioning, prevent or slow substantial decline in functioning, or increase ability to remain at home safely. DESIGN Retrospective analysis. SETTING Home health agencies. PARTICIPANTS Fee-for-service beneficiaries (N=1,006,562) admitted to 9250 Medicare-certified home health agencies in 2009. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Institutional admission during home health care, community discharge, and institutional admission within 30 days of discharge. RESULTS Nonprofit (vs for-profit) home health agencies were more likely to discharge beneficiaries to the community (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13-1.33) and less likely to have beneficiaries incur institutional admissions within 30 days of discharge (OR, .93; 95% CI, .88-.97). Agencies in rural (vs urban) counties were less likely to discharge patients to the community (OR, .83; 95% CI, .77-.90) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.24; 95% CI, 1.18-1.30) and within 30 days of discharge (OR, 1.15; 95% CI, 1.10-1.22). Agencies with contract (vs in-house) therapy staff were less likely to discharge beneficiaries to the community (OR, .79, 95% CI, .70-.91) and more likely to have beneficiaries incur institutional admissions during home health (OR, 1.09; 95% CI, 1.03-1.15) and within 30 days of discharge (OR, 1.17; 95% CI, 1.07-1.28). CONCLUSIONS As payers continue to test and implement reimbursement mechanisms that seek to reward value over volume of services, greater attention should be paid to organizational factors that facilitate better coordinated, higher quality home health care for beneficiaries who may benefit from rehabilitation.
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Affiliation(s)
- Tracy M Mroz
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Ann Meadow
- Office of Research, Development, and Information, Centers for Medicare & Medicaid Services, Baltimore, MD
| | | | - Bruce Leff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of Geriatric Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Berry LL, Connor SR, Stuart B. Practical Ideas for Improving the Quality of Hospice Care. J Palliat Med 2017; 20:449-452. [PMID: 28186829 DOI: 10.1089/jpm.2017.0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Leonard L Berry
- 1 University Distinguished Professor, Regents Professor, Mays Business School, Texas A&M University , College Station, Texas.,2 Institute for Healthcare Improvement , Cambridge, Massachusetts
| | - Stephen R Connor
- 3 Worldwide Hospice Palliative Care Alliance , Fairfax Station, Virginia
| | - Brad Stuart
- 4 Advanced Care Innovation Strategies , Forestville, California
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Stevenson DG, Dalton JB, Grabowski DC, Huskamp HA. Nearly half of all Medicare hospice enrollees received care from agencies owned by regional or national chains. Health Aff (Millwood) 2017; 34:30-8. [PMID: 25561641 DOI: 10.1377/hlthaff.2014.0599] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Analyses of ownership in the US hospice sector have focused on the growth of for-profit hospice care and on aggregate differences in patient populations and service use patterns between for-profit and not-for-profit agencies. Such comparisons, although useful, do not offer insights about the types of organizations within the hospice sector, including the emergence of multiagency chains. Using Medicare cost report data for the period 2000-11, we tracked the evolution of the US hospice industry. We not only describe the market's composition by profit status but also provide new information about the roles of regional and national chains. Almost half of all Medicare hospice enrollees in 2011 received hospice services from a multiagency chain. A handful of companies play a prominent role, although the presence of smaller for-profit and not-for-profit hospice chains also has grown in recent years. By focusing on the role of the diverse organizations that provide hospice care, our analyses can help inform efforts to monitor and assure quality of care, to assess payment adequacy and options for reform, and to facilitate greater transparency and accountability within the hospice marketplace.
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Affiliation(s)
- David G Stevenson
- David G. Stevenson is an associate professor in the Department of Health Policy at Vanderbilt University, in Nashville, Tennessee
| | - Jesse B Dalton
- Jesse B. Dalton is a research analyst in the Department of Health Care Policy at Harvard Medical School, in Boston, Massachusetts
| | - David C Grabowski
- David C. Grabowski is a professor of health care policy at Harvard Medical School
| | - Haiden A Huskamp
- Haiden A. Huskamp is a professor of health care policy at Harvard Medical School
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Oud L. Predictors of Transition to Hospice Care Among Hospitalized Older Adults With a Diagnosis of Dementia in Texas: A Population-Based Study. J Clin Med Res 2017; 9:23-29. [PMID: 27924171 PMCID: PMC5127211 DOI: 10.14740/jocmr2783w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Decedent 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. METHODS We 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. RESULTS There 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)). CONCLUSIONS This 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.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX 79763, USA.
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50
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Wang SY, Aldridge MD, Canavan M, Cherlin E, Bradley E. Continuous Home Care Reduces Hospice Disenrollment and Hospitalization After Hospice Enrollment. J Pain Symptom Manage 2016; 52:813-821. [PMID: 27697564 PMCID: PMC5154927 DOI: 10.1016/j.jpainsymman.2016.05.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/20/2016] [Accepted: 05/25/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT Among the four levels of hospice care, continuous home care (CHC) is the most expensive care, and infrequently provided in practice. OBJECTIVES To identify hospice and patient characteristics associated with the use of CHC and to examine the associations between CHC utilization and hospice disenrollment or hospitalization after hospice enrollment. METHODS Using 100% fee-for-service Medicare claims data for beneficiaries aged 66 years or older who died between July and December 2011, we identified the percentage of hospice agencies in which patients used CHC in 2011 and determined hospice and patient characteristics associated with the use of CHC. Using multivariable analyses, we examined the associations between CHC utilization and hospice disenrollment and hospitalization after hospice enrollment, adjusted for hospice and patient characteristics. RESULTS Only 42.7% of hospices (1533 of 3592 hospices studied) provided CHC to at least one patient during the study period. Patients enrolled with for-profit, larger, and urban located hospices were more likely to use CHC (P < 0.001). Within these 1533 hospices, only 11.4% of patients used CHC. Patients who were white, had cancer, and had more comorbidities were more likely to use CHC. In multivariable models, compared with patients who did not use CHC, patients who used CHC were less likely to have hospice disenrollment (adjusted odds ratio 0.21; 95% CI 0.19, 0.23) and less likely to be hospitalized after hospice enrollment (adjusted odds ratio 0.37; 95% CI 0.34, 0.40). CONCLUSION Although a minority of patients uses CHC, such services may be protective against hospice disenrollment and hospitalization after hospice enrollment.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Melissa D Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J. Peters VA Medical Center, Bronx, New York, USA
| | - Maureen Canavan
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Emily Cherlin
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Elizabeth Bradley
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
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