Hospice eligibility in patients who died in a tertiary care center

Oncology hospitalist impact on hospice utilization

BACKGROUND

Unplanned hospitalizations among patients with advanced cancer are often sentinel events prompting goals of care discussions and hospice transitions. Late referrals to hospice, especially those at the end of life, are associated with decreased quality of life and higher total health care costs. Inpatient management of patients with solid tumor malignancies is increasingly shifting from oncologists to oncology hospitalists. However, little is known about the impact of oncology hospitalists on the timing of transition to hospice.

OBJECTIVE

To compare hospice discharge rate and time to hospice discharge on an inpatient oncology service led by internal medicine-trained hospitalists and a service led by oncologists.

METHODS

At Smilow Cancer Hospital, internal medicine-trained hospitalists were integrated into one of two inpatient medical oncology services allowing comparison between the new, hospitalist-led service (HS) and the traditional, oncologist-led service (TS). Discharges from July 26, 2021, through January 31, 2022, were identified from the electronic medical record. The odds ratio for discharge disposition by team was calculated by logistic regression using a multinomial distribution. Adjusted length of stay before discharge was assessed using multivariable linear regression.

RESULTS

The HS discharged 47/400 (11.8%) patients to inpatient hospice, whereas the TS service discharged 18/313 (5.8%), yielding an adjusted odds ratio of 1.94 (95% CI, 1.07-3.51; p = .03). Adjusted average length of stay before inpatient hospice disposition was 6.83 days (95% CI, 4.22-11.06) for the HS and 16.29 days (95% CI, 7.73-34.29) for the TS (p = .003).

CONCLUSIONS

Oncology hospitalists improve hospice utilization and time to inpatient hospice referral on an inpatient medical oncology service.

PLAIN LANGUAGE SUMMARY

Patients with advanced cancer are often admitted to the hospital near the end of life. These patients generally have a poor chance of long-term survival and may prefer comfort-focused care with hospice. In this study, oncology hospitalists discharged a higher proportion of patients to inpatient hospice with less time spent in the hospital before discharge.

Factors Associated With Inpatient Hospice Utilization Among Hospitalized Decedents With Comfort Measures Only Status

Background: Patients with serious illness may elect to transition their care to comfort measures only (CMO) while in the hospital. Although studies have shown that routine hospice care is underutilized, the rate of general inpatient hospice (GIP) use among CMO patients during their terminal admission remains unclear. Objectives: We sought to (1) examine the rate of GIP utilization and (2) identify factors associated with its use among hospitalized CMO decedents. Methods: CMO decedents in two academic, tertiary care hospitals in the United States who died between October 1, 2020 and October 31, 2021, were subgrouped based on their primary medical service (GIP vs. non-GIP) at the time of inpatient death. Data abstracted from the electronic health record included demographics, primary diagnosis codes, Rothman Index (RI), time of CMO order, ordering clinician type, time of death, and length of stay (LOS). Multivariable logistic regression analysis was performed, adjusting for relevant covariates. Results: Of 1475 CMO decedents, only 321 (n = 22%) patients received GIP. On multivariable analysis, CMO patients who died in an ICU were five times less likely (odds ratio [OR] = 0.18, confidence interval [95% CI] 0.11-0.29) to receive GIP. Every 10-point increase in RI raised the likelihood of receiving GIP by 59% (OR = 1.59, 95% CI 1.39-1.80). Conclusions: Most CMO decedents died in the hospital without GIP. Compared with GIP decedents, non-GIP decedents were less acutely ill. There was no difference in total LOS between the two groups. CMO decedents were much less likely to receive GIP in an ICU. The RI may help clinicians identify CMO patients who would benefit from GIP earlier in their terminal admission.

What happens during early outpatient palliative care consultations for persons with newly diagnosed advanced cancer? A qualitative analysis of provider documentation

BACKGROUND

Early outpatient palliative care consultations are recommended by clinical oncology guidelines globally. Despite these recommendations, it is unclear which components should be included in these encounters.

AIM

Describe the evaluation and treatment recommendations made in early outpatient palliative care consultations.

DESIGN

Outpatient palliative care consultation chart notes were qualitatively coded and frequencies tabulated.

SETTING/PARTICIPANTS

Outpatient palliative care consultations were automatically triggered as part of an early versus delayed randomized controlled trial (November 2010 to April 2013) for patients newly diagnosed with advanced cancer living in the rural Northeastern US.

RESULTS

In all, 142 patients (early = 70; delayed = 72) had outpatient palliative care consultations. The top areas addressed in these consultations were general evaluations-marital/partner status (81.7%), spirituality/emotional well-being (80.3%), and caregiver/family support (79.6%); symptoms-mood (81.7%), pain (73.9%), and cognitive/mental status (68.3%); general treatment recommendations-counseling (39.4%), maintaining current medications (34.5%), and initiating new medication (23.9%); and symptom-specific treatment recommendations-pain (22.5%), constipation (12.7%), depression (12.0%), advanced directive completion (43.0%), identifying a surrogate (21.8%), and discussing illness trajectory (21.1%). Compared to the early group, providers were more likely to evaluate general pain ( p = 0.035) and hospice awareness ( p = 0.005) and discuss/recommend hospice ( p = 0.002) in delayed group participants.

CONCLUSION

Outpatient palliative care consultations for newly diagnosed advanced cancer patients can address patients' needs and provide recommendations on issues that might not otherwise be addressed early in the disease course. Future prospective studies should ascertain the value of early outpatient palliative care consultations that are automatically triggered based on diagnosis or documented symptom indicators versus reliance on oncologist referral.

Identifying Advanced Illness Patients in the Emergency Department and Having Goals-of-Care Discussions to Assist with Early Hospice Referral

BACKGROUND

The emergency department (ED) is often where patients with advanced illness (AI) present when faced with an acute deterioration in their disease.

OBJECTIVES

To investigate the effectiveness of our AI Management program in the ED on key outcomes.

METHODS

We conducted a pre-post study with a retrospective chart review with ED patients at an academic, tertiary care hospital in the New York metropolitan area. We assessed changes from baseline to intervention period on percent of patients identified in the ED with AI, percent who received an ED-led goals-of-care (GOC) discussion, and percent referred to hospice from the ED. We used the Fisher's exact test or the Mann-Whitney test to compare groups, as appropriate.

RESULTS

Our sample consisted of 82 patients (21 baseline and 61 intervention). Patients in the baseline period had a median age of 75 years, with 61.9% being female, whereas those in the intervention period had a median age of 83 years, with 67.2% being female. Patients in the intervention, compared with baseline, were significantly more likely to be identified as having AI in the ED (90.2% vs. 0.0%; p < 0.0001), to receive an ED-led GOC conversation (83.6% vs. 0.0%; p < 0.0001), and to be discharged to home hospice (39.3% vs. 0.0%; p < 0.0001).

CONCLUSIONS

The ED provides a critical opportunity to identify AI patients, have ED-led GOC discussions, and refer appropriate patients to hospice.

Post-Discharge Survival Outcomes of Patients with Advanced Cancer from the University of Texas MD Anderson Cancer Center Investigational Cancer Therapeutics (Phase I Trials) Inpatient Unit

BACKGROUND

Patients with advanced cancer who progress on standard therapy are potential candidates for phase I clinical trials. Due to their aggressive disease and complex comorbid conditions, these patients often need inpatient admission. This study assessed the outcomes of such patients after they were discharged to hospice care.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with solid tumor malignancies who were discharged to hospice care from the inpatient service.

RESULTS

One hundred thirty-three patients were included in the study cohort. All patients had metastatic disease and an Eastern Cooperative Oncology Group performance status ≥3. The median survival after discharge to hospice from an inpatient setting was 16 days, with a survival rate of 5% at 3 months after discharge. The median survival after the last cancer treatment was 46 days, with survival of 17% at 3 months, and 5% at 6 months. Patients with lactate dehydrogenase (LDH) >618 IU/L had a median post-discharge survival of 11 days versus 20 days for patients with LDH ≤618 IU/L.

CONCLUSIONS

Patients with metastatic cancer participating in phase I trials who have poor performance status and require inpatient admission have a very short survival after discharge to hospice. A high LDH level predicts an even shorter survival.

Redesigning Advanced Cancer Care Delivery: Three Ways to Create Higher Value Cancer Care

The authors believe their cancer care model constructed from quality-improving strategies has potential to help US clinicians respond effectively to an urgent policy imperative.

Verwijzen naar het hospice: verwijsgedrag van artsen en ervaren belemmeringen in Deventer en omgeving

PHYSICIANS' REFERRAL PATTERNS AND PERCEIVED BARRIERS IN THE DEVENTER REGION IN THE NETHERLANDS:

OBJECTIVE

To examine physicians' perceived referral patterns and barriers to referral of terminally ill patients to a hospice (institute).

DESIGN

Survey study among physicians practicing in hospital and other settings in the region of Deventer, The Netherlands, in 2011-2012.

METHOD

We translated two available American instruments into Dutch. The questionnaire assessed hospice referral, knowledge about hospice, attitudes and barriers and reasons not to refer. We queried physicians who had referred patients to the local hospice about expectations and suggested areas for improvement with two open-ended items.

RESULTS

In total, 240 physicians received the questionnaire. The response rate was 47%. The physicians were generally positive about hospice care. They indicated experiencing few barriers in hospice referrals, but 32% of the physicians (21% of those practicing in the hospital, and 39% in other settings), indicated the patient being unready as a strong barrier. Half of the physicians (51%) believed that hospice is being underutilized and 22% (35% and 14%, respectively) thought that they would refer more frequently if they had more knowledge about hospice care. Of the physicians, 35% answered all six knowledge questions correctly. Communication with the hospice may be improved.

CONCLUSION

Despite positive attitudes toward hospice care, it may be underutilized due to poor knowledge and communication with the hospice. Perhaps, this is also due to limited patient-physician communication on prognosis, which further research may address.

Delivering maximum clinical benefit at an affordable price: engaging stakeholders in cancer care

Cancer costs continue to increase alarmingly despite much debate about how they can be reduced. The oncology community needs to take greater responsibility for our own practice patterns, especially when using expensive tests and treatments with marginal value: we cannot continue to accept novel therapeutics with very small benefits for exorbitant prices. Patients, payers, and pharmaceutical communities should be constructively engaged to communicate medically and economically possible goals, and eventually, to reduce use and costs. Diagnostic tests and treatments should have to show true value to be added to existing protocols. In this article, we discuss three key drivers of costs: end-of-life care patterns, medical imaging, and drugs. We propose health-care models that have the potential to decrease costs and discuss solutions to maintain clinical benefit at an affordable price.

Patterns of hospice use in patients dying from hematologic malignancies

BACKGROUND

Hospice brings substantial clinical benefits to dying patients and families but is underutilized by patients dying of hematologic malignancies (HM); nationwide, only 2% of HM patients use hospice. There are 70,000 deaths among U.S. patients with hematologic malignancies yearly.

OBJECTIVE

We measured the use and length of stay (LOS) in hospice among patients with HMs at a large academic cancer center.

DESIGN

This was a single center retrospective review of adult patients (≥18 years) with lymphoma, leukemia, myelodysplastic syndrome, aplastic anemia, and multiple myeloma referred for hospice.

MEASUREMENTS

Information included demographics, transplant, hospice type, LOS, and use of "expanded access" services.

RESULTS

Fifty-nine patients were referred to hospice, and 53 utilized hospice services, 25% of 209 HM decedents. Thirty-five received home hospice and 18 used inpatient hospice. The median home hospice LOS was nine days (SD 13) and inpatient hospice six days (SD 10). Nine patients with "expanded access" hospice received only a few blood transfusions, and none received radiation.

CONCLUSIONS

HM patients are referred late or never for hospice services. Studies evaluating earlier integration of palliative and hospice care with usual HM care are warranted. We present a one-page negotiation form that we have found useful in negotiations among HM physicians, hospice medical directors, and payers.

Medical manuscripts impact of hospice enrollment on cost and length of stay of a terminal admission

OBJECTIVE

To determine whether hospice enrollment at the time of a terminal admission alters the length of stay (LOS) or costs compared with patients not enrolled in hospice.

METHODS

Retrospective chart review of all nontraumatic inpatient deaths of patients with a previous admission in the preceding 12 months at an academic hospital.

RESULTS

209 patients had a nontraumatic death and an admission in the year prior to the terminal admission. Patients enrolled in hospice had a shorter LOS (P = .02) and lower cost (P < .0001) than patients not enrolled at the time of their terminal admission.

CONCLUSIONS

Enrollment in hospice during a terminal admission decreased cost and LOS. Hospice may be a way to provide more cost-effective, appropriate care to dying patients.

Perceptions and Attitudes About Hospice and Palliative Care Among Community-Dwelling Older Adults

It is expected that the American geriatric population will have an increased need for hospice and palliative care services over the next few decades. We surveyed 187 community dwelling older adults about several aspects related to end-of-life (EOL) care. Participants were much more familiar with the term hospice than palliative care. In general, they had positive attitudes towards hospice and palliative care. Although experience caring for a dying relative was common, it wasn't associated with better attitudes towards hospice and palliative care or better familiarity with these terms. Familiarity with the term palliative care was associated with better attitudes towards EOL care. Our findings highlight the need for enhanced end-of-life care education among older adults, and reinforce the need for further research in this area.

Reducing the cost of cancer care: how to bend the curve downward

Health care and cancer care costs are rising unsustainably such that insurance costs have doubled in 10 years. Oncologists find themselves both victims of high costs and the cause of high-cost care by what we do and what we do not do. We previously outlined five ways that oncologists could personally bend the cost curve downward and five societal attitudes that would require change to lower costs. Here, we present some practical ways to reduce costs while maintaining or improving quality, including: 1) evidence-based surveillance after curative therapy; 2) reduced use of white cell stimulating factors (filgrastim and pegfilgrastim); 3) better integration of palliative care into usual oncology care; and 4) use of evidence-based, cost-conscious clinical pathways that allow appropriate care and lead to equal or better outcomes at one-third lower cost.