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Rezaeiahari M, Brown CC, Schmit T, Tilford JM. Economic Report of General Inpatient Hospice in an Academic Medical Center. Am J Hosp Palliat Care 2024; 41:800-804. [PMID: 37772492 DOI: 10.1177/10499091231204971] [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: 09/30/2023] Open
Abstract
This study examined if there was difference in cost of care after implementation of scattered bed inpatient hospice, first implemented in October 2021 in an Academic Medical Center in Arkansas. This retrospective, cross-sectional study compared the cost of care during the pre-implementation phase (n = 121, July 2020-March 2021) to patients admitted to hospice care (n = 84, October 2021-June 2022). Hospice length of stay (LOS) was 4 times longer than the LOS after a Do Not Resuscitate order (DNR) was placed for patients in the pre-implementation period. The end of life costs after the implementation of inpatient hospice was 69% less than the end of life costs in the pre-implementation period.
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Affiliation(s)
- Mandana Rezaeiahari
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Clare C Brown
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Troy Schmit
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J Mick Tilford
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Corr CA. Some Reflections on the 50th Anniversary of Hospice Care in America. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231218217. [PMID: 38039094 DOI: 10.1177/00302228231218217] [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: 12/03/2023]
Abstract
This article celebrates the 50th anniversary of hospice care in America. It also offers a brief recounting of one person's reflections on some aspects of the history, achievements, and current status of American hospice care.
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Affiliation(s)
- Charles A Corr
- School of Humanities, Southern Illinois University at Edwardsville, Edwardsville, IL, USA
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3
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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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4
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Zhang Y, Shao H, Zhang M, Li J. Healthcare Utilization and Mortality After Hospice Live Discharge Among Medicare Patients With and Without Alzheimer's Disease and Related Dementias. J Gen Intern Med 2023; 38:2272-2278. [PMID: 36650330 PMCID: PMC10406979 DOI: 10.1007/s11606-023-08031-8] [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: 09/16/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Little is known about post-discharge outcomes among patients who were discharged alive from hospice. OBJECTIVE To compare healthcare utilization and mortality after hospice live discharge among Medicare patients with and without Alzheimer's disease and related dementias (ADRD). DESIGN Retrospective cohort study using Medicare claims data of a 20% random sample of Medicare fee-for-service (FFS) patients. PARTICIPANTS A total of 153,696 Medicare FFS patients experienced live discharge from hospice between 2014 and 2019. MEASURES Two types of burdensome transition (type 1: live discharge from hospice followed by hospitalization and subsequent hospice readmission; type 2: live discharge from hospice followed by hospitalization with the patient deceased in the hospital), acute care utilization, hospice readmission, and mortality in the 30 and 180 days after live discharge and between live discharge and death. RESULTS Compared with non-ADRD patients, ADRD patients were less likely to experience burdensome transitions (type 1: adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.90-0.98; type 2: aOR, 0.70; 95% CI, 0.65-0.75), more likely to have ED visits (aOR, 1.05; 95% CI, 1.01-1.09), less likely to die (aOR, 0.71; 95% CI, 0.69-0.73), and less likely to be readmitted to hospice (aOR, 0.86; 95% CI, 0.84-0.89) 30 days after live discharge. Results of 180-day post-discharge outcomes were largely consistent with results of 30-day outcomes. Among patients who died as of December 31, 2019, ADRD patients were less likely to be hospitalized (aOR, 0.88; 95% CI, 0.85-0.92) and more likely to be readmitted to hospice (aOR, 1.12; 95% CI, 1.08-1.16) between live discharge and death. Significant racial/ethnicity disparities in acute care utilization and mortality after live discharge existed in both ADRD and non-ADRD groups. CONCLUSION ADRD patients had lower mortality, a longer survival time, a lower rate of hospitalization, and an initially lower but gradually increasing rate of hospice readmission than non-ADRD patients after hospice live discharge. These different trajectories warrant further investigation of the eligibility of their initial hospice enrollment. Black patients had significantly worse outcomes after hospice live discharge compared with White patients.
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Affiliation(s)
- Yongkang Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, 402 East 67th Street, New York, NY, 10065, USA.
| | - Hui Shao
- Center for Drug Evaluation and Safety, Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Manyao Zhang
- Department of Population Health Sciences, Weill Medical College of Cornell University, 402 East 67th Street, New York, NY, 10065, USA
| | - Jing Li
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
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5
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Li Z, Hung P, Shi K, Fu Y, Qian D. Association of rurality, type of primary caregiver and place of death with end-of-life medical expenditures among the oldest-old population in China. Int J Equity Health 2023; 22:1. [PMID: 36597134 PMCID: PMC9809123 DOI: 10.1186/s12939-022-01813-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 12/21/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Understanding whether the type of primary caregiver and end-of-life (EOL) care location are associated with EOL medical expenditures is crucial to inform global debates on policies for efficient and effective EOL care. This study aims to assess trends in the type of primary caregiver and place of death stratified by rural‒urban status among the oldest-old population from 1998-2018 in China. A secondary objective is to determine the associations between rurality, the type of primary caregiver, place of death and EOL medical expenditures. METHODS: A total of 20,149 deaths of people aged 80 years or older were derived from the Chinese Longitudinal Health Longevity Survey (CLHLS). Cochran-Armitage tests and Cuzick's tests were used to test trends in the type of primary caregiver and place of death over time, respectively. Tobit models were used to estimate the marginal associations of rurality, type of primary caregiver, and place of death with EOL medical expenditures because CLHLS sets 100,000 Chinese yuan (approximately US$15,286) as the upper limit of the outcome variable. RESULTS: Of the 20,149 oldest-old people, the median age at death was 97 years old, 12,490 (weighted, 58.6%, hereafter) were female, and 8,235 lived in urban areas. From 1998-2018, the prevalence of informal caregivers significantly increased from 94.3% to 96.2%, and home death significantly increased from 86.0% to 89.5%. The proportion of people receiving help from informal caregivers significantly increased in urban decedents (16.5%) but decreased in rural decedents (-4.0%), while home death rates significantly increased among both urban (15.3%) and rural (1.8%) decedents. In the adjusted models, rural decedents spent less than urban decedents did (marginal difference [95% CI]: $-229 [$-378, $-80]). Those who died in hospitals spent more than those who died at home ($798 [$518, $1077]). No difference in medical expenditures by type of primary caregiver was observed. CONCLUSIONS Over the past two decades, the increases in informal caregiver utilization and home deaths were unequal, leading to substantially higher EOL medical expenditures among urban decedents and deceased individuals who died at hospitals than among their counterparts who lived in rural areas and died at home.
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Affiliation(s)
- Zhong Li
- grid.89957.3a0000 0000 9255 8984School of Health Policy and Management, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166 Jiangsu China ,grid.89957.3a0000 0000 9255 8984Institution of Healthy Jiangsu Development, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166 Jiangsu China ,grid.89957.3a0000 0000 9255 8984Center for Global Health, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166 Jiangsu China
| | - Peiyin Hung
- grid.254567.70000 0000 9075 106XDepartment of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
| | - Kewei Shi
- grid.422418.90000 0004 0371 6485Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA USA
| | - You Fu
- grid.89957.3a0000 0000 9255 8984Department of Review and Investigation, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166 Jiangsu China
| | - Dongfu Qian
- grid.89957.3a0000 0000 9255 8984School of Health Policy and Management, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166 Jiangsu China ,grid.89957.3a0000 0000 9255 8984Institution of Healthy Jiangsu Development, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166 Jiangsu China ,grid.89957.3a0000 0000 9255 8984Center for Global Health, Nanjing Medical University, 101 Longmian Avenue, Nanjing, 211166 Jiangsu China
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6
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What are the outcomes of hospice care for cancer patients? A systematic review. Support Care Cancer 2023; 31:64. [DOI: 10.1007/s00520-022-07524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 11/12/2022] [Indexed: 12/24/2022]
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Hunt LJ, Gan S, Boscardin WJ, Yaffe K, Ritchie CS, Aldridge MD, Smith AK. A national study of disenrollment from hospice among people with dementia. J Am Geriatr Soc 2022; 70:2858-2870. [PMID: 35670444 PMCID: PMC9588572 DOI: 10.1111/jgs.17912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with dementia (PWD) are at high risk for hospice disenrollment, yet little is known about patterns of disenrollment among the growing number of hospice enrollees with dementia. DESIGN Retrospective, observational cohort study of 100% Medicare beneficiaries with dementia aged 65 and older enrolled in the Medicare Hospice Benefit between July 2012 and December 2017. Outcome measures included hospice-initiated disenrollment for patients whose rate of decline ceased to meet the Medicare hospice eligibility guideline of "expected death within 6 months" (extended prognosis) and patient-initiated disenrollment (revocation). Hospice, regional, and patient risk factors and variation were assessed with multilevel mixed-effects logistic regression models. RESULTS Among 867,695 hospice enrollees with dementia, 70,945 (8.2%) were disenrolled due to extended prognosis and 43,133 (5.0%) revoked within 1-year of their index admission. There was substantial variation in hospice provider disenrollment due to extended prognosis (10th-90th percentile 4.5%-14.6%, adjusted median odds ratio (MOR) 1.86, 95% confidence interval (CI) 1.82, 1.91) and revocation (10th-90th percentile 2.5%-10.1%, MOR 2.09, 95% CI 2.03, 2.14). Among hospital referral regions (HRR), there was more variation in revocation (10th-90th percentile 3.5%-7.6%, MOR 1.4, 95% CI 1.34, 1.47) than extended prognosis (10th-90th percentile 7.0%-9.5%, MOR 1.23, 95% CI 1.18, 1.27), with much higher revocation rates noted in HRRs located in the Southeast and Southern California. A number of patient and hospice characteristics were associated with higher odds of both types of disenrollment (younger age, female sex, minoritized race and ethnicity, Medicaid dual eligibility, Medicare Part C enrollment), while some were associated with revocation only (more comorbidities, newer, smaller, and for-profit hospices). CONCLUSIONS In this nationally representative study of hospice enrollees with dementia, hospice disenrollment varied by type of hospice, geographic region, and patient characteristics including age, sex, race, and ethnicity. These findings raise important questions about whether and how the Medicare Hospice Benefit could be adapted to reduce disparities and better support PWD.
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Affiliation(s)
- Lauren J. Hunt
- Department of Physiological Nursing, University of California, San Francisco
- Global Brain Health Institute, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Siqi Gan
- Northern California Institute for Research and Education, San Francisco, CA
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kristine Yaffe
- Department of Psychiatry, University of California, San Francisco
- Department of Neurology, University of California, San Francisco
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, MA
- Mongan Institute for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, NY, NY
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Atodaria KP, Cohen SJ, Dhruv S, Ginnaram SR, Shah S. Trends in Palliative Care, Hospice Utilization, and Outcomes in Hospitalized Pancreatic Cancer Patients: A Nationwide Analysis. Cureus 2022; 14:e29351. [DOI: 10.7759/cureus.29351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
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9
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Balasubramanian I, Finkelstein E, Malhotra R, Ozdemir S, Malhotra C. Healthcare Cost Trajectories in the Last 2 Years of Life Among Patients With a Solid Metastatic Cancer: A Prospective Cohort Study. J Natl Compr Canc Netw 2022; 20:997-1004.e3. [PMID: 36075386 DOI: 10.6004/jnccn.2022.7038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Most studies describe the "average healthcare cost trend" among patients with cancer. We aimed to delineate heterogeneous trajectories of healthcare cost during the last 2 years of life of patients with a metastatic cancer and to assess the associated sociodemographic and clinical characteristics and healthcare use. PATIENTS AND METHODS We analyzed a sample of 353 deceased patients from a cohort of 600 with a solid metastatic cancer in Singapore, and we used group-based trajectory modeling to identify trajectories of total healthcare cost during the last 2 years of life. RESULTS The average cost trend showed that mean monthly healthcare cost increased from SGD $3,997 during the last 2 years of life to SGD $7,516 during the last month of life (USD $1 = SGD $1.35). Group-based trajectory modeling identified 4 distinct trajectories: (1) low and steadily decreasing cost (13%); (2) steeply increasing cost in the last year of life (14%); (3) high and steadily increasing cost (57%); and (4) steeply increasing cost before the last year of life (16%). Compared with the low and steadily decreasing cost trajectory, patients with private health insurance (β [SE], 0.75 [0.37]; P=.04) and a greater preference for life extension (β [SE], -0.14 [0.07]; P=.06) were more likely to follow the high and steadily increasing cost trajectory. Patients in the low and steadily decreasing cost trajectory were most likely to have used palliative care (62%) and to die in a hospice (27%), whereas those in the steeply increasing cost before the last year of life trajectory were least likely to have used palliative care (14%) and most likely to die in a hospital (75%). CONCLUSIONS The study quantifies healthcare cost and shows the variability in healthcare cost trajectories during the last 2 years of life. Policymakers, clinicians, patients, and families can use this information to better anticipate, budget, and manage healthcare costs.
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Affiliation(s)
| | - Eric Finkelstein
- Lien Centre for Palliative Care.,Program in Health Services and Systems Research, and
| | - Rahul Malhotra
- Program in Health Services and Systems Research, and.,Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore
| | - Semra Ozdemir
- Lien Centre for Palliative Care.,Program in Health Services and Systems Research, and
| | - Chetna Malhotra
- Lien Centre for Palliative Care.,Program in Health Services and Systems Research, and
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Starr LT, Bullock K, Washington K, Aryal S, Parker Oliver D, Demiris G. Anxiety, Depression, Quality of Life, Caregiver Burden, and Perceptions of Caregiver-Centered Communication among Black and White Hospice Family Caregivers. J Palliat Med 2022; 25:596-605. [PMID: 34793244 PMCID: PMC8982115 DOI: 10.1089/jpm.2021.0302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Anxiety, depression, and reduced quality of life (QOL) are common problems for hospice family caregivers, but it is unknown if disparities in these experiences exist among Black and White caregivers. Objectives: To compare anxiety, depression, QOL, caregiver burden, and perceptions of caregiver-centered hospice team communication between Black and White hospice family caregivers. Design: Secondary analysis of baseline data from two randomized clinical trials. Setting/Subjects: Seven hundred twenty-two Black and White hospice family caregivers ages 18+ from Midwestern and Northeastern United States. Measurements: Measures included the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire (PHQ-9), Caregiver Quality-of-Life Index-Revised (CQLI-R), Zarit Burden Interview (ZBI-7), and Caregiver-Centered Communication Questionnaire (CCCQ). Results: Black and White caregivers differed across demographic and socioeconomic variables. Nearly one-third of hospice family caregivers reported moderate-to-severe anxiety (32.1%) and moderate-to-severe depressive symptoms (32.0%). White caregivers reported lower QOL than Black caregivers (p = 0.04), specifically in emotional (p = 0.02) and social (p = 0.0005) domains. In multiple regression analyses controlling for caregiver and patient factors, we found no racial differences in depression, anxiety, QOL, caregiver burden, or perceptions of caregiver-centered hospice communication. Conclusions: Despite demographic and socioeconomic differences, Black and White hospice family caregivers experience similarly high levels of anxiety, depression, burden, and perceptions of hospice communication. Interventions to support hospice family caregivers across racial groups and research that identifies factors that mediate social determinants of health in this population are needed. The development and validation of culture-concordant mental health screening tools in racially diverse populations is recommended. Trial registration: ClinicalTrials.gov NCT02929108 and ClinicalTrials.gov NCT01444027.
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Affiliation(s)
- Lauren T. Starr
- Department of Biobehavioral and Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karen Bullock
- Department of Social Work, College of Humanities and Social Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Karla Washington
- Division of Palliative Medicine, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Subhash Aryal
- BECCA (Biostatistics * Evaluation * Collaboration * Consultation * Analysis) Lab, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Debra Parker Oliver
- Division of Palliative Medicine, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Barnes Jewish College, Goldfarb School of Nursing, St. Louis, Missouri, USA
| | - George Demiris
- Department of Biobehavioral and Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Di Nitto M, Artico M, Piredda M, De Maria M, Magnani C, Marchetti A, Mastroianni C, Latina R, De Marinis MG, D’Angelo D. Factors influencing place of death and disenrollment among patients receiving specialist palliative care. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022189. [PMID: 35545986 PMCID: PMC9534221 DOI: 10.23750/abm.v93is2.12637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/04/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIM OF THE WORK Place of death and disenrollment from specialized palliative care services (SPCSs) are two aspects that determine service utilization. These aspects should be determined by patient needs and preferences, but they are often associated to patient sociodemographic or contextual characteristics. The aim of this study was to describe which factors are associated with utilizing SPCSs in terms of place of death and disenrollment. METHODS Retrospective cohort study. Patients (>18 years) who died or were disenrolled during SPCSs utilization. Two hierarchical regression models were performed, and variables were categorized in predisposing, enabling, and need factors according to the Andersen behavioral model of health services use. RESULTS We included 35,869 patients (52,5% male, mean age 74,6 ± 12,3 SD), where 17,225 patients died in hospice and 16,953 at home, while 1,691 patients were disenrolled. Dying at home was associated with older age, oncological diagnosis, painful symptoms and longer survival time. Instead, service disenrollment was associated with less education, longer wait time and longer length of stay. CONCLUSIONS SPCS utilization was not influenced only by patient need, but also by other factors, such as social and contextual factors. These factors need to be considered by health care providers and efforts are needed for 1) identifying barriers and implementing effective interventions to support patients and caregivers in their preferred place of care and death and 2) for avoiding SPCS disenrollment with an increased probability of aggressive treatments and worse quality of life for patients.
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Affiliation(s)
- Marco Di Nitto
- Department of biomedicine and prevention, University of Rome “Tor Vergata”, Rome, Italy
| | - Marco Artico
- Department of Palliative Care and Pain Therapy Unit, Azienda ULSS n.4 Veneto Orientale, San Donà di Piave, Italy
| | - Michela Piredda
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy
| | - Maddalena De Maria
- Department of biomedicine and prevention, University of Rome “Tor Vergata”, Rome, Italy
| | | | - Anna Marchetti
- Research Unit Nursing Science, Campus Bio-Medico di Roma University, Rome, Italy
| | | | - Roberto Latina
- Deptment of Health Promotion Sciences, Maternal & Infant Care, Internal Medicine & Excellence Specialists University of Palermo, Palermo, Italy
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12
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Luth EA, Russell DJ, Xu JC, Lauder B, Ryvicker MB, Dignam RR, Baughn R, Bowles KH, Prigerson HG. Survival in hospice patients with dementia: the effect of home hospice and nurse visits. J Am Geriatr Soc 2021; 69:1529-1538. [PMID: 33608869 DOI: 10.1111/jgs.17066] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/15/2021] [Accepted: 01/26/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hospice patients with dementia are at increased risk for live discharge and long lengths of stay (>180 days), causing patient and family caregiver stress and burden. The location and timing of clinician visits are important factors influencing whether someone dies as expected, in hospice, or experiences a live discharge or long length of stay. OBJECTIVE Examine how home hospice and nurse visit frequency relate to dying in hospice within the Medicare-intended 6-month period. DESIGN Retrospective cohort study. SETTING Non-profit hospice agency. PARTICIPANTS Three thousand eight hundred and thirty seven patients with dementia who received hospice services from 2013 to 2017. METHODS Multivariable survival analyses examined the effects of receiving home hospice (vs. nursing home) and timing of nurse visits on death within 6 months of hospice enrollment, compared to live discharge or long length of stay. Models adjust for relevant demographic and clinical factors. RESULTS Thirty-nine percent (39%) of patients experienced live discharge or long length of stay. Home hospice patients were more likely to experience live discharge or long length of stays (HR for death: 0.77, 95%CI: 0.69-0.86, p < 0.001). Frequency of nurse visits was inversely associated with live discharge and long lengths of stay (HR for death: 2.87, 95%CI: 2.47-3.33, p < 0.001). CONCLUSION Nearly 40% of patients with dementia in our study experienced live discharge or a long length of stay. Additional research is needed to understand why home hospice may result in live discharge or a long length of stay for patients with dementia. Nurse visits were associated with death, suggesting their responsiveness to deteriorating patient health. Hospice guidelines may need to permit longer stays so community-dwelling patients with dementia, a growing segment of hospice patients, can remain continuously enrolled in hospice and avoid burden and costs associated with live discharge.
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Affiliation(s)
- Elizabeth A Luth
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David J Russell
- Center for Home Care & Policy Research, Visiting Nurse Service of New York, New York, New York, USA.,Department of Sociology, Appalachian State University, Boone, North Carolina, USA
| | - Jiehui Cici Xu
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Bonnie Lauder
- Hospice and Palliative Care Services, Visiting Nurse Service of New York, New York, New York, USA
| | - Miriam B Ryvicker
- Center for Home Care & Policy Research, Visiting Nurse Service of New York, New York, New York, USA
| | - Ritchell R Dignam
- Hospice and Palliative Care Services, Visiting Nurse Service of New York, New York, New York, USA
| | - Rosemary Baughn
- Hospice and Palliative Care Services, Visiting Nurse Service of New York, New York, New York, USA
| | - Kathryn H Bowles
- Center for Home Care & Policy Research, Visiting Nurse Service of New York, New York, New York, USA.,Biobehavioral Health Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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Jones TM, Brody AA. Adaptation and Piloting for Hospice Social Workers of Aliviado Dementia Care, a Dementia Symptom Management Program. Am J Hosp Palliat Care 2020; 38:452-458. [PMID: 33016082 DOI: 10.1177/1049909120962459] [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: 11/16/2022] Open
Abstract
BACKGROUND Forty-five percent of hospice patients currently have a primary or secondary diagnosis of Alzheimer's disease or related disorders. However, few programs have focused specifically on assisting hospices in providing evidence-based symptom management to persons living with dementia (PLWD). OBJECTIVE To adapt and pilot the training component of Aliviado Dementia Care, a dementia symptom management quality improvement program originally developed for home healthcare, for use by social workers as part of the hospice interdisciplinary team. DESIGN A prospective pre-post design was utilized, measuring knowledge, confidence, and attitudes at baseline, and immediately and 1-month post-training. Analysis was performed using paired t-tests and repeated measures ANOVA. SUBJECTS Hospice social workers currently practicing in the United States with at least 1 year of experience. MEASUREMENTS The Dementia Symptom Knowledge Assessment and a post-training continuing education evaluation form. RESULTS Forty-six subjects were enrolled, of whom 26 completed the first post-test and 23 both post-tests. There was a poor baseline level of knowledge and confidence in caring for PLWD. Significant improvements occurred following training, particularly in implementing non-pharmacologic interventions for behavioral and psychological symptoms of dementia (BPSD) (16.64% increase, p < .0001) and confidence in managing behavioral symptoms (16.86%, p = .01) and depression (25.18%, p < .0001). Changes were maintained over time. All respondents were either very satisfied or satisfied with the quality and content of the program. CONCLUSIONS The training modules of Aliviado Dementia Care were successfully tailored for use by hospice social workers, showing significant improvement in knowledge and confidence in caring for behavioral symptoms in PLWD. Future work will examine whether the larger program, including this training, can subsequently improve patient outcomes in hospice.
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Affiliation(s)
- Tessa M Jones
- 5894New York University Silver School of Social Work, New York, NY, USA
| | - Abraham A Brody
- Hartford Institute for Geriatric Nursing, 5894New York University Rory Meyers College of Nursing, New York, NY, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, The Bronx, NY, USA
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14
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Ornstein KA, Roth DL, Huang J, Levitan EB, Rhodes JD, Fabius CD, Safford MM, Sheehan OC. Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort. JAMA Netw Open 2020; 3:e2014639. [PMID: 32833020 PMCID: PMC7445597 DOI: 10.1001/jamanetworkopen.2020.14639] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain. Objective To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death. Design, Setting, and Participants This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020. Main Outcomes and Measures The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records. Results The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents. Conclusions and Relevance Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.
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Affiliation(s)
- Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David L. Roth
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jin Huang
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - J. David Rhodes
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - Chanee D. Fabius
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Monika M. Safford
- Division of General Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Orla C. Sheehan
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
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15
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Frasca M, Galvin A, Raherison C, Soubeyran P, Burucoa B, Bellera C, Mathoulin-Pelissier S. Palliative versus hospice care in patients with cancer: a systematic review. BMJ Support Palliat Care 2020; 11:188-199. [PMID: 32680891 DOI: 10.1136/bmjspcare-2020-002195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Guidelines recommend an early access to specialised palliative medicine services for patients with cancer, but studies have reported a continued underuse. Palliative care facilities deliver early care, alongside antineoplastic treatments, whereas hospice care structures intervene lately, when cancer-modifying treatments stop. AIM This review identified factors associated with early and late interventions of specialised services, by considering the type of structures studied (palliative vs hospice care). DESIGN We performed a systematic review, prospectively registered on PROSPERO (ID: CRD42018110063). DATA SOURCES We searched Medline and Scopus databases for population-based studies. Two independent reviewers extracted the data and assessed the study quality using Joanna Briggs Institute critical appraisal checklists. RESULTS The 51 included articles performed 67 analyses. Most were based on retrospective cohorts and US populations. The median quality scores were 19/22 for cohorts and 15/16 for cross-sectional studies. Most analyses focused on hospice care (n=37). Older patients, men, people with haematological cancer or treated in small centres had less specialised interventions. Palliative and hospice facilities addressed different populations. Older patients received less palliative care but more hospice care. Patients with high-stage tumours had more palliative care while women and patients with a low comorbidity burden received more hospice care. CONCLUSION Main disparities concerned older patients, men and people with haematological cancer. We highlighted the challenges of early interventions for older patients and of late deliveries for men and highly comorbid patients. Additional data on non-American populations, outpatients and factors related to quality of life and socioeconomic status are needed.
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Affiliation(s)
- Matthieu Frasca
- Department of Palliative Medicine, CHU of Bordeaux, Bordeaux, Aquitaine, France .,Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Angeline Galvin
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Chantal Raherison
- Department of Pneumology, CHU of Bordeaux, Bordeaux, Aquitaine, France
| | - Pierre Soubeyran
- CIC1401, Bergonie institute, Comprehensive Cancer Center, Bordeaux, Aquitaine, France.,UMR 1218, ACTION, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Benoît Burucoa
- Department of Palliative Medicine, CHU of Bordeaux, Bordeaux, Aquitaine, France
| | - Carine Bellera
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France.,CIC1401, Bergonie institute, Comprehensive Cancer Center, Bordeaux, Aquitaine, France
| | - Simone Mathoulin-Pelissier
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France.,UMR 1218, ACTION, University of Bordeaux, Bordeaux, Aquitaine, France
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16
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Stevens ER, Nucifora KA, Hagan H, Jordan AE, Uyei J, Khan B, Dombrowski K, des Jarlais D, Braithwaite RS. Cost-effectiveness of Direct Antiviral Agents for Hepatitis C Virus Infection and a Combined Intervention of Syringe Access and Medication-assisted Therapy for Opioid Use Disorders in an Injection Drug Use Population. Clin Infect Dis 2020; 70:2652-2662. [PMID: 31400755 PMCID: PMC7286369 DOI: 10.1093/cid/ciz726] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/29/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND There are too many plausible permutations and scale-up scenarios of combination hepatitis C virus (HCV) interventions for exhaustive testing in experimental trials. Therefore, we used a computer simulation to project the health and economic impacts of alternative combination intervention scenarios for people who inject drugs (PWID), focusing on direct antiviral agents (DAA) and medication-assisted treatment combined with syringe access programs (MAT+). METHODS We performed an allocative efficiency study, using a mathematical model to simulate the progression of HCV in PWID and its related consequences. We combined 2 previously validated simulations to estimate the cost-effectiveness of intervention strategies that included a range of coverage levels. Analyses were performed from a health-sector and societal perspective, with a 15-year time horizon and a discount rate of 3%. RESULTS From a health-sector perspective (excluding criminal justice system-related costs), 4 potential strategies fell on the cost-efficiency frontier. At 20% coverage, DAAs had an incremental cost-effectiveness ratio (ICER) of $27 251/quality-adjusted life-year (QALY). Combinations of DAA at 20% with MAT+ at 20%, 40%, and 80% coverage had ICERs of $165 985/QALY, $325 860/QALY, and $399 189/QALY, respectively. When analyzed from a societal perspective (including criminal justice system-related costs), DAA at 20% with MAT+ at 80% was the most effective intervention and was cost saving. While DAA at 20% with MAT+ at 80% was more expensive (eg, less cost saving) than MAT+ at 80% alone without DAA, it offered a favorable value compared to MAT+ at 80% alone ($23 932/QALY). CONCLUSIONS When considering health-sector costs alone, DAA alone was the most cost-effective intervention. However, with criminal justice system-related costs, DAA and MAT+ implemented together became the most cost-effective intervention.
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Affiliation(s)
- Elizabeth R Stevens
- Department of Population Health, New York University School of Medicine, New York, New York, USA
- New York University College of Global Public Health, New York, New York, USA
| | - Kimberly A Nucifora
- Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Holly Hagan
- New York University College of Global Public Health, New York, New York, USA
- Center for Drug Use and Human Immunodeficiency Virus Research, New York University College of Global Public Health, New York, New York, USA
| | - Ashly E Jordan
- Center for Drug Use and Human Immunodeficiency Virus Research, New York University College of Global Public Health, New York, New York, USA
- School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Jennifer Uyei
- Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Bilal Khan
- Department of Sociology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Kirk Dombrowski
- Department of Sociology, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Don des Jarlais
- New York University College of Global Public Health, New York, New York, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, New York, USA
- Center for Drug Use and Human Immunodeficiency Virus Research, New York University College of Global Public Health, New York, New York, USA
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Live Discharge From Hospice Due to Acute Hospitalization: The Role of Neighborhood Socioeconomic Characteristics and Race/Ethnicity. Med Care 2020; 58:320-328. [PMID: 31876664 DOI: 10.1097/mlr.0000000000001278] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute hospitalization is a frequent reason for live discharge from hospice. Although risk factors for live discharge among hospice patients have been well documented, prior research has not examined the role of neighborhood socioeconomic characteristics, or how these characteristics relate to racial/ethnic disparities in hospice outcomes. OBJECTIVE To examine associations between neighborhood socioeconomic characteristics and risk for live discharge from hospice because of acute hospitalization. The authors also explore the moderating role of race/ethnicity in any observed relationship. RESEARCH DESIGN Retrospective cohort study using electronic medical records of hospice patients (N=17,290) linked with neighborhood-level socioeconomic data (N=55 neighborhoods). Multilevel models were used to identify the independent significance of patient and neighborhood-level characteristics for risk of live discharge because of acute hospitalization. RESULTS Compared with the patients in the most well-educated and affluent sections of New York City [quartile (Q)4], the odds of live discharge from hospice because of acute hospitalization were greater among patients who resided in neighborhoods where lower proportions of residents held college degrees [Q1 adjusted odds ratio (AOR), 1.36; 95% confidence interval (CI), 1.06-1.75; Q2 AOR, 1.41; 95% CI, 1.07-1.84] and median household incomes were lower (Q1 AOR, 1.42; 95% CI, 1.10-1.85; Q2 AOR, 1.43; 95% CI, 1.10-1.85; Q3 AOR, 1.39; 95% CI, 1.07-1.80). However, these observed relationships were not equally distributed by patient race/ethnicity; the association of neighborhood socioeconomic disadvantage and risk for live discharge was significantly lower among Hispanic compared with white patients. CONCLUSIONS Findings demonstrate neighborhood socioeconomic disadvantage poses a significant risk for live discharge from hospice. Additional research is needed to clarify the social mechanisms underlying this association, including greater attention to the experiences of hospice patients from under-represented racial/ethnic groups.
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18
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Currow DC, Agar MR, Phillips JL. Role of Hospice Care at the End of Life for People With Cancer. J Clin Oncol 2020; 38:937-943. [DOI: 10.1200/jco.18.02235] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patient-defined factors that are important at the end of life include being physically independent for as long as possible, good symptom control, and spending quality time with friends and family. Hospice care adds to the quality of care and these patient-centered priorities for people with cancer and their families in the last weeks and days of life. Evidence from large observational studies demonstrate that hospice care can improve outcomes directly and support better and more appropriate health care use for people in the last stages of cancer. Team-based community hospice care has measurable benefits for patients, their family caregivers, and health services. In addition to improved symptom control for patients and a greater likelihood of time spent at home, caregiver outcomes are better when hospice care is accessed: informational needs are better met, and caregivers have an improved ability to move on with life after the patient’s death compared with people who did not have access to these services. Hospice care continues to evolve as its reach expands and the needs of patients continue to broaden. This is reflected in the transition from hospice being based on excellence in nursing to teams with a broad range of health professionals to meet the complex and changing needs of patients and their families. Additional integration of cancer services with hospice care will help to provide more seamless care for patients and supporting family caregivers during their caregiving and after the death of the patient.
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Affiliation(s)
- David C. Currow
- University of Technology Sydney, Ultimo, NSW, Australia
- University of Hull, Hull, United Kingdom
| | - Meera R. Agar
- University of Technology Sydney, Ultimo, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
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19
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Huang YT, Wang YW, Chi CW, Hu WY, Lin R, Shiao CC, Tang WR. Differences in medical costs for end-of-life patients receiving traditional care and those receiving hospice care: A retrospective study. PLoS One 2020; 15:e0229176. [PMID: 32078660 PMCID: PMC7032706 DOI: 10.1371/journal.pone.0229176] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 02/02/2020] [Indexed: 12/20/2022] Open
Abstract
Background Hospice care has a positive effect on medical costs. The correlation between survival time after receiving hospice care and medical costs has not been previously investigated in the literature on Taiwan. This study aimed to compare the differences in medical costs between traditional care and hospice care among end-of-life patients with cancer. Methods Data from Taiwan’s National Health Insurance program on all patients who had passed away between 2010 and 2013 were used. Those whose year of death was between 2010 and 2013 were defined as end-of-life patients. The patients were divided into two groups: traditional care and hospice care. We then analyzed the differences in end-of-life medical cost between the two groups. Results From 2010 to 2013, the proportion of patients receiving hospice care significantly increased from 22.2% to 41.30%. In the hospice group, compared with the traditional group, the proportions of hospital stays over 14 days and deaths in a hospital were significantly higher, but the proportions of outpatient clinic visits; emergency room admissions; intensive care unit admissions; use of ventilator; use of cardiopulmonary resuscitation; and use of hemodialysis, surgery, and chemotherapy were significantly lower. Total medical costs were significantly lower. A greater number of days of survival for end-of-life patients when receiving hospice care results in higher saved medical costs. Conclusion Hospice care can effectively save a large amount of end-of-life medical costs, and more medical costs are saved when patients are referred to hospice care earlier.
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Affiliation(s)
- Ya-Ting Huang
- Department of Nursing, Camillian Saint Mary`s Hospital Luodong, Luodong, Yilan, Taiwan, R.O.C.,Saint Mary's Junior College of Medicine, Nursing and Management, Sanxing Township, Taiwan, R.O.C
| | - Ying-Wei Wang
- Health Promotion Administration, Ministry of Health and Welfare. Datong Dist., Taipei City, Taiwan, R.O.C
| | - Chou-Wen Chi
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan Dist., Taoyuan City, Taiwan, R.O.C.,College of Medicine, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC
| | - Wen-Yu Hu
- Department of Nursing College of Medicine, National Taiwan University, Taipei, Taiwan R.O.C
| | - Rung Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou, Guishan Dist., Taoyuan City, Taiwan, R.O.C.,Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC.,Graduate Institute of Clinical Medicine, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC
| | - Chih-Chung Shiao
- Saint Mary's Junior College of Medicine, Nursing and Management, Sanxing Township, Taiwan, R.O.C.,Division of Nephrology, Department of Internal Medicine, Camillian Saint Mary`s Hospital Luodong, Luodong, Yilan, Taiwan, R.O.C
| | - Woung-Ru Tang
- School of Nursing, Chang Gung University, Kwei-Shan, Tao-Yuan, Taiwan, ROC
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20
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Factors Affecting Racial Disparities in End-of-Life Care Costs Among Lung Cancer Patients: A SEER-Medicare-based Study. Am J Clin Oncol 2019; 42:143-153. [PMID: 30300168 DOI: 10.1097/coc.0000000000000485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Racial disparities exist in end-of-life lung cancer care, which could potentially lead to considerable racial differences in end-of-life care costs. This study for the first time estimates the racial differences in end-of-life care costs among lung cancer patients, and identifies and quantifies factors that contribute the most to these differences using a statistical decomposition method. METHODS This is a retrospective analysis of patients 66 years and older, diagnosed with stage I-IV lung cancer, who died on or before December 31, 2013, using the Surveillance Epidemiology and End Result-Medicare data from 1991 to 2013. Ordinary least square regression of logarithmically transformed cost was used to estimate racial differences in end-of-life care costs among lung cancer patients. Blinder-Oaxaca decomposition was used to identify and quantify factors that contributed the most to these differences. RESULTS Non-Hispanic blacks had 10% to 13% higher end-of-life care costs as compared with non-Hispanic whites. Geographic variations, baseline comorbidity indices and stage at diagnosis contributed the most to explaining the racial differences in costs, with geographic variation explaining most of the differences. However, the observed factors could only explain 25% to 32% of the racial differences in end-of-life care costs. CONCLUSIONS Geographic differences in access to timely and appropriate care, and provider practice patterns, should be examined to understand the reasons behind geographic variations in racial disparity. Provider-level educational interventions to reduce small area practice variations and differential management of patients by race, as well as racially sensitive patient-level educational and navigational interventions might be critical in improving quality of care and reducing costs during end-of-life.
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21
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Uyei J, Taddei TH, Kaplan DE, Chapko M, Stevens ER, Braithwaite RS. Setting ambitious targets for surveillance and treatment rates among patients with hepatitis C related cirrhosis impacts the cost-effectiveness of hepatocellular cancer surveillance and substantially increases life expectancy: A modeling study. PLoS One 2019; 14:e0221614. [PMID: 31449554 PMCID: PMC6709904 DOI: 10.1371/journal.pone.0221614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/03/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hepatocelluar cancer (HCC) is the leading cause of death among people with hepatitis C virus (HCV)-related cirrhosis. Our aim was to determine the optimal surveillance frequency for patients with HCV-related compensated cirrhosis. METHODS We developed a decision analytic Markov model and validated it against data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) study group and published epidemiologic studies. Four strategies of different surveillance intervals were compared: no surveillance and ultrasound surveillance every 12, 6, and 3 months. We estimated lifetime survival, life expectancy, quality adjusted life years (QALY), total costs associated with each strategy, and incremental cost effectiveness ratios. We applied a willingness to pay threshold of $100,000. Analysis was conducted for two scenarios: a scenario reflecting current HCV and HCC surveillance compliance rates and treatment use and an aspirational scenario. RESULTS In the current scenario the preferred strategy was 3-month surveillance with an incremental cost-effectiveness ratio (ICER) of $7,159/QALY. In the aspirational scenario, 6-month surveillance was preferred with an ICER of $82,807/QALY because treating more people with HCV led to a lower incidence of HCC. Sensitivity analyses suggested that surveillance every 12 months would suffice in the particular circumstance when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available. Compared with the current scenario, the aspirational scenario resulted in a 1.87 year gain in life expectancy for the cohort because of large reductions in decompensated cirrhosis and HCC incidence. CONCLUSIONS HCC surveillance has good value for money for patients with HCV-related compensated cirrhosis. Investments to improve adherence to surveillance should be made when rates are suboptimal. Surveillance every 12 months will suffice when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available.
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Affiliation(s)
- Jennifer Uyei
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York, NY, United States of America
- * E-mail:
| | - Tamar H. Taddei
- VA Connecticut-Healthcare System, West Haven, CT, United States of America
| | - David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States of America
| | - Michael Chapko
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, United States of America
| | - Elizabeth R. Stevens
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - R. Scott Braithwaite
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York, NY, United States of America
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Li Z, Pan Z, Zhang L, He R, Jiang S, Xu C, Lu F, Zhang P, Li B. End-of-life cost and its determinants for cancer patients in urban China: a population-based retrospective study. BMJ Open 2019; 9:e026309. [PMID: 30898830 PMCID: PMC6528019 DOI: 10.1136/bmjopen-2018-026309] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/22/2019] [Accepted: 01/30/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE This study aimed to define the end-of-life (EOL) healthcare utilisation and its cost and determinants for cancer patients and to proactively inform related strategies in mainland China. DESIGN A population-based retrospective study. SETTING AND PARTICIPANTS Data from 894 cancer patients were collected in urban Yichang, China from 01 July 2015 to 30 June 2017. OUTCOME MEASURES Emergency department (ED) visits, outpatient and inpatient hospitalisation services, intensive care unit (ICU) admission and total costs were used as the main outcomes. RESULTS In this study, 66.8% of the 894 patients were male, and the average age was 60.4 years. Among these patients, 37.6% died at home, and patients had an average of 4.86 outpatient services, 2.23 inpatient hospitalisation services and 1.44 ED visits. Additionally, 5.9% of these patients visited the ICU at least once. During the EOL periods, the costs in the last 6 months, 3 months, 1 month and 1 week were US$18 234, US$13 043, US$6349 and US$2085, respectively. The cost increased dramatically as death approached. The estimation results of generalised linear regression models showed that aggressive care substantially affected expenditure. Patients with Urban Employee Basic Medical Insurance spent more than those with Urban Resident-based Basic Medical Insurance or the New Rural Cooperative Medical Scheme. The place of death and the survival time are also risk factors for increased EOL cost. CONCLUSION The findings suggested that the EOL cost for cancer patients is associated with aggressive care, insurance type and survival time. Timing palliative care is urgently needed to address ineffective and irrational healthcare utilisation and to reduce costs. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of the Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571). All the data used in this study were de-identified.
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Affiliation(s)
- Zhong Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zijing Pan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruibo He
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shan Jiang
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Chengzhong Xu
- Yichang Center for Disease Control and Prevention, Yichang, China
| | - Fangfang Lu
- Yichang Center for Disease Control and Prevention, Yichang, China
| | - Pei Zhang
- Yichang Center for Disease Control and Prevention, Yichang, China
| | - Boyang Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Wladkowski SP, Wallace CL. Current Practices of Live Discharge from Hospice: Social Work Perspectives. HEALTH & SOCIAL WORK 2019; 44:30-38. [PMID: 30561640 DOI: 10.1093/hsw/hly040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 03/13/2018] [Indexed: 06/09/2023]
Abstract
Hospice provides holistic support for individuals living with terminal illness and to their caregivers during the bereavement period. However, some individuals who enroll in hospice services are decertified as they do not experience a decline in health as quickly as required by current regulations, a practice referred to as a live discharge. The interruption in care can affect the physical and psychosocial care needs for individuals and caregivers and leave hospice clinicians with questions about how to best support them. However, there are no formal guidelines to support this process. This qualitative study (N = 24) explored the current practices of hospice social workers across the United States engaged in the live discharge process. Results from this study emphasize the need to bridge the gaps between policy and practice. Specifically, results highlight the challenges hospice social workers face to replicate or supplement the holistic support and unique services hospice provides for individuals discharged alive, and suggest further research to develop live discharge guidelines to identify appropriate support for patients and their caregivers who no longer meet hospice eligibility requirements.
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Affiliation(s)
- Stephanie P Wladkowski
- Stephanie P. Wladkowski, PhD, LMSW, is assistant professor, School of Social Work, Eastern Michigan University, 317 Marshall Hall, Ypsilanti, MI 48197; e-mail: . Cara L. Wallace, PhD, LMSW, is assistant professor, School of Social Work, Saint Louis University
| | - Cara L Wallace
- Stephanie P. Wladkowski, PhD, LMSW, is assistant professor, School of Social Work, Eastern Michigan University, 317 Marshall Hall, Ypsilanti, MI 48197; e-mail: . Cara L. Wallace, PhD, LMSW, is assistant professor, School of Social Work, Saint Louis University
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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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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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Hay CM, Kelley JL, Edwards RP, Pombier KM, Comerci JT. Super-Utilization of Health Care Resources Among Gynecologic Oncology Patients. Am J Med Qual 2018; 33:509-513. [PMID: 29463092 DOI: 10.1177/1062860618757343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Super-utilizers account for many emergency department visits (EDV) and hospitalizations. Among Medicare/Medicaid patients, 5% to 10% account for >50% of spending. Little is known about super-utilization in gynecologic oncology. Charts of 64 gynecologic oncology patients with ≥3 EDV and/or admissions over 12 months were reviewed retrospectively. Cancer type distribution was 47% ovarian, 23% cervical, 23% endometrial, and 6% vulvar. Treatment at index visit was 61% chemotherapy, 16% no treatment, 8% recent surgery, and 6% radiation. Mean visits was 5.7 (SD 3.9, range 3-28). Most common presenting complaints were gastrointestinal and pain. Patients near end of life were more likely to be admitted. EDV frequently occurred outside standard work hours (63%). EDV/admissions resulted in total variable expenses of $1 462 581 ($982 933 direct expense, $479 648 service expense). Interventions to decrease super-utilization could target symptom management, off-hour support, patients on chemotherapy, and end of life. Approaches could include multidisciplinary resources, palliative care teams, extending office hours, and earlier initiation of hospice.
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Affiliation(s)
- Casey M Hay
- 1 Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joseph L Kelley
- 1 Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Robert P Edwards
- 1 Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kathleen M Pombier
- 1 Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John T Comerci
- 1 Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
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Wilson A, Martins-Welch D, Williams M, Tortez L, Kozikowski A, Earle B, Attivissimo L, Rosen L, Pekmezaris R. Risk Factor Assessment of Hospice Patients Readmitted within 7 Days of Acute Care Hospital Discharge. Geriatrics (Basel) 2018; 3:geriatrics3010004. [PMID: 31011052 PMCID: PMC6371090 DOI: 10.3390/geriatrics3010004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 11/16/2022] Open
Abstract
Factors surrounding readmission rates for hospice patients within seven days are still relatively unknown. The present study specifically investigates the seven-day readmission rate of patients newly discharged to hospice, and the predictive factors associated with readmission for this population. In a retrospective case-control study, we seek to identify potential predictors by comparing the characteristics of patients discharged to hospice and readmitted within one week to patients who were not readmitted. Cases (n = 46) were patients discharged to home hospice and readmitted to the hospital within seven days. Controls (n = 117) were patients discharged to home hospice and not readmitted to the hospital within seven days. Significant risk factors for readmission within seven days were found to be: age (p < 0.01), race (p < 0.001), language (p < 0.001), and insurance (p < 0.001). Further study of these predictors may identify opportunities for interventions that address patient and family concerns that may lead to readmission.
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Affiliation(s)
- Anthony Wilson
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | - Diana Martins-Welch
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | - Myia Williams
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
- Correspondence: ; Tel.: +1-516-600-1479
| | - Leanne Tortez
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | - Andrzej Kozikowski
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | - Bridget Earle
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
| | | | - Lisa Rosen
- Feinstein Institute for Medical Research, Manhasset, NY 11030, USA;
| | - Renee Pekmezaris
- Northwell Health, Manhasset, NY 11030, USA; (A.W.); (D.M.-W.); (L.T.); (A.K.); (B.E.); (R.P.)
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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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Whitney RL, Bell JF, Tancredi DJ, Romano PS, Bold RJ, Joseph JG. Hospitalization Rates and Predictors of Rehospitalization Among Individuals With Advanced Cancer in the Year After Diagnosis. J Clin Oncol 2017; 35:3610-3617. [PMID: 28850290 PMCID: PMC5946701 DOI: 10.1200/jco.2017.72.4963] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Among individuals with advanced cancer, frequent hospitalization increasingly is viewed as a hallmark of poor-quality care. We examined hospitalization rates and individual- and hospital-level predictors of rehospitalization among individuals with advanced cancer in the year after diagnosis. Methods Individuals diagnosed with advanced breast, colorectal, non-small-cell lung, or pancreatic cancer from 2009 to 2012 (N = 25,032) were identified with data from the California Cancer Registry (CCR). After linkage with inpatient discharge data, multistate and log-linear Poisson regression models were used to calculate hospitalization rates and to model rehospitalization in the year after diagnosis, accounting for survival. Results In the year after diagnosis, 71% of individuals with advanced cancer were hospitalized, 16% had three or more hospitalizations, and 64% of hospitalizations originated in the emergency department. Rehospitalization rates were significantly associated with black non-Hispanic (incidence rate ratio [IRR], 1.29; 95% CI, 1.17 to 1.42) and Hispanic (IRR, 1.11; 95% CI, 1.03 to 1.20) race/ethnicity; public insurance (IRR, 1.37; 95% CI, 1.23 to 1.47) and no insurance (IRR, 1.17; 95% CI, 1.02 to 1.35); lower socioeconomic status quintiles (IRRs, 1.09 to 1.29); comorbidities (IRRs, 1.13 to 1.59); and pancreatic (IRR, 2.07; 95% CI, 1.95 to 2.20) and non-small-cell lung (IRR, 1.69; 95% CI, 1.54 to 1.86) cancers versus colorectal cancer. Rehospitalization rates were significantly lower after discharge from a hospital that had an outpatient palliative care program (IRR, 0.90; 95% CI, 0.83 to 0.97) and were higher after discharge from a for-profit hospital (IRR, 1.33; 95% CI, 1.14 to 1.56). Conclusion Individuals with advanced cancer experience a heavy burden of hospitalization in the year after diagnosis. Efforts to reduce hospitalization and provide care congruent with patient preferences might target individuals at higher risk. Future work might explore access to palliative care in the community and related health care use among individuals with advanced cancer.
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Affiliation(s)
- Robin L. Whitney
- Robin L. Whitney, University of California, San Francisco, Fresno; and Robin L. Whitney, Janice F. Bell, Daniel J. Tancredi, Patrick S. Romano, Richard J. Bold, and Jill G. Joseph, University of California, Davis, Sacramento, CA
| | - Janice F. Bell
- Robin L. Whitney, University of California, San Francisco, Fresno; and Robin L. Whitney, Janice F. Bell, Daniel J. Tancredi, Patrick S. Romano, Richard J. Bold, and Jill G. Joseph, University of California, Davis, Sacramento, CA
| | - Daniel J. Tancredi
- Robin L. Whitney, University of California, San Francisco, Fresno; and Robin L. Whitney, Janice F. Bell, Daniel J. Tancredi, Patrick S. Romano, Richard J. Bold, and Jill G. Joseph, University of California, Davis, Sacramento, CA
| | - Patrick S. Romano
- Robin L. Whitney, University of California, San Francisco, Fresno; and Robin L. Whitney, Janice F. Bell, Daniel J. Tancredi, Patrick S. Romano, Richard J. Bold, and Jill G. Joseph, University of California, Davis, Sacramento, CA
| | - Richard J. Bold
- Robin L. Whitney, University of California, San Francisco, Fresno; and Robin L. Whitney, Janice F. Bell, Daniel J. Tancredi, Patrick S. Romano, Richard J. Bold, and Jill G. Joseph, University of California, Davis, Sacramento, CA
| | - Jill G. Joseph
- Robin L. Whitney, University of California, San Francisco, Fresno; and Robin L. Whitney, Janice F. Bell, Daniel J. Tancredi, Patrick S. Romano, Richard J. Bold, and Jill G. Joseph, University of California, Davis, Sacramento, CA
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Shin J, Yoon SJ, Kim SH, Lee ES, Koh SJ, Park J. A Qualitative Study of Physicians’ Perspectives on Non-Cancer Hospice-Palliative Care in Korea: Focus on AIDS, COPD and Liver Cirrhosis. ACTA ACUST UNITED AC 2017. [DOI: 10.14475/kjhpc.2017.20.3.177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jinyoung Shin
- Department of Family Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Seok-Joon Yoon
- Department of Family Medicine, Konkuk University School of Medicine, Seoul, Korea
- Department of Family Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun-Hyun Kim
- Department of Family Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Eon Sook Lee
- Department of Family Medicine, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Jeanno Park
- Palliative and Hospice Center, Bobath Memorial Hospital, Seongnam, Korea
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Chiang JK, Kao YH. Predictors of high healthcare costs in elderly patients with liver cancer in end-of-life: a longitudinal population-based study. BMC Cancer 2017; 17:568. [PMID: 28836965 PMCID: PMC5571574 DOI: 10.1186/s12885-017-3561-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/17/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Studies have indicated a pervasive pattern of decreasing healthcare costs during elderly patients' last year of life. The aim of this study was to explore the predictors of high healthcare costs (HC) in elderly liver cancer patients in Taiwan during their last month of life (LML). METHODS Costs of hospitalization, outpatient visits, aggressiveness of care, and associated costs for elderly (age ≥ 65 y) patients with liver cancer in the LML were analyzed using a national insurance database. An HC was defined as being greater than the 90th percentile (US $5093) in the LML, amounting to 38.95% of total healthcare costs. RESULTS We enrolled 2121 subjects who died during 1997-2011. Mean healthcare costs per person in their LML were US $8042 ± 3477 in the HC group and US $1407 ± 1464 in the non-HC group (p < 0.001). For patients receiving aggressive end-of-life (EOL) cancer care (e.g. intensive care, cardiopulmonary resuscitation, anticancer treatment, and a high number of admission days), comorbidities of chronic kidney disease, esophageal bleeding, and receiving opioids in the LML, were significantly independent positive predictors of HCs; but admission times, comorbidities of ascites, and hypertension were negative predictors. CONCLUSION These findings could inform healthcare providers by avoiding aggressive treatments during EOL for elderly patients with liver cancer and to save on healthcare costs. Shorter admission days and more admission times in the last month of life could decrease healthcare costs.
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Affiliation(s)
- Jui-Kun Chiang
- Department of Family Medicine, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan
| | - Yee-Hsin Kao
- Department of Family Medicine, Tainan Municipal Hospital, 670 Chung-Te Road, Tainan, 701, Taiwan.
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Associations of Hospice Disenrollment and Hospitalization With Continuous Home Care Provision. Med Care 2017; 55:848-855. [PMID: 28692573 DOI: 10.1097/mlr.0000000000000776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine rates of hospice disenrollment and posthospice hospitalization among patients who are enrolled in hospices that provide continuous home care (CHC) (CHC hospices) compared with patients who are enrolled in hospices that do not offer CHC (non-CHC hospices). METHODS We performed a retrospective cohort study among Medicare fee-for-service decedents between July and December 2011, who were 66 years and older and had used hospice in their last 6 months of life. We used propensity score matching to account for potential confounding characteristics of hospices. Generalized estimating equation models were applied to estimate between CHC hospices and non-CHC hospices the associations of hospice disenrollment/hospitalization, adjusted for patient characteristics. We also conducted subgroup analyses to examine how the association might have differed by hospice size, and by the percentage of enrollees who received CHC. RESULTS After matching, we identified 936 pairs of CHC and non-CHC hospices, well balanced in terms of organizational characteristics. In fully adjusted models, compared with non-CHC hospices, CHC hospices had significantly lower disenrollment rates (adjusted rate ratio, 0.73; 95% confidence interval, 0.60-0.87), and lower hospitalization rates (adjusted rate ratio, 0.79; 95% confidence interval, 0.66-0.95). These associations were significantly more pronounced among larger hospices (those with >175 enrollees during study period), and among hospices in which at least 7.3% of enrollees used CHC. CONCLUSIONS CHC hospices had significantly lower rates of hospice disenrollment and posthospice hospitalization, suggesting CHC service available may enable higher quality of end-of-life care.
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Aldridge MD, Epstein AJ, Brody AA, Lee EJ, Morrison RS, Bradley EH. Association between Hospice Spending on Patient Care and Rates of Hospitalization and Medicare Expenditures of Hospice Enrollees. J Palliat Med 2017; 21:55-61. [PMID: 28817376 DOI: 10.1089/jpm.2017.0101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice. OBJECTIVE To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees. DESIGN Longitudinal, observational cohort study (2008-2010). SETTING/SUBJECTS Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355). MEASUREMENTS We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures. RESULTS Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices. CONCLUSIONS Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.
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Affiliation(s)
- Melissa D Aldridge
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatrics Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center , Bronx, New York
| | - Andrew J Epstein
- 3 Leonard Davis Institute of Health Economics and Division of Internal Medicine, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Abraham A Brody
- 2 Geriatrics Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center , Bronx, New York.,4 Hartford Institute for Geriatric Nursing, New York University College of Nursing , New York, New York
| | - Eric J Lee
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - R Sean Morrison
- 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Geriatrics Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center , Bronx, New York
| | - Elizabeth H Bradley
- 5 Department of Health Policy and Management, Yale School of Public Health , New Haven, Connecticut.,6 Yale Global Health Leadership Institute , New Haven, Connecticut
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Kaufmann TL, Kamal AH. Oncology and Palliative Care Integration: Cocreating Quality and Value in the Era of Health Care Reform. J Oncol Pract 2017; 13:580-588. [PMID: 28682666 DOI: 10.1200/jop.2017.023762] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Recent payment reforms in health care have spurred thinking regarding how strengthened partnerships can cocreate quality and value. Oncology is an important area in which to consider further collaborations in patient care, as a result of increasing treatment complexity from an expanding armamentarium of interventions, large resource expenditures related to cancer care, and a growing disease prevalence related to an aging population. Many have highlighted the important role of palliative care in the routine care of patients with advanced cancer and high symptom burden. Yet, how integration can occur that translates research into usual clinical practice while prioritizing the right patients and settings to maximize outcomes of interest has been inadequately described. We review the evidence for integration of palliative care into routine oncology care and then map the benefits to the requirements put forward by the Centers for Medicare and Medicaid Services Oncology Care Model as a use case; we also discuss applications to other evolving payment models.
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Affiliation(s)
- Tara L Kaufmann
- University of Pennsylvania, Philadelphia, PA; and Duke Cancer Institute, Durham, NC
| | - Arif H Kamal
- University of Pennsylvania, Philadelphia, PA; and Duke Cancer Institute, Durham, NC
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Aldridge MD, Bradley EH. Epidemiology And Patterns Of Care At The End Of Life: Rising Complexity, Shifts In Care Patterns And Sites Of Death. Health Aff (Millwood) 2017; 36:1175-1183. [DOI: 10.1377/hlthaff.2017.0182] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Melissa D. Aldridge
- Melissa D. Aldridge ( ) is an associate professor in the Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, in New York City
| | - Elizabeth H. Bradley
- Elizabeth H. Bradley is president of and a professor of political science and science, technology, and society at Vassar College, in Poughkeepsie, New York
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Yim CK, Barrón Y, Moore S, Murtaugh C, Lala A, Aldridge M, Goldstein N, Gelfman LP. Hospice Enrollment in Patients With Advanced Heart Failure Decreases Acute Medical Service Utilization. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003335. [PMID: 28292824 DOI: 10.1161/circheartfailure.116.003335] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with advanced heart failure (HF) enroll in hospice at low rates, and data on their acute medical service utilization after hospice enrollment is limited. METHODS AND RESULTS We performed a descriptive analysis of Medicare fee-for-service beneficiaries, with at least one home health claim between July 1, 2009, and June 30, 2010, and at least 2 HF hospitalizations between July 1, 2009, and December 31, 2009, who subsequently enrolled in hospice between July 1, 2009, and December 31, 2009. We estimated panel-negative binomial models on a subset of beneficiaries to compare their acute medical service utilization before and after enrollment. Our sample size included 5073 beneficiaries: 55% were female, 45% were ≥85 years of age, 13% were non-white, and the mean comorbidity count was 2.38 (standard deviation 1.22). The median number of days between the second HF hospital discharge and hospice enrollment was 45. The median number of days enrolled in hospice was 15, and 39% of the beneficiaries died within 7 days of enrollment. During the study period, 11% of the beneficiaries disenrolled from hospice at least once. The adjusted mean number of hospital, intensive care unit, and emergency room admissions decreased from 2.56, 0.87, and 1.17 before hospice enrollment to 0.53, 0.19, and 0.76 after hospice enrollment. CONCLUSIONS Home health care Medicare beneficiaries with advanced HF who enrolled in hospice had lower acute medical service utilization after their enrollment. Their pattern of hospice use suggests that earlier referral and improved retention may benefit this population. Further research is necessary to understand hospice referral and palliative care needs of advanced HF patients.
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Affiliation(s)
- Cindi K Yim
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Yolanda Barrón
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Stanley Moore
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Chris Murtaugh
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Anuradha Lala
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Melissa Aldridge
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Nathan Goldstein
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA
| | - Laura P Gelfman
- From the Division of Cardiology and Population Health Science and Policy (A.L.) and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.A., N.G., L.P.G.), New York, NY; Icahn School of Medicine at Mount Sinai, New York, NY (C.K.Y.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY (Y.B., C.M.); and Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY (M.A., L.P.G.). S. Moore is an independent contractor in Bonny Doon, CA.
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Dolin R, Hanson LC, Rosenblum SF, Stearns SC, Holmes GM, Silberman P. Factors Driving Live Discharge From Hospice: Provider Perspectives. J Pain Symptom Manage 2017; 53:1050-1056. [PMID: 28323079 DOI: 10.1016/j.jpainsymman.2017.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients. OBJECTIVE The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program. METHODS We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach. RESULTS Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices. CONCLUSION This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate.
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Affiliation(s)
- Rachel Dolin
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA.
| | - Laura C Hanson
- Division of Geriatric Medicine, Center for Aging and Health, Palliative Care Program, The University of North Carolina at Chapel Hill, North Carolina, USA
| | | | - Sally C Stearns
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - George M Holmes
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - Pam Silberman
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
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Sutradhar R, Barbera L, Seow HY. Palliative homecare is associated with reduced high- and low-acuity emergency department visits at the end of life: A population-based cohort study of cancer decedents. Palliat Med 2017; 31:448-455. [PMID: 27507635 DOI: 10.1177/0269216316663508] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prior work shows that palliative homecare services reduce the subsequent need for hospitalizations and emergency services; however, no study has investigated whether this association is present for emergency department visits of high acuity or whether it only applies to low-acuity emergency department visits. AIM To examine the association between palliative versus standard homecare nursing and the rate of high-acuity and low-acuity emergency department visits among cancer decedents during their last 6 months of life. DESIGN This is a retrospective cohort study of end-of-life homecare patients in Ontario, Canada, who had confirmed cancer cause of death from 2004 to 2009. A multivariable Poisson regression analysis was implemented to examine the association between the receipt of palliative homecare nursing (vs standard homecare nursing) and the rate of high- and low-acuity emergency department visits, separately. RESULTS There were 54,743 decedents who received homecare nursing in the last 6 months of life. The receipt of palliative homecare nursing decreased the rate of low-acuity emergency department visits (relative rate = 0.53, 95% confidence interval = 0.50-0.56) and was significantly associated with a larger decrease in the rate of high-acuity emergency department visits (relative rate = 0.37, 95% confidence interval = 0.35-0.38). CONCLUSION Receiving homecare nursing with palliative intent may decrease the need for dying cancer patients to visit the emergency department, for both high and low-acuity visits, compared to receiving general homecare nursing. Policy implications include building support for additional training in palliative care to generalist homecare nurses and increasing access to palliative homecare nursing.
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Affiliation(s)
- Rinku Sutradhar
- 1 Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,2 Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,3 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lisa Barbera
- 1 Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,3 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,4 Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Hsien-Yeang Seow
- 1 Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,2 Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,5 Department of Oncology, McMaster University, Hamilton, ON, Canada
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Wilk AS, Hirth RA, Zhang W, Wheeler JRC, Turenne MN, Nahra TA, Sleeman KK, Messana JM. Persistent Variation in Medicare Payment Authorization for Home Hemodialysis Treatments. Health Serv Res 2017; 53:649-670. [PMID: 28105639 DOI: 10.1111/1475-6773.12650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy. DATA SOURCES/STUDY SETTING Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD). STUDY DESIGN We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities. DATA COLLECTION We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims. PRINCIPAL FINDINGS MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts. CONCLUSIONS Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity.
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Affiliation(s)
- Adam S Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Richard A Hirth
- Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Wei Zhang
- Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI
| | - John R C Wheeler
- Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Tammie A Nahra
- Department of Health Management and Policy, University of Michigan School of Public Health, Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Kathryn K Sleeman
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Joseph M Messana
- Division of Nephrology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
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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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Kleinpell R, Vasilevskis EE, Fogg L, Ely EW. Exploring the association of hospice care on patient experience and outcomes of care. BMJ Support Palliat Care 2016; 9:e13. [PMID: 27531840 DOI: 10.1136/bmjspcare-2015-001001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 07/08/2016] [Accepted: 07/25/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To examine the association of the use of hospice care on patient experience and outcomes of care. Promoting high-value, safe and effective care is an international healthcare imperative. However, the extent to which hospice care may improve the value of care is not well characterised. METHODS A secondary analysis of variations in care was conducted using the Dartmouth Atlas Report, matched to the American Hospital Association Annual Survey Database to abstract organisational characteristics for 236 US hospitals to examine the relationship between hospice usage and a number of variables that represent care value, including hospital care intensity index, hospital deaths, intensive care unit (ICU) deaths, patient satisfaction and a number of patient quality indicators. Structural equation modelling was used to demonstrate the effect of hospice use on patient experience, clinical and efficiency outcomes. RESULTS Hospice admissions in the last 6 months of life were correlated with a number of variables, including increases in patient satisfaction ratings (r=0.448, p=0.01) and better pain control (r=0.491, p=0.01), and reductions in hospital days (r=-0.517, p=0.01), fewer hospital deaths (r=-0.842, p=0.01) and fewer deaths occurring with an ICU admission during hospitalisation (r=-0.358, p=0.01). The structural equation model identified that use of hospice care was inversely related to hospital mortality (-0.885) and ICU mortality (-0.457). CONCLUSIONS The results of this investigation demonstrate that greater use of hospice care during the last 6 months of life is associated with improved patient experience, including satisfaction and pain control, as well as clinical outcomes of care, including decreased ICU and hospital mortality.
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Affiliation(s)
- Ruth Kleinpell
- Rush University Medical Center and Rush University College of Nursing, Chicago, Illinois, USA
| | - Eduard E Vasilevskis
- Department of Medicine, Vanderbilt University Medical Center, Veteran's Affairs, Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Louis Fogg
- Rush University Medical Center and Rush University College of Nursing, Chicago, Illinois, USA
| | - E Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Veteran's Affairs, Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
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Tan WS, Lee A, Yang SY, Chan S, Wu HY, Ng CWL, Heng BH. Integrating palliative care across settings: A retrospective cohort study of a hospice home care programme for cancer patients. Palliat Med 2016; 30:634-41. [PMID: 26867937 DOI: 10.1177/0269216315622126] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Terminally ill patients at the end-of-life do transit between care settings due to their complex care needs. Problems of care fragmentation could result in poor quality of care. AIM We aimed to evaluate the impact of an integrated hospice home care programme on acute care service usage and on the share of home deaths. SETTINGS/PARTICIPANTS The retrospective study cohort comprised patients who were diagnosed with cancer, had an expected prognosis of 1 year or less, and were referred to a home hospice. The intervention group comprised deceased patients enrolled in the integrated hospice home care programme between September 2012 and June 2014. The historical comparison group comprised deceased patients who were referred to other home hospices between January 2007 and January 2011. RESULTS There were 321 cases and 593 comparator subjects. Relative to the comparator group, the share of hospital deaths was significantly lower for programme participants (12.1% versus 42.7%). After adjusting for differences at baseline, the intervention group had statistically significantly lower emergency department visits at 30 days (incidence rate ratio: 0.38; 95% confidence interval: 0.31-0.47), 60 days (incidence rate ratio: 0.61; 95% confidence interval: 0.54-0.69) and 90 days (incidence rate ratio: 0.69; 95% confidence interval: 0.62-0.77) prior to death. Similar results held for the number of hospitalisations at 30 days (incidence rate ratio: 0.48; 95% confidence interval: 0.40-0.58), 60 days (incidence rate ratio: 0.71; 95% confidence interval: 0.62-0.82) and 90 days (incidence rate ratio: 0.77; 95% confidence interval: 0.68-0.88) prior to death. CONCLUSION Our results demonstrated that by integrating services between acute care and home hospice care, a reduction in acute care service usage could occur.
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Affiliation(s)
- Woan Shin Tan
- Health Services & Outcomes Research Department, National Healthcare Group, Singapore
| | - Angel Lee
- Palliative Medicine Department, Tan Tock Seng Hospital, Singapore Dover Park Hospice, Singapore
| | - Sze Yee Yang
- Palliative Medicine Department, Tan Tock Seng Hospital, Singapore Dover Park Hospice, Singapore
| | | | - Huei Yaw Wu
- Palliative Medicine Department, Tan Tock Seng Hospital, Singapore Dover Park Hospice, Singapore
| | - Charis Wei Ling Ng
- Health Services & Outcomes Research Department, National Healthcare Group, Singapore
| | - Bee Hoon Heng
- Health Services & Outcomes Research Department, National Healthcare Group, Singapore
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Aldridge MD, Epstein AJ, Brody AA, Lee EJ, Cherlin E, Bradley EH. The Impact of Reported Hospice Preferred Practices on Hospital Utilization at the End of Life. Med Care 2016; 54:657-63. [PMID: 27299952 PMCID: PMC5266506 DOI: 10.1097/mlr.0000000000000534] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Affordable Care Act requires hospices to report quality measures across a range of processes and practices. Yet uncertainties exist regarding the impact of hospice preferred practices on patient outcomes. OBJECTIVE Assess the impact of 6 hospice preferred practices and hospice organizational characteristics on hospital utilization and death using the first national data on hospice preferred practices. DESIGN 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 (84% response rate) and followed until death. OUTCOME MEASURES The proportion of patients at each hospice admitted to the hospital, emergency department (ED), and intensive care unit (ICU), and who died in the hospital after hospice enrollment. RESULTS Hospices that reported assessing patient preferences for site of death at admission had lower odds of being in the highest quartile for hospital death (AOR=0.36; 95% CI, 0.14-0.93) and ED visits (AOR=0.27; 95% CI, 0.10-0.76). Hospices that reported more frequently monitoring symptoms had lower odds of being in the highest quartile for ICU stays (AOR=0.48; 95% CI, 0.24-0.94). In adjusted analyses, a higher proportion of patients at for-profit compared with nonprofit hospices experienced a hospital admission (15.3% vs. 10.9%, P<0.001), ED visit (21.8% vs. 15.6%, P<0.001), and ICU stay (5.1% vs. 3.0%, P<0.001). CONCLUSIONS Hospitalization of patients following hospice enrollment varies substantially across hospices. Two of the 6 preferred practices examined were associated with hospitalization rates and for-profit hospices had persistently high hospitalization rates regardless of preferred practice implementation.
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Affiliation(s)
- Melissa D Aldridge
- *Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York †Geriatrics Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY ‡Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA §New York University College of Nursing, New York, NY ∥Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, CT
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Ornstein KA, Aldridge MD, Mair CA, Gorges R, Siu AL, Kelley AS. Spousal Characteristics and Older Adults' Hospice Use: Understanding Disparities in End-of-Life Care. J Palliat Med 2016; 19:509-15. [PMID: 26991831 DOI: 10.1089/jpm.2015.0399] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hospice use has been shown to benefit quality of life for patients with terminal illness and their families, with further evidence of cost savings for Medicare and other payers. While disparities in hospice use by patient diagnosis, race, and region are well documented and attention to the role of family members in end-of-life decision-making is increasing, the influence of spousal characteristics on the decision to use hospice is unknown. OBJECTIVES To determine the association between spousal characteristics and hospice use. DESIGN We used data from the Health and Retirement Study (HRS), a prospective cohort study, linked to the Dartmouth Atlas of Health Care and Medicare claims. SETTING National study of 1567 decedents who were married or partnered at the time of death (2000-2011). MEASURES Hospice use at least 1 day in the last year of life as measured via Medicare claims data. Spousal factors (e.g., education and health status) measured via survey. RESULTS In multivariate models controlling for patient factors and regional variation, spouses with lower educational attainment than their deceased spouse had decreased likelihood of hospice use (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40-0.82). Health of the spouse was not significantly associated with likelihood of decedent hospice use in adjusted models. IMPLICATIONS Although the health of the surviving spouse was not associated with hospice use, their educational level was a predictor of hospice use. Spousal and family characteristics, including educational attainment, should be examined further in relation to disparities in hospice use. Efforts to increase access to high-quality end-of-life care for individuals with serious illness must also address the needs and concerns of caregivers and family.
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Affiliation(s)
- Katherine A Ornstein
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,2 Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Melissa D Aldridge
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Christine A Mair
- 4 Department of Sociology and Anthropology, University of Maryland , Baltimore, Maryland
| | - Rebecca Gorges
- 5 Harris School of Public Policy, University of Chicago , Chicago, Illinois
| | - Albert L Siu
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,3 James J. Peters Veterans Affairs Medical Center , Bronx, New York
| | - Amy S Kelley
- 1 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,3 James J. Peters Veterans Affairs Medical Center , Bronx, New York
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Wang SY, Aldridge MD, Gross CP, Canavan M, Cherlin E, Johnson-Hurzeler R, Bradley E. Transitions Between Healthcare Settings of Hospice Enrollees at the End of Life. J Am Geriatr Soc 2016; 64:314-22. [PMID: 26889841 PMCID: PMC4762182 DOI: 10.1111/jgs.13939] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To characterize the number and types of care transitions in the last 6 months of life of individuals who used hospice and to examine factors associated with having multiple transitions in care. DESIGN Retrospective cohort study. SETTING One hundred percent fee-for-service Medicare decedent claims data. PARTICIPANTS Medicare beneficiaries aged 66 and older who died between July 1, 2011, and December 31, 2011, and were enrolled in hospice at some time during the last 6 months of life. MEASUREMENTS Hierarchical generalized linear modeling was used to identify individual, hospice, and regional factors associated with transitions. The sequence of transitions across healthcare settings was described. Healthcare transitions after hospice enrollment included from and to the hospital, skilled nursing facility, home health agency program, hospice, or home without receiving any service in these four healthcare settings. RESULTS Of 311,090 hospice decedents, 31,675 (10.2%) had at least one transition after hospice enrollment, and this varied substantially across the United States; 6.6% of all decedents had more than one transition in care after hospice enrollment (range 2-19 transitions). Of hospice users with transitions, 53.4% were admitted to hospitals, 17.7% were admitted to skilled nursing facilities, 9.6% used home health agencies, and 25.8% had transitions to home without receiving the services from the healthcare settings examined. In adjusted analyses, decedents who were younger, nonwhite, enrolled in a for-profit or small hospice program, or had less access to hospital-based palliative care had significantly higher odds of having at least one transition. CONCLUSION A notable proportion of hospice users experience at least one transition in care in the last 6 months of life, suggesting that further research on the effect of transitions on users and families is warranted.
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Affiliation(s)
- Shi-Yi Wang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
| | - Melissa D. Aldridge
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York and James J. Peters VA Medical Center, Bronx, NY
| | - Cary P. Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Maureen Canavan
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT
| | - Emily Cherlin
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT
| | - Rosemary Johnson-Hurzeler
- John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, Connecticut, CT
| | - Elizabeth Bradley
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT
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Chiang JK, Kao YH, Lai NS. The Impact of Hospice Care on Survival and Healthcare Costs for Patients with Lung Cancer: A National Longitudinal Population-Based Study in Taiwan. PLoS One 2015; 10:e0138773. [PMID: 26406871 PMCID: PMC4583292 DOI: 10.1371/journal.pone.0138773] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/02/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The healthcare costs of cancer care are highest in the last month of life. The effect of hospice care on end-of-life (EOL) healthcare costs is not clearly understood. PURPOSE The purpose of this study was to evaluate the effect of hospice care on survival and healthcare costs for lung cancer patients in their final month of life. METHODS We adopted Taiwan's National Health Insurance Research Claims Database to analyze data for 3399 adult lung cancer patients who died in 1997-2011. A logistic regression analysis was performed to determine the predictors of high healthcare cost, defined as costs falling above the 90th percentile. Patients who received hospice cares were assigned to a hospice (H) group and those who did not were assigned to a non-hospice (non-H) group. RESULTS The patients in the H group had a longer mean (median) survival time than those in the non-H group did (1.40 ± 1.61 y (0.86) vs. 1.10 ± 1.47 (0.61), p<0.001). The non-H group had a lower mean healthcare cost than the H group (US $1,821 ± 2,441 vs. US $1,839 ± 1,638, p<0.001). And, there were a total of 340 patients (10%) with the healthcare costs exceeding the 90th percentile (US $4,721) as the cutoff value of high cost. The non-H group had a higher risk of high cost than the H group because many more cases in the non-H group had lower costs. Moreover, the risk of high health care costs were predicted for patients who did not receive hospice care (odds ratio [OR]: 3.68, 95% confidence interval [CI]: 2.44-5.79), received chemotherapy (OR: 1.51, 95% CI: 1.18-1.96) and intubation (OR: 2.63, 95% CI: 1.64-4.16), and those who had more emergency department visits (OR: 1.78, 95% CI: 1.24-2.52), longer hospital admission in days (OR: 1.08, 95% CI: 1.07-1.09), and received radiotherapy (OR: 1.33, 95% CI: 1.00-1.78). Lower risks of high health care costs were observed in patients with low socioeconomic status (OR: 0.58, 95% CI: 0.40-0.83), or previous employment (OR: 0.66, 95% CI: 0.47-0.92). After propensity-score matching, the patients of the non-H group had a higher mean cost and a higher risk of high cost. Similar results were obtained from logistic regression analysis in propensity score-matched patients. CONCLUSIONS The survival of the hospice group was longer than non-H group, and patients in the non-H group were 3.74 times more likely to have high healthcare costs at EOL. The positive predictors for high health care costs were patients who did not receive hospice care, who received chemotherapy and intubation, who had more emergency department visits and longer hospital admission, and who received radiotherapy. Negative predictors were patients who had a low socioeconomic status or previous employment. The issue of how to reduce the high health care costs for patients with lung cancer in the last month of life is a challenge for policy makers and health care providers.
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Affiliation(s)
- Jui-Kun Chiang
- Department of Family Medicine, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan
| | - Yee-Hsin Kao
- Department of Family Medicine, Tainan Municipal Hospital, Tainan, Taiwan
| | - Ning-Sheng Lai
- Department of Allergy, Immunology and Rheumatology, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
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Abstract
Inpatient hospice care can reduce futile treatment and medical costs. However, the cost trimming effect of home-based hospice care in hospital has yet not been explored. This study evaluates the impact of home-based hospice care on end-of-life expenditure in hospitals with different spending intensity. This is a population-based retrospective study in Taiwan. Cancer decedents were identified in the National Health Insurance Research Database (NHIRD) from 2009 to 2011. They are categorized by hospital spending intensity. A hierarchical linear regression model with a random-intercept model was used to analyze the relationship between end-of-life expenditure (dependent variable) with and without home-based hospice, and both patient-level and hospital-level characteristics. A total of 78,613 cancer decedents were identified in the NHIRD from 2009 to 2011. Of these decedents, 17,638, 43,286, and 17,689 were categorized by hospital spending intensity as high, moderate, and low, respectively. Decedents with home-based hospice care were associated with US$2452 less in expenditure per patient compared with those without home-based hospice care. The majority of savings occurred in the last 3 months of life. These savings with home-based hospice care were consistent in hospitals with different levels of spending intensity. Home-based hospice reduced one-fifth expenditure at the end of life of cancer decedents treated in hospitals with different spending intensity.
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Affiliation(s)
- Li-Fu Chen
- From the Department of Emergency Medicine, National Yang-Ming University Hospital, I-Lan, Taiwan (L-FC); School of Medicine, National Yang-Ming University, Taipei, Taiwan (L-FC); Department of Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan (C-MC); School of Medicine, Tzu Chi University, Hualian, Taiwan (C-MC); and Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan (C-YH)
| | - Chun-Ming Chang
- From the Department of Emergency Medicine, National Yang-Ming University Hospital, I-Lan, Taiwan (L-FC); School of Medicine, National Yang-Ming University, Taipei, Taiwan (L-FC); Department of Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan (C-MC); School of Medicine, Tzu Chi University, Hualian, Taiwan (C-MC); and Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan (C-YH)
| | - Chih-Yuan Huang
- From the Department of Emergency Medicine, National Yang-Ming University Hospital, I-Lan, Taiwan (L-FC); School of Medicine, National Yang-Ming University, Taipei, Taiwan (L-FC); Department of Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan (C-MC); School of Medicine, Tzu Chi University, Hualian, Taiwan (C-MC); and Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan (C-YH)
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Kerr CW, Donohue KA, Tangeman JC, Serehali AM, Knodel SM, Grant PC, Luczkiewicz DL, Mylotte K, Marien MJ. Cost savings and enhanced hospice enrollment with a home-based palliative care program implemented as a hospice-private payer partnership. J Palliat Med 2015; 17:1328-35. [PMID: 25375799 DOI: 10.1089/jpm.2014.0184] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In the United States, 5% of the population is responsible for nearly half of all health care expenditures, with a large concentration of spending driven by individuals with expensive chronic conditions in their last year of life. Outpatient palliative care under the Medicare Hospice Benefit excludes a large proportion of the chronically ill and there is widespread recognition that innovative strategies must be developed to meet the needs of the seriously ill while reducing costs. OBJECTIVE This study aimed to evaluate the impact of a home-based palliative care program, implemented through a hospice-private payer partnership, on health care costs and utilization. METHODS This was a prospective, observational database study where insurance enrollment and claims data were analyzed. The study population consisted of Home Connections (HC) program patients enrolled between January 1, 2010 and December 31, 2012 who subsequently expired (n=149) and who were also Independent Health members. A control group (n=537) was derived using propensity-score matching. The primary outcome variable was overall costs within the last year of life. Costs were also examined at six months, three months, one month, and two weeks. Inpatient, outpatient, ancillary, professional, and pharmacy costs were compared between the two groups. Medical service utilization and hospice enrollment and length of stay were also evaluated. RESULTS Cost savings were apparent in the last three months of life—$6,804 per member per month (PMPM) cost for palliative care participants versus $10,712 for usual care. During the last two weeks of life, total allowed PMPM was $6,674 versus $13,846 for usual care. Enhanced hospice entry (70% versus 25%) and longer length of stay in hospice (median 34 versus 9 days) were observed. CONCLUSIONS Palliative care programs partnered with community hospice providers may achieve cost savings while helping provide care across the continuum.
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DiMartino LD, Weiner BJ, Mayer DK, Jackson GL, Biddle AK. Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review. J Palliat Med 2015; 17:1384-99. [PMID: 25115197 DOI: 10.1089/jpm.2014.0092] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Frequent emergency department (ED) visits are an indicator of poor quality of cancer care. Coordination of care through the use of palliative care teams may limit aggressive care and improve outcomes for patients with cancer at the end of life. OBJECTIVES To systematically review the literature to determine whether palliative care interventions implemented in the hospital, home, or outpatient clinic are more effective than usual care in reducing ED visits among patients with cancer at the end of life. ELIGIBILITY CRITERIA PubMed, EMBASE, and CINAHL databases were searched from database inception to May 7, 2014. Only randomized/non-randomized controlled trials (RCTs) and observational studies examining the effect of palliative care interventions on ED visits among adult patients with cancer with advanced disease were considered. DATA EXTRACTION AND DATA SYNTHESIS Data were abstracted from the articles that met all the inclusion criteria. A second reviewer independently abstracted data from 2 articles and discrepancies were resolved. From 464 abstracts, 2 RCTs, 10 observational studies, and 1 non-RCT/quasi-experimental study were included. Overall there is limited evidence to support the use of palliative care interventions to reduce ED visits, although studies examining effect of hospice care and those conducted outside of the United States reported a statistically significant reduction in ED visits. CONCLUSIONS Evidence regarding whether palliative care interventions implemented in the hospital, home or outpatient clinic are more effective than usual care at reducing ED visits is not strongly substantiated based on the literature reviewed. Improvements in the quality of reporting for studies examining the effect of palliative care interventions on ED use are needed.
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Affiliation(s)
- Lisa D DiMartino
- 1 Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
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Wang SY, Aldridge MD, Gross CP, Canavan M, Cherlin E, Johnson-Hurzeler R, Bradley E. Geographic Variation of Hospice Use Patterns at the End of Life. J Palliat Med 2015; 18:771-80. [PMID: 26172615 DOI: 10.1089/jpm.2014.0425] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Little is known about state-level variation in patterns of hospice use, an important indicator of quality of care at the end of life. Findings may identify states where targeted efforts for improving end-of-life care may be warranted. OBJECTIVE Our aim was to characterize the state-level variation in patterns of hospice use among decedents and to examine state, county, and individual factors associated with these patterns. METHODS We conducted a retrospective analysis of Medicare fee-for-service decedents. The primary outcome measures were state-level hospice use during the last 6 months of life and the state's proportion of hospice users with very short hospice enrollment (≤7 days), very long hospice enrollment (≥180 days), and hospice disenrollment prior to death. RESULTS In 2011, the percentage of decedents who used hospice in the last 6 months of life nationally was 47.1%, and varied across states from 20.3% in Alaska to 60.8% in Utah. Hospice utilization patterns also varied by state, with the percentage of hospice users with very short hospice enrollment ranging from 23.0% in the District of Columbia to 39.9% in Connecticut. The percentage of very long hospice use varied from 5.7% in Connecticut to 15.9% in Delaware. The percentage of hospice disenrollment ranged from 6.2% in Hawaii to 19.0% in the District of Columbia. Nationally, state-level hospice use among decedents was positively correlated with the percentage of potentially concerning patterns (including very short hospice enrollment, very long hospice enrollment, and hospice disenrollment) among hospice users (the Pearson correlation coefficient=0.52, p value<0.001). Oregon was the only state in the highest quartile of hospice use and the lowest quartiles of both very short and very long hospice enrollment. CONCLUSIONS The percentage of decedents who use hospice may mask important state-level variation in these patterns, including the timing of hospice enrollment, a potentially important component of the quality of end-of-life care.
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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 and Yale University School of Medicine , New Haven, Connecticut
| | - Melissa D Aldridge
- 3 Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York and James J. Peters VA Medical Center , Bronx, New York
| | - Cary P Gross
- 2 Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine , New Haven, Connecticut.,4 Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine , New Haven, Connecticut
| | - Maureen Canavan
- 5 Department of Health Policy and Management, Yale University School of Public Health , New Haven, Connecticut
| | - Emily Cherlin
- 5 Department of Health Policy and Management, Yale University School of Public Health , New Haven, Connecticut
| | - Rosemary Johnson-Hurzeler
- 6 John D. Thompson Hospice Institute for Education, Training, and Research, Inc. , Branford, Connecticut
| | - Elizabeth Bradley
- 5 Department of Health Policy and Management, Yale University School of Public Health , New Haven, Connecticut
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