Black And Hispanic Patients Receive Hospice Care Similar To That Of White Patients When In The Same Hospices

Naming racism as a root cause of inequities in palliative care research: a scoping review

BACKGROUND

Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist.

OBJECTIVE

To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings.

METHODS

Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results.

RESULTS

We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common.

CONCLUSION

While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

Overall US Hospice Quality According to Decedent Caregivers-Natural Language Processing and Sentiment Analysis of 3389 Online Caregiver Reviews

Objectives: With an untapped quality resource in online hospice reviews, study aims were exploring hospice caregiver experiences and assessing their expectations of the hospice Medicare benefit. Methods: Topical and sentiment analysis was conducted using natural language processing (NLP) of Google and Yelp caregiver reviews (n = 3393) between 2013-2023 using Google NLP. Stratified sampling weighted by hospice size to approximate the daily census of US hospice enrollees. Results: Overall caregiver sentiment of hospice care was neutral (S = .14). Therapeutic, achievable expectations and misperceptions, unachievable expectations were, respectively, the most and least prevalent domains. Four topics with the highest prevalence, all had moderately positive sentiments: caring staff, staff professionalism and knowledge; emotional, spiritual, bereavement support; and responsive, timely or helpful. Lowest sentiments scores were lack of staffing; promises made, but not kept, pain, symptoms and medications; sped-up death, hasted, or sedated; and money, staff motivations. Significance of Results: Caregivers overall rating of hospice was neutral, largely due to moderate sentiment on achievable expectations in two-thirds of reviews mixed with unachievable expectations in one-sixth of reviews. Hospice caregivers were most likely to recommend hospices with caring staff, providing quality care, responsive to requests, and offering family support. Lack of staff, inadequate pain-symptom management were the two biggest barriers to hospice quality. All eight CAHPS measures were found in the discovered review topics. Close-ended CAHPS scores and open-ended online reviews have complementary insights. Future research should explore associations between CAHPS and review insights.

Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia

Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.

Black Caregivers' Symptom Management, Cultural, and Religious Experiences With Home Hospice Care

CONTEXT

Informal Black or African American (Black/AA) caregivers are at high risk for caregiver burden due to both greater caregiving responsibilities and unmet needs. However, there has been minimal research on the challenges Black/AA caregivers face after hospice enrollment.

OBJECTIVES

This study seeks to address this knowledge gap by applying qualitative methods to understand Black/AA caregivers' experiences around symptom management, cultural, and religious challenges during home hospice care.

METHODS

Data from small group discussions with 11 bereaved Black/AA caregivers of patients who received home hospice care were qualitatively analyzed.

RESULTS

Caregivers struggled most with managing patients' pain, lack of appetite, and decline near end of life (EoL). Cultural needs (e.g., knowing their language, having familiarity with foods) were perceived as not on top of mind for many Black/AA caregivers. However, there was a concern of stigma around mental health preventing care recipients from sharing their mental health concerns and seeking resources. Many caregivers relied on their personal religious networks rather than services provided by hospice chaplains. Lastly, caregivers reported increased burden during this phase of caregiving but were satisfied with the overall hospice experience.

CONCLUSION

Our results suggest that tailored approaches that target mental health stigma in the Black/AA community and reduce caregiver distress around end of life symptoms may improve hospice outcomes among Black/AA hospice caregivers. Hospice spiritual services should consider offering services complementary to caregivers' existing religious networks. Future qualitative and quantitative studies should examine the clinical implications of these results in terms of patient, caregiver, and hospice outcomes.

Hospice Glassdoor and CAHPS® Scores-Glassdoor Scores and Hospice Financial Characteristics Predict Hospice Consumer Assessment of Healthcare Providers and Systems Scores

BACKGROUND

Recent public data transparency on both decedent caregiver satisfaction and employee satisfaction is impacting the three most essential needs of any hospice, admitting hospice enrollees, attracting hospice professionals and delivering on quality.

AIM

Explore the relationship between Glassdoor hospice employee recommendation data, hospice financial characteristics, and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) scores among the 50 largest US hospices.

DESIGN

Retrospective data with multivariate regression analysis.

DATA SOURCES

Provider CAHPS hospice survey data from 2019-2020 and Glassdoor employee recommendation data.

RESULTS

Glassdoor Composite and CAHPS Composite were positively correlated (r = .469, p < .01). Glassdoor scores, profit status, and acquisition status predicted Hospice CAHPS scores and explained 44% of the variation in CAHPS Composite. Being a large, for-profit hospice in acquisition status each predicted lower CAHPS scores. Non-profit hospices had significantly higher Glassdoor and CAHPS scores than for-profit hospices. CAHPS Composite and CAHPS Star Rating have potential as global indicators to inform customers of a given hospice's overall quality on the Hospice Compare website of CMS.

CONCLUSIONS

Hospice leaders seeking improvements in CAHPS scores are encouraged to seek feedback on whether their own employees would recommend their hospice to a friend. Communication and responsiveness were the strongest indicators of overall hospice quality. Skelton hospice staffing models must give way to realistic models that value company culture and employee satisfaction. Hospice quality and hospice profits are not necessarily mutually exclusive. Future research should explore the difference in themes emerging from positive and negative online caregiver reviews.

Patient-Reported Quality Measures for Palliative Care: The Time is now

CONTEXT

While progress has been made in the ability to measure the quality of hospice and specialty palliative care, there are notable gaps. A recent analysis conducted by Center for Medicare and Medicaid Services (CMS) revealed a paucity of patient-reported measures, particularly in palliative care domains such as symptom management and communication.

OBJECTIVES

The research team, consisting of quality measure and survey developers, psychometricians, and palliative care clinicians, used established state-of-the art methods for developing and testing patient-reported measures.

METHODS

We applied a patient-centered, patient-engaged approach throughout the development and testing process. This sequential process included 1) an information gathering phase; 2) a pre-testing phase; 3) a testing phase; and 4) an endorsement phase.

RESULTS

To fill quality measure gaps identified during the information gathering phase, we selected two draft measures ("Feeling Heard and Understood" and "Receiving Desired Help for Pain") for testing with patients receiving palliative care in clinic-based settings. In the pre-testing phase, we used an iterative process of cognitive interviews to refine draft items and corresponding response options for the proposed measures. The alpha pilot test supported establishment of protocols for the national beta field test. Measures met conventional criteria for reliability, had strong face and construct validity, and there was diversity in program level scores. The measures received National Quality Forum (NQF) endorsement.

CONCLUSION

These measures highlight the key role of patient voices in palliative care and fill a much-needed gap for patient-reported experience measures in our field.

Hispanics and Hospice: A Systematic Literature Review

Background. Hospice has been shown to improve patient and family satisfaction with care, reduce hospitalizations and hospital costs, and reduce pain and symptoms. Despite more than 40 years of hospice care and related research in the U.S., few studies examining hospice experiences have included Hispanics. Thus, little is known about hospice barriers, facilitators, and outcomes among Hispanics.Aim. This systematic literature review aimed to provide a comprehensive overview of studies assessing knowledge of and attitudes toward hospice, barriers and facilitators to hospice use, utilization patterns, and hospice-related outcomes among Hispanics.Design. Between March 2019 and March 2020 we searched Ovid Medline (PubMed), EMBASE, and CINAHL, using search terms for hospice care, end-of-life care, Hispanics, and Latinos. All steps were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. U.S. studies that examined Hispanics' knowledge and attitudes towards hospice, facilitators or barriers to hospice use, hospice use, and hospice-related outcomes were included. Qualitative studies and non-empirical work were excluded. Study quality was assessed using Hawker's quality criteria.Results. Of the 4,841 abstracts reviewed, 41 peer-reviewed articles met the inclusion criteria. These studies largely report lower hospice knowledge and awareness among Hispanics and mixed results around hospice use and outcomes in comparison to Whites.Conclusion. There has been relatively little research focused specifically on Hispanics' experience with hospice. Future research should focus on testing interventions for overcoming hospice-related disparities among Hispanics and on improving access to quality hospice care among terminally ill Hispanics.

A Decade of Studying Drivers of Disparities in End-of-Life Care for Black Americans: Using the NIMHD Framework for Health Disparities Research to Map the Path Ahead

OBJECTIVE

The purpose of this paper is to provide a review of the existing literature on racial disparities in quality of palliative and end-of-life care and to demonstrate gaps in the exploration of underlying mechanisms that produce these disparities.

BACKGROUND

Countless studies over several decades have revealed that our healthcare system in the United States consistently produces poorer quality end-of-life care for Black compared with White patients. Effective interventions to reduce these disparities are sparse and hindered by a limited understanding of the root causes of these disparities.

METHODS

We searched PubMed, CINAHL and PsychInfo for research manuscripts that tested hypotheses about causal mechanisms for disparities in end-of-life care for Black patients. These studies were categorized by domains outlined in the National Institute of Minority Health and Health Disparities (NIMHD) framework, which are biological, behavioral, physical/built environment, sociocultural and health care systems domains. Within these domains, studies were further categorized as focusing on the individual, interpersonal, community or societal level of influence.

RESULTS

The majority of the studies focused on the Healthcare System and Sociocultural domains. Within the Health Care System domain, studies were evenly distributed among the individual, interpersonal, and community level of influence, but less attention was paid to the societal level of influence. In the Sociocultural domain, most studies focused on the individual level of influence. Those focusing on the individual level of influence tended to be of poorer quality.

CONCLUSIONS

The sociocultural environment, physical/built environment, behavioral and biological domains remain understudied areas of potential causal mechanisms for racial disparities in end-of-life care. In the Healthcare System domain, social influences including healthcare policy and law are understudied. In the sociocultural domain, the majority of the studies still focused on the individual level of influence, missing key areas of research in interpersonal discrimination and local and societal structural discrimination. Studies that focus on individual factors should be better screened to ensure that they are of high quality and avoid stigmatizing Black communities.

Anxiety, Depression, Quality of Life, Caregiver Burden, and Perceptions of Caregiver-Centered Communication among Black and White Hospice Family Caregivers

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.

Variation in Hospice Experiences by Care Setting for Patients With Dementia

OBJECTIVES

Use of hospice care among patients with dementia has been steadily increasing. Our objectives were to characterize quality of hospice care experiences among decedents who had a primary diagnosis of dementia and their caregivers and investigate differences across settings of hospice care.

DESIGN

We analyzed Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from caregiver respondents whose family members received hospice care.

SETTING AND PARTICIPANTS

Data from 96,845 caregiver respondents whose family members had a primary diagnosis of dementia and died in 2017 or 2018 while receiving hospice care in 2829 hospices.

METHODS

We calculated quality measure scores overall and stratified by setting, adjusting for mode of survey administration and differences in case mix, and examined variability in hospice-level scores among decedents with dementia.

RESULTS

Mean quality measure scores ranged from 69.0 (Getting Hospice Care Training) to 90.9 (Getting Emotional Support). Measure scores varied significantly across settings, with caregivers of decedents who received care in a nursing home (NH), acute care hospital (ACH), or assisted living facility (ALF) consistently reporting poorer quality of care. Hospice-level scores varied substantially, with a wide range between the 10th and 90th percentiles of hospice performance (eg, 25 points).

CONCLUSIONS AND IMPLICATIONS

There are important opportunities to improve hospice care for patients with dementia and their caregivers, particularly with respect to caregiver training, symptom management, and across all dimensions within the NH, ACH, and ALF settings. Variability in care experiences across hospices, as well as long lengths of stay for those with dementia, highlight the importance of informed and timely hospice referral.

Racial/Ethnic Differences in Emergency Department Utilization and Experience

BACKGROUND

Previous work has demonstrated racial/ethnic differences in emergency department (ED) utilization, but less is known about racial/ethnic differences in the experience of care received during an ED visit.

OBJECTIVE

To examine differences in self-reported healthcare utilization and experiences with ED care by patients' race/ethnicity.

DESIGN

Adult ED patients discharged to community (DTC) were surveyed (response rate: 20.25%) using the Emergency Department Patient Experience of Care (EDPEC) DTC Survey. Linear regression was used to estimate case-mix-adjusted differences in patient experience between racial/ethnic groups.

PARTICIPANTS

3122 survey respondents who were discharged from the EDs of 50 hospitals nationwide January-March 2016.

MAIN MEASURES

Six measures: getting timely care, doctor and nurse communication, communication about medications, receipt of sufficient information about test results, whether hospital staff discussed the patient's ability to receive follow-up care, and willingness to recommend the ED.

KEY RESULTS

Black and Hispanic patients were significantly more likely than White patients to report visiting the ED for an ongoing health condition (40% Black, 30% Hispanic, 28% White, p<0.001), report having visited an ED 3+ times in the last 6 months (26% Black, 25% Hispanic, 19% White, p<0.001), and report not having a usual source of care (19% Black, 19% Hispanic, 8% White, p<0.001). Compared with White patients, Hispanic patients more often reported that hospital staff talked with them about their ability to receive needed follow-up care (+7.2 percentile points, p=0.038) and recommended the ED (+7.2 points, p=0.037); Hispanic and Black patients reported better doctor and nurse communication (+6.4 points, p=0.008; +4 points, p=0.036, respectively).

CONCLUSIONS

Hispanic and Black ED patients reported higher ED utilization, lacked a usual source of care, and reported better experience with ED care than White patients. Results may reflect differences in care delivery by staff and/or different expectations of ED care among Hispanic and Black patients.

Improving Care Experiences for Patients and Caregivers at End of Life: A Systematic Review

BACKGROUND

End-of-life care is increasing as the US population ages. Approaches to providing high-quality end-of-life care vary across setting, diseases, and populations. Several data collection tools measure patient and/or caregiver care experiences at end of life and can be used for quality improvement. Previous reviews examined palliative care improvements or available measures but none explicitly on improving care experiences. We reviewed literature on improving patient and/or caregiver end-of-life care experiences.

DESIGN

We searched U.S. English-language peer-reviewed and grey literature after 2000 on adult end-of-life care experiences. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for quantitative studies, Enhancing Transparency in Reporting the Synthesis of Qualitative Research approach for qualitative studies, and Assessment of Multiple Systematic Reviews tool for the literature reviews.

SETTING

Palliative and hospice care.

POPULATION

Full-text abstraction of 84 articles, identifying 16 articles.

MEASURES

Patient and/or caregiver end-of-life care experiences (captured through administrative data or direct report).

RESULTS

Articles examined palliative care experiences across settings; none studied hospice care experiences. Patients and/or caregivers assessed overall care experiences, clinician-staff interactions, provider communication, respect and trust, timeliness of care, spiritual support, caregiver knowledge of care plans, or bereavement support. Efforts aimed at improving end-of-life care experiences are limited and show mixed results.

CONCLUSIONS

Literature on improving patient and/or caregiver end-of-life care experiences is emerging and focused on palliative care experiences. Evidence on improving hospice care experiences is lacking. Research on strategies for improving end-of-life care experiences should go beyond overall care experiences to include specific aspects of palliative and hospice care experiences.

Factors Associated With Home-Hospice Utilization

Utilization of hospice for end-of-life care is known to be lower among racial and ethnic minority groups than among White populations when controlling for other socioeconomic factors. Certain patient, provider, and community characteristics may influence home-hospice use. We sought to identify patient, provider, and community factors associated with home-hospice use. Our final analytic sample included 1,208,700 hospice patients who received home-hospice from 2,148 Medicare-certified hospice providers in 2016. We found that an increase in the proportion of hospice patients with a primary diagnosis of dementia decreased the odds that home-hospice was provided (OR = 1.42, 95% CI = 1.36-1.48). Patients who received hospice care from a provider with a higher proportion of dually enrolled patients were less likely to receive home-hospice (OR = 1.42, 95% CI = 1.36-1.48) and hospices located in ZIP-codes with higher proportion of Hispanic resident were less likely to provide home-hospice (OR = 1.00, 95% CI = 0.99-0.99). Additional research is needed to clarify the mechanisms underlying these associations.

Association between Receipt of Emotional Support and Caregivers' Overall Hospice Rating

Background: A major goal of hospice care is to provide individually tailored emotional and spiritual support to caregivers of hospice patients. Objectives: Examine the association between reported emotional support and caregivers' overall rating of hospice care, overall and by race/ethnicity/language. Subjects: We analyzed survey data corresponding to 657,805 decedents/caregivers who received care from 3160 hospice programs during January 2017-December 2018. Measurements: Linear regression models examined the association between caregiver-reported receipt of emotional and spiritual support ("too little" vs. "right amount" vs. "too much") and overall rating of the hospice (0 vs. 100 rating). Interaction terms assessed variation in this association by race/ethnicity/language. Results: "Too much" emotional support was less common than "too little," except for caregivers of Hispanic decedents responding in Spanish. "Too little" support was strongly associated with lower hospice ratings for all groups (compared to "right amount" of support, p < 0.001). In contrast, the negative association between "too much" support and hospice rating was much smaller (p < 0.001) among caregivers of white and black decedents. "Too much" support was associated with more positive ratings among caregivers of Hispanic decedents (p < 0.001). Conclusions: Receipt of "too much" support is a less common and much weaker driver of poor hospice ratings than receipt of "too little" support for all groups, and is not always viewed negatively. This suggests that for hospice evaluation, "too much" support should not be scored equivalently to "too little" support and that providing enough support should be a hospice priority.

Racial Differences in Pain Management for Patients Receiving Hospice Care

OBJECTIVES

To investigate racial differences in implementation of 11 evidence-based cancer pain management strategies in a matched sample of patients in hospice.

SAMPLE & SETTING

32 African American and 32 Caucasian American older adults (aged 65 years or older) with cancer pain receiving hospice care in the midwestern United States.

METHODS & VARIABLES

Matched cohort secondary data analysis of postintervention data in a cluster randomized controlled trial was used. Main outcomes are the summative and individual Cancer Pain Practice Index scores.

RESULTS

There were few statistically significant or clinically meaningful differences in implementation of individual best practices for pain management by race. Assessment of primary pain characteristics and management of opioid-induced constipation with a bowel regimen was significantly lower in African Americans than in Caucasian Americans.

IMPLICATIONS FOR NURSING

African American older adults receiving hospice care at the end of life received pain management that was, overall, comparable to matched Caucasian American older adults. Hospice and oncology nurses play a critical role in effective pain management and should continue to implement evidence-based guidelines for pain management into daily practice. Diffusing the hospice model and principles of pain and symptom management into other settings and specialty care areas may reduce widespread pain disparities.

Closing the Gap in Hospice Utilization for the Minority Medicare Population

Background: Medicare spends about 20% more on the last year of life for Black and Hispanic people than White people. With lower hospice utilization rates, racial/ethnic minorities receive fewer hospice-related benefits such as lesser symptoms, lower costs, and improved quality of life. For-profit hospices have higher dropout rates than nonprofit hospices, yet target racial/ethnic minority communities more through community outreach. This analysis examined the relationship between hospice utilization and for-profit hospice status and conducted an economic analysis of racial/ethnic minority utilization. Method: Cross-sectional analysis of 2014 Centers for Medicare & Medicaid Services (CMS), U.S. Census, and Hospice Analytics data. Measures included Medicare racial/ethnic minority hospice utilization, for-profit hospice status, estimated cost savings, and several demographic and socioeconomic variables. Results: The prevalence of for-profit hospices was associated with significantly increased hospice utilization among racial/ethnic minorities. With savings of about $2,105 per Medicare hospice enrollee, closing the gap between the White and racial/ethnic minority populations would result in nearly $270 million in annual cost savings. Discussion: Significant disparities in hospice use related to hospice for-profit status exist among the racial/ethnic minority Medicare population. CMS and state policymakers should consider lower racial/ethnic minority hospice utilization and foster better community outreach at all hospices to decrease patient costs and improve quality of life.

Factors Associated With Live Discharge of Heart Failure Patients From Hospice: A Multimethod Study

OBJECTIVES

This study identified sociodemographic and clinical factors that predicted live discharge among home hospice patients with heart failure, and related these findings to perspectives among health care providers about challenges to caring for these patients.

BACKGROUND

Hospice patients with heart failure are frequently discharged from hospice before death ("live discharge"). However, little is known about the factors and circumstances associated with live discharge among patients with heart failure.

METHODS

Quantitative analyses of patient medical records (N = 1,498) and qualitative interviews were performed with health care providers (n = 19) at a not-for-profit hospice agency in New York City.

RESULTS

Thirty percent of home hospice patients with heart failure experienced a live discharge, most frequently due to 911 calls that led to acute hospitalization. The odds of acute hospitalization were higher for younger patients (age 18 to 74 years: adjusted odds ratio [AOR]: 2.10; 95% confidence interval [CI]: 1.34 to 3.28), African American (AOR: 2.06; 95% CI: 1.31 to 3.24) or Hispanic (AOR: 2.99; 95% CI: 1.99 to 4.50) patients, and higher functioning patients (Palliative Performance Scores of 50% to 70%; AOR: 5.68; 95% CI: 3.66 to 8.79). Qualitative interviews with health care providers highlighted the unique characteristics of heart failure (e.g., sudden changes in patients' condition), the importance of patients' understanding of hospice and their own prognosis, and the role of sociocultural and family context in precipitating and potentially preventing live discharge (e.g., absence of social supports in the home).

CONCLUSIONS

Live discharge from hospice, especially due to acute hospitalization, is common with heart failure. Greater attention is needed for patients' knowledge of and readiness for hospice care, especially among younger and diverse populations, and for factors related to the social and family context in which hospice care is provided.

Inpatient care experiences differ by preferred language within racial/ethnic groups

Objective

To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups.

Data Source

2014‐2015 HCAHPS survey data.

Study Design

We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient‐mix adjusted overall, between‐ and within‐hospital differences in patient experience by language, using linear regression.

Data Collection Methods

Surveys from 5 480 308 patients discharged from 4517 hospitals 2014‐2015.

Principal Findings

Within each racial/ethnic group, mean reported experiences for non‐English‐preferring patients were almost always worse than their English‐preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within‐hospital differences by language were often larger than between‐hospital differences and were largest for Care Coordination. Where between‐hospital differences existed, non‐English‐preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English‐preferring counterparts.

Conclusions

Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non‐English‐preferring patients, focusing on cultural competence and language‐appropriate services.

Effects of Caregiver and Decedent Characteristics on CAHPS Hospice Survey Scores

CONTEXT

The Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) Hospice Survey assesses the care experiences of hospice patients and their families. Public reporting of hospice performance on these survey measures began in February 2018.

OBJECTIVES

Develop an appropriate case-mix adjustment (CMA) model to allow for fair comparisons between hospices.

METHODS

We analyzed CAHPS Hospice Survey data reflecting experiences of 915,442 patients who received care from 2513 hospice programs between April 2015 and March 2016. Decedent and caregiver characteristics were identified for inclusion in CMA based on their variation across hospices (as measured by intraclass correlation coefficients [ICCs]) and how predictive they were of responses to survey questions (as assessed by linear regression).

RESULTS

The final CMA model included decedent age, payer for hospice care, primary diagnosis, length of final episode of hospice care, caregiver age, caregiver education, relationship to decedent, survey language/language spoken at home, and response percentile. The characteristics that varied most across hospices were language (ICC = 0.48 for Spanish survey or home language) and payer for hospice care (ICC = 0.42 for Medicare only; ICC = 0.35 for Medicare and private insurance). The characteristics that were most predictive of caregivers' survey responses were payer for hospice care, caregiver education, and survey language/language spoken at home. Lack of appropriate adjustment would incorrectly rank hospices by 1.2-5.4 percentile points.

CONCLUSION

To ensure fair comparisons across hospices, CAHPS Hospice Survey measure scores should be adjusted for several caregiver and decedent characteristics.

Hispanic Hospice Patients' Experiences of End-Stage Restlessness

End-stage restlessness, or terminal agitation, is experienced by some patients during their final days and is characterized by physical, emotional, or spiritual distress, agitation or anxiety. End-stage restlessness negatively affects the patient's death experience and can be distressing to the family and care team. Using the 2007 National Home and Hospice Care survey, this study examined factors associated with experiencing end-stage restlessness among non-Hispanic white and Hispanic hospice patients deceased at time of discharge. Results showed that being Hispanic/Latino, experiencing dyspnea, pain, and receiving palliative sedation treatment were risk factors for experiencing end-stage restlessness. The association between pain and restlessness was stronger for Hispanics compared with non-Hispanic whites. The Hispanic population remains underrepresented and little is known about the patient-centered experiences of Hispanic hospice users. Findings indicated that dying Hispanic patients continue to experience pain and other negative symptoms, even when hospice care is in place. Thus, it is important that social workers provide education to interdisciplinary team members about culturally competent practices, and advocate for a patient-centered approach to care.