Browsing by keyword "Hospice Care"
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Managed care, hospice use, site of death, and medical expenditures in the last year of lifeBACKGROUND: We examined deaths of Medicare beneficiaries in Massachusetts and California to evaluate the effect of managed care on the use of hospice and site of death and to determine how hospice affects the expenditures for the last year of life. METHODS: Medicare data for beneficiaries in Massachusetts (n = 37 933) and California (n = 27 685) who died in 1996 were merged with each state's death certificate files to determine site and cause of death. Expenditure data were Health Care Financing Administration payments and were divided into 30-day periods from the date of death back 12 months. RESULTS: In Massachusetts, only 7% of decedents were enrolled in managed care organizations (MCOs); in California, 28%. More than 60% of hospice users had cancer. Hospice use was much lower in Massachusetts than in California (12% vs 18%). In both states, decedents enrolled in MCOs used hospice care much more than those enrolled in fee-for-service plans (17% vs 11% in Massachusetts and 25% vs 15% in California). This pattern persisted for those with cancer and younger (aged 65-74 years) decedents. Decedents receiving hospice care were significantly (P<.001 for both) less likely to die in the hospital (11% vs 43% in Massachusetts and 5% vs 43% in California). Enrollment in MCOs did not affect the proportion of in-hospital deaths (those enrolled in fee-for-service plans vs MCOs: 40% vs 39% in Massachusetts; and 37% vs 34% in California). Expenditures in the last year of life were $28 588 in Massachusetts and $27 814 in California; about one third of the expenditures occurred in the last month before death. Hospital services accounted for more than 50% of all expenditures in both states, despite 77% of decedents being hospitalized in Massachusetts and just 55% being hospitalized in California. Among patients with cancer, expenditures were 13% to 20% lower for those in hospice. CONCLUSIONS: Medicare-insured decedents in California were more than 4 times more likely to be enrolled in MCOs, were 50% more likely to use a hospice, and had a 30% lower hospitalization rate than decedents in Massachusetts, yet there are few differences in out-of-hospital deaths or expenditures in the last year of life. However, patients with cancer using hospice did have significant savings.
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Pediatric Hospice: The career potential for pediatric residents and a comparison between systems in UK and USBackground:Hospice and palliative care have been gaining significant momentum in the American consciousness for the past ten years. However, the vast majority of the conversations and developments have been concerned with the end of life care of adults. Objectives:This paper seeks to examine the definition and development of pediatric palliative and hospice care both in the United Kingdom and the United States. By examining both the existing models of end of life care for children as well as understanding how such models developed, it is expected that a more educated evaluation of the pros and cons of each system can be produced. Also, by delineating both the barriers to pediatric hospice and palliative care as well as the existing local resources, one can more accurately assess the potential growth of hospice and palliative care within the realm of pediatrics, and therefore also assess its career potential. Methods:Extensive literature searches formed the base of this study. Practical experience in hospice care delivery within the Worcester community was gained by two days of home visits with hospice nurses from UMASS Memorial Hospice, Worcester MA, as well as attendance at a weekly multidisciplinary hospice meeting. Practical experience in hospice & palliative care delivery in the United Kingdom was attained through a three week rotation with the Academic Palliative Medicine Unit, University of Sheffield, Sheffield England and a one week rotation with the Specialist Paediatric Palliative Care Team, Royal Children's Hospital at Alder Hey, Liverpool England. The Sheffield rotation included multidisciplinary meetings and placements at three adult hospices as well as inpatient adult palliative care services at two hospitals and outpatient palliative care service at a third; a day-visit to Helen's House Pediatric Hospice in Oxford England was also arranged. In the Liverpool rotation, all care was pediatric, including inpatient and outpatient services, multidisciplinary meetings, two hospices and two home visits. Results:Pediatric hospice in the UK is primarily based on a freestanding residential hospice model that offers both respite care to children with life-limiting disease as well as terminal care. In the UK, pediatric hospice care services are more widespread, with 29 freestanding hospices, 7 hospices in the planning and/or planning stages, and 5 hospice-at-home services. Conversely, although the US began to investigate pediatric-specific palliative and hospice care before the UK, it lags behind the UK in services offered. Home care services are the preferred model for pediatric hospice care in the US, but the number of programs are few and far between. In addition, the first and only freestanding residential pediatric hospice in the US opened only in March 2004. Similarities between the 2 countries lie in the current slow integration of pediatric palliative care into the physician community; in neither country has it become an officially recognized subspecialty. However, the future seems bleaker for American pediatricians, who have recently suffered a setback as the American Board of Internal Medicine pushes forward for official recognition of the subspecialty by the American Board of Medical Specialties; the American Board of Pediatrics is not prepared to support the same advancement and so faces to lose the possibility of certification in pediatric palliative care. Conclusion:The resources and facilities of pediatric residential hospices are as phenomenal as the culture of care that enwraps all who enter. It is difficult not to get excited when faced with such enormous compassion and personal connection in a professional context. While every effort should be made to support such facilities, it must be recognized that there is a lack of both demand and financial stability for residential pediatric hospices. Compared to all deaths, there is a very low incidence of non-sudden pediatric death in the US. Both low incidence and poor economics have pressured the American Board of Pediatrics to not sponsor the development of the new certification exam in hospice & palliative care, effectively blocking the rightful professional development and recognition of such a specialty in pediatrics.
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Racial and ethnic differences in end-of-life costs: why do minorities cost more than whitesBACKGROUND: Racial and ethnic minorities generally receive fewer medical interventions than whites, but racial and ethnic patterns in Medicare expenditures and interventions may be quite different at life's end. METHODS: Based on a random, stratified sample of Medicare decedents (N = 158 780) in 2001, we used regression to relate differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions (eg, ventilators), and hospice to racial and ethnic differences in Medicare expenditures in the last 6 months of life. RESULTS: In the final 6 months of life, costs for whites average $20,166; blacks, $26,704 (32% more); and Hispanics, $31,702 (57% more). Similar differences exist within sexes, age groups, all causes of death, all sites of death, and within similar geographic areas. Differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status, and hospice use account for 53% and 63% of the higher costs for blacks and Hispanics, respectively. While whites use hospice most frequently (whites, 26%; blacks, 20%; and Hispanics, 23%), racial and ethnic differences in end-of-life expenditures are affected only minimally. However, fully 85% of the observed higher costs for nonwhites are accounted for after additionally modeling their greater end-of-life use of the intensive care unit and various intensive procedures (such as, gastrostomies, used by 10.5% of blacks, 9.1% of Hispanics, and 4.1% of whites). CONCLUSIONS: At life's end, black and Hispanic decedents have substantially higher costs than whites. More than half of these cost differences are related to geographic, sociodemographic, and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.
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Racial and ethnic differences in hospice use among patients with heart failureBACKGROUND: Heart failure is the leading noncancer diagnosis for patients in hospice care and the leading cause of hospitalization among Medicare beneficiaries. Racial and ethnic differences in hospice patients are well documented for patients with cancer but poorly described for those with heart failure. METHODS: On the basis of a national sample of 98 258 Medicare beneficiaries 66 years and older on January 1, 2001, with a diagnosis of heart failure who had at least 1 physician or hospital encounter and who were not enrolled in hospice care between January 1 and December 31, 2000, we determined the effect of race and ethnicity on hospice entry for patients with heart failure in 2001 after adjusting for sociodemographic, clinical, and geographic factors. RESULTS: In unadjusted analysis, blacks (odds ratio [OR], 0.52) and Hispanics (0.43) used hospice care for heart failure less than whites. Racial and ethnic differences in patients who received hospice care for heart failure persisted after adjusting for markers of income, urbanicity, severity of illness, local density of hospice use, and medical comorbidity (adjusted OR for blacks, 0.59; 95% confidence interval, 0.47-0.73; and adjusted OR for Hispanics, 0.49; 95% confidence interval, 0.37-0.66; compared with whites). Advanced age, greater comorbidity, emergency department visits, hospitalizations, and greater local density of hospice use were also associated with hospice use. CONCLUSIONS: In a national sample of Medicare beneficiaries with heart failure, blacks and Hispanics used hospice care for heart failure less than whites after adjustment for individual and market factors. To understand the mechanisms underlying these findings, further examination of patient preferences and physician referral behavior is needed.
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Statin discontinuation in nursing home residents with advanced dementiaOBJECTIVES: To describe patterns of, and factors associated with, statin use and discontinuation in nursing home (NH) residents progressing to advanced dementia and followed for at least 90 days. DESIGN: Retrospective inception cohort using a dataset linking 2007 to 2008 Minimum Data Set (MDS) to Medicare denominator and Part D files. SETTING: All NHs in five states (Minnesota, Massachusetts, Pennsylvania, California, Florida). PARTICIPANTS: NH residents with dementia. MEASUREMENTS: Residents who developed advanced dementia were observed from baseline (date of progression to very severe cognitive impairment with eating problems) and followed for at least 90 days to statin discontinuation or death. Logistic regression was used to identify baseline factors associated with statin use. Cox proportional hazard regression was used to identify factors associated with time to statin discontinuation. RESULTS: Of 10,212 residents, 16.6% (n = 1,699) used statins. Greater odds of statin use were associated with having diabetes mellitus (adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI) = 1.09-1.40), stroke (AOR = 1.31, 95% CI = 1.16-1.48), and hypertension (AOR = 1.35, 95% CI = 1.18-1.54); hospice enrollment was associated with lower odds (AOR = 0.75, 95% CI = 0.64-0.89). In follow-up, 37.2% (n = 632) discontinued statins. Median time to discontinuation was 36 days (interquartile range 12-110 days). Shorter time to discontinuation was associated with hospitalization in past 30 days (adjusted hazard ratio (AHR) = 1.67, 95% CI = 1.40-1.99) and more daily medications (AHR = 1.02, 95% CI = 1.01-1.04). When statins were discontinued, 15.0% (n = 95) of residents stopped only statins, and 47.5% (n = 300) stopped at least one other medication. CONCLUSION: Most NH residents who use statins at the time of progression to advanced dementia continue use in follow-up. Geriatrics Society.
