- Email: [email protected]
The Impact of Hospice Enrollment on Health Care Utilization (SA528-A)
412
Schedule With Abstracts
depression, and nausea burden compared to patients with low performance status. Conversely, patients with low PPS suffered from twice as much fatigue and anorexia burden compared to high PPS. Conclusion. Symptom distress profiles, including frequency and burden, evolve as patients transition across the disease trajectory. Palliative care management should be tailored to prevent and control troublesome symptoms as predicted by changes in performance status.
Implications for Research, Policy, or Practice. Symptom burdens for communitydwelling patients may be predictable; preventive strategies may ameliorate suffering.
Transitions and Missed Opportunities in Rural Advanced Illness (SA527-C) Joy Buck, PhD, West Virginia University, Martinsburg, WV. (Buck has no relevant financial relationships to disclose.) Objectives 1. Identify opportunities to improve clinical outcomes among persons with chronic illness and their caregivers. 2. Describe the influence of culture at the intersection of rural formal and informal care transitions. Background. The resurgence of advanced black lung disease among working-age miners does not bode well for Appalachia, a region where rates of poverty, disability, and premature death are among the highest in the nation. The intergenerational and system burdens associated with regional health disparities are profound. Integrated palliative care promises to reduce these burdens. Little is known about its feasibility within the sociocultural context of strained rural health structures and processes. Research Objectives. To analyze the influence of culture at the intersection of informal and formal care of persons with advanced illness in Appalachia. Method. A longitudinal embedded case design and criterion-based sampling were employed to select participant/caregiver cases from homehealth and hospice settings. Semi-structured interviews and monthly calls with participants (n ¼ 56) over a 12-month period were recorded and transcribed verbatim. Perspectives of
Vol. 45 No. 2 February 2013
professionals were solicited through interviews and electronic surveys (n ¼ 41). Data were managed in Atlas TI 7 and analyzed thematically using the palliative care domains as a sentizing frame. Result. Cultural influences included rugged independence; reliance on family and distrust of outsiders; divergent interpretations of illness, health care needs, transitions, and palliative care; and medical subculture inflexibility. Contextual factors shaping the intersection of formal and informal care included: (1) financial insecurity; (2) uncertainty about health care reform; (3) complicated family and behavioral health issues; and (4) sociocultural dissonance among care networks, systems, and carers. Conclusion. The root causes of rural health disparities are multifaceted and negatively impact intergenerational quality of life. Sociocultural dissonance at the intersection of formal and informal care contributes to preventable illness burden and missed opportunities to ease transitions in rural chronic and advanced illness.
Implications for Research, Policy, or Practice. A more comprehensive understanding of the sociocultural context of living with and caring for persons with serious illness is critical to the effective translation of palliative care science into rural advanced care and policy.
The Impact of Hospice Enrollment on Health Care Utilization (SA528-A) Amy Kelley, MD MSHS, Mount Sinai School of Medicine, New York, NY. (Kelly has no relevant financial relationships to disclose.) Objectives 1. Examine the impact of hospice enrollment on Medicare costs and hospital use. 2. Consider hospice as an important intervention that simultaneously improves care quality and reduces costs. Background. Healthcare reform seeks to improve quality and lower costs. The Medicare hospice benefit has potential to achieve this goal, yet few studies have examined the impact of hospice on Medicare costs and hospital use. Research Objectives. To examine the impact of hospice, as ideally used (enrollment 53-105 days prior to death) and as typically used (enrollment 14-30 days prior to death), on Medicare costs and hospital use.
Vol. 45 No. 2 February 2013
Schedule With Abstracts
Method. We used data from the nationally-representative Health and Retirement Study (20022008) linked with individual Medicare claims. Hospice enrollees were matched to non-hospice controls using propensity scores and outcomes were evaluated using multivariable regression. Result. Eighty-six (68%) subjects enrolled in hospice 53-105 days prior to death were matched to 1322 non-hospice decedents; while 138 (78%) subjects enrolled in hospice 14-30 days before death were matched to 1568 non-hospice decedents. Within both enrollment periods, hospice patients had significantly lower costs and hospital use than matched non-hospice controls (p values < .05). Adjusted Medicare savings for those enrolled 53105 days and 14-30 days prior to death was -$2,848 and -$6,356, respectively. The adjusted decrease in hospital days was -9.9 and -4.2 days, respectively, and the decrease in intensive care unit (ICU) days was -5.7 and -2.5 days. While the adjusted reductions in hospital death were similar, -39% (53-105 days) and -35% (14-30 days), the reductions in ICU admission and 30-day hospital readmission were larger among those enrolled during the ‘‘ideal’’ period: -24% and -39% (53105 days) versus -11% and -11% (14-30 days). Conclusion. Hospice enrollment during both the ‘‘ideal’’ period 53-105 days and the ‘‘typical’’ period 14-30 days prior to death lowers Medicare costs, rates of hospital and ICU use, 30-day hospital readmission and in-hospital death. Implications for Research, Policy, or Practice. Building upon prior studies, these findings suggest hospice is a critical component in achieving our goals for healthcare reform: namely, improved quality and reduced costs.
Patterns of Functional Decline in Hospice: What Can Patients and Families Expect? (SA528-B) Pamela Harris Kansas City Hospice and Palliative Care, Overland Park, KS. David Casarett, MD MA, University of Pennsylvania, Philadelphia, PA. Teresa Craig, CPA, Suncoast Solutions, Clearwater, FL. Joan Teno, MD, Warren Alpert School of Medicine of Brown University, Providence, RI. Betty Oldanie, MBA, Hospice of the Florida Suncoast, Clearwater, FL. (All authors listed above had no relevant financial relationships to disclose.)
413
Objectives 1. Anticipate likely trajectories of decline for hospice patients based on patient characteristics. 2. Anticipate levels of functional status on the last day of life based on patient characteristics. Background. Although a decline in functional status is expected during hospice enrollment, it is not known whether decline happens more quickly for some groups of patients than for others. Research Objectives. To describe the trajectory of patients’ functional decline after they are referred to hospice. Method. Prospective electronic health recordbased study of patients in three hospice programs in the Southeast, Northeast, and Midwest US. Result. A total of 10,344 patients were admitted between October 1, 2010 and May 31, 2011, for whom 53,286 PPS scores were recorded. After adjusting for the baseline PPS score, patients’ scores declined an average of 3.45 points/week (95% confidence interval: 2.98-3.94). Three distinct trajectories of decline were identified. The most rapid decline was observed for patients with cancer (adjusted decline of 7.84 points/ week; 95% CI 7.14-8.47) and stroke (6.37; 5.747.63). A significantly slower decline was observed in patients with pulmonary disease (4.55; 3.71-5.39) and cardiac disease (3.85; 3.22-4.48). The slowest decline was seen in patients with debility (1.47; 0.35-2.59) and dementia (1.33; 0.28-2.38). Of the 8,669 patients who died, 1,959 (22.6%) had a PPS score recorded in the last day of life. In an inverse probabilityweighted sample of these patients, 35.9% had PPS scores of at least 40, indicating some oral intake, variable mental status, limited self-care, and an ability to get out of bed for at least part of the day. Conclusion. Although functional status generally declines among hospice patients, this decline is heterogeneous and some patients retain some physical and cognitive function on up until the last day of life.
Implications for Research, Policy, or Practice. Data that define trajectories of decline among hospice patients can assist healthcare providers in developing appropriate care plans.
Schedule With Abstracts
depression, and nausea burden compared to patients with low performance status. Conversely, patients with low PPS suffered from twice as much fatigue and anorexia burden compared to high PPS. Conclusion. Symptom distress profiles, including frequency and burden, evolve as patients transition across the disease trajectory. Palliative care management should be tailored to prevent and control troublesome symptoms as predicted by changes in performance status.
Implications for Research, Policy, or Practice. Symptom burdens for communitydwelling patients may be predictable; preventive strategies may ameliorate suffering.
Transitions and Missed Opportunities in Rural Advanced Illness (SA527-C) Joy Buck, PhD, West Virginia University, Martinsburg, WV. (Buck has no relevant financial relationships to disclose.) Objectives 1. Identify opportunities to improve clinical outcomes among persons with chronic illness and their caregivers. 2. Describe the influence of culture at the intersection of rural formal and informal care transitions. Background. The resurgence of advanced black lung disease among working-age miners does not bode well for Appalachia, a region where rates of poverty, disability, and premature death are among the highest in the nation. The intergenerational and system burdens associated with regional health disparities are profound. Integrated palliative care promises to reduce these burdens. Little is known about its feasibility within the sociocultural context of strained rural health structures and processes. Research Objectives. To analyze the influence of culture at the intersection of informal and formal care of persons with advanced illness in Appalachia. Method. A longitudinal embedded case design and criterion-based sampling were employed to select participant/caregiver cases from homehealth and hospice settings. Semi-structured interviews and monthly calls with participants (n ¼ 56) over a 12-month period were recorded and transcribed verbatim. Perspectives of
Vol. 45 No. 2 February 2013
professionals were solicited through interviews and electronic surveys (n ¼ 41). Data were managed in Atlas TI 7 and analyzed thematically using the palliative care domains as a sentizing frame. Result. Cultural influences included rugged independence; reliance on family and distrust of outsiders; divergent interpretations of illness, health care needs, transitions, and palliative care; and medical subculture inflexibility. Contextual factors shaping the intersection of formal and informal care included: (1) financial insecurity; (2) uncertainty about health care reform; (3) complicated family and behavioral health issues; and (4) sociocultural dissonance among care networks, systems, and carers. Conclusion. The root causes of rural health disparities are multifaceted and negatively impact intergenerational quality of life. Sociocultural dissonance at the intersection of formal and informal care contributes to preventable illness burden and missed opportunities to ease transitions in rural chronic and advanced illness.
Implications for Research, Policy, or Practice. A more comprehensive understanding of the sociocultural context of living with and caring for persons with serious illness is critical to the effective translation of palliative care science into rural advanced care and policy.
The Impact of Hospice Enrollment on Health Care Utilization (SA528-A) Amy Kelley, MD MSHS, Mount Sinai School of Medicine, New York, NY. (Kelly has no relevant financial relationships to disclose.) Objectives 1. Examine the impact of hospice enrollment on Medicare costs and hospital use. 2. Consider hospice as an important intervention that simultaneously improves care quality and reduces costs. Background. Healthcare reform seeks to improve quality and lower costs. The Medicare hospice benefit has potential to achieve this goal, yet few studies have examined the impact of hospice on Medicare costs and hospital use. Research Objectives. To examine the impact of hospice, as ideally used (enrollment 53-105 days prior to death) and as typically used (enrollment 14-30 days prior to death), on Medicare costs and hospital use.
Vol. 45 No. 2 February 2013
Schedule With Abstracts
Method. We used data from the nationally-representative Health and Retirement Study (20022008) linked with individual Medicare claims. Hospice enrollees were matched to non-hospice controls using propensity scores and outcomes were evaluated using multivariable regression. Result. Eighty-six (68%) subjects enrolled in hospice 53-105 days prior to death were matched to 1322 non-hospice decedents; while 138 (78%) subjects enrolled in hospice 14-30 days before death were matched to 1568 non-hospice decedents. Within both enrollment periods, hospice patients had significantly lower costs and hospital use than matched non-hospice controls (p values < .05). Adjusted Medicare savings for those enrolled 53105 days and 14-30 days prior to death was -$2,848 and -$6,356, respectively. The adjusted decrease in hospital days was -9.9 and -4.2 days, respectively, and the decrease in intensive care unit (ICU) days was -5.7 and -2.5 days. While the adjusted reductions in hospital death were similar, -39% (53-105 days) and -35% (14-30 days), the reductions in ICU admission and 30-day hospital readmission were larger among those enrolled during the ‘‘ideal’’ period: -24% and -39% (53105 days) versus -11% and -11% (14-30 days). Conclusion. Hospice enrollment during both the ‘‘ideal’’ period 53-105 days and the ‘‘typical’’ period 14-30 days prior to death lowers Medicare costs, rates of hospital and ICU use, 30-day hospital readmission and in-hospital death. Implications for Research, Policy, or Practice. Building upon prior studies, these findings suggest hospice is a critical component in achieving our goals for healthcare reform: namely, improved quality and reduced costs.
Patterns of Functional Decline in Hospice: What Can Patients and Families Expect? (SA528-B) Pamela Harris Kansas City Hospice and Palliative Care, Overland Park, KS. David Casarett, MD MA, University of Pennsylvania, Philadelphia, PA. Teresa Craig, CPA, Suncoast Solutions, Clearwater, FL. Joan Teno, MD, Warren Alpert School of Medicine of Brown University, Providence, RI. Betty Oldanie, MBA, Hospice of the Florida Suncoast, Clearwater, FL. (All authors listed above had no relevant financial relationships to disclose.)
413
Objectives 1. Anticipate likely trajectories of decline for hospice patients based on patient characteristics. 2. Anticipate levels of functional status on the last day of life based on patient characteristics. Background. Although a decline in functional status is expected during hospice enrollment, it is not known whether decline happens more quickly for some groups of patients than for others. Research Objectives. To describe the trajectory of patients’ functional decline after they are referred to hospice. Method. Prospective electronic health recordbased study of patients in three hospice programs in the Southeast, Northeast, and Midwest US. Result. A total of 10,344 patients were admitted between October 1, 2010 and May 31, 2011, for whom 53,286 PPS scores were recorded. After adjusting for the baseline PPS score, patients’ scores declined an average of 3.45 points/week (95% confidence interval: 2.98-3.94). Three distinct trajectories of decline were identified. The most rapid decline was observed for patients with cancer (adjusted decline of 7.84 points/ week; 95% CI 7.14-8.47) and stroke (6.37; 5.747.63). A significantly slower decline was observed in patients with pulmonary disease (4.55; 3.71-5.39) and cardiac disease (3.85; 3.22-4.48). The slowest decline was seen in patients with debility (1.47; 0.35-2.59) and dementia (1.33; 0.28-2.38). Of the 8,669 patients who died, 1,959 (22.6%) had a PPS score recorded in the last day of life. In an inverse probabilityweighted sample of these patients, 35.9% had PPS scores of at least 40, indicating some oral intake, variable mental status, limited self-care, and an ability to get out of bed for at least part of the day. Conclusion. Although functional status generally declines among hospice patients, this decline is heterogeneous and some patients retain some physical and cognitive function on up until the last day of life.
Implications for Research, Policy, or Practice. Data that define trajectories of decline among hospice patients can assist healthcare providers in developing appropriate care plans.