scholarly journals Hospice Utilization and Its Effect on Acute Care Needs at the End of Life in Medicare Beneficiaries With Hepatocellular Carcinoma

2017 ◽  
Vol 13 (3) ◽  
pp. e197-e206 ◽  
Author(s):  
Hanna K. Sanoff ◽  
YunKyung Chang ◽  
Melissa Reimers ◽  
Jennifer L. Lund
Keyword(s):  
Hepatocellular Carcinoma ◽  
End Of Life ◽  
Acute Care ◽  
Symptom Burden ◽  
Health Care Use ◽  
Care Utilization ◽  
Hospital Death ◽  
Medicare Beneficiaries ◽  
Care Needs ◽  
Hospice Use

Introduction: Hepatocellular carcinoma (HCC) is a poor-prognosis cancer with a high symptom burden. Multidisciplinary HCC care is complex and unique in cancer medicine. We sought to determine whether the distinct process affects hospice use and how hospice affects end-of-life acute care utilization. Patients and Methods: Patients dying after HCC diagnosed from 2004 to 2011 were identified within SEER-Medicare. Hospice use and associated factors were described using logistic regression. Coarse exact and propensity score matching created groups of hospice and nonhospice comparators balanced on clinical characteristics. Health care use from first hospice claim to death and the matched duration in the nonhospice group were compared. Results: Of 7,992 decedent patients with HCC, 63% used hospice before death, with a median duration of 18 days (interquartile range, 5-51 days). Initial treatment with surgery and ablation (odds ratio [OR], 0.63; 95% CI, 0.53 to 0.74) or chemoembolization/radioembolization (OR, 0.71; 95% CI, 0.62 to 0.80) was associated with decreased odds of subsequent hospice use compared with untreated patients. Hospice use was more likely in those consulting hematology/oncology (OR, 1.33; 95% CI, 1.13 to 1.56) but not in those consulting gastroenterology (OR, 0.79; 95% CI, 0.65 to 0.95). Hospice patients had lower rates of hospitalization (7.9% v 47.8%; risk ratio [RR], 0.16; 95% CI, 0.14 to 0.19), intensive care unit stay (2.8% v 25.3%; RR, 0.11; 95% CI, 0.09 to 0.14), and in-hospital death (3.5% v 58.4%; RR, 0.06; 95% CI, 0.05 to 0.07). Conclusion: Processes of care influence which patients with HCC are referred to hospice. Hospice use has a marked effect on acute care use at the end of life in patients with HCC. Efforts to incorporate cancer-focused palliative care might improve the quality of end-of-life care in HCC.

scholarly journals Goals-of-Care Consult and Future Costs, Acute Care and Hospice Use in Matched Cohorts of African Americans and Whites

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 521-521
Author(s):  
Lauren Starr ◽  
Connie Ulrich ◽  
Scott Appel ◽  
Paul Junker ◽  
Nina O’Connor ◽  
...  
Keyword(s):  
African Americans ◽  
End Of Life ◽  
Acute Care ◽  
Secondary Analysis ◽  
Care Utilization ◽  
Goals Of Care ◽  
Palliative Care Consultation ◽  
Significant Difference ◽  
Hospice Use ◽  
Care Costs

Abstract African Americans receive less hospice care and more aggressive end-of-life care than Whites. Little is known about how palliative care consultation to discuss goals-of-care (“PCC”) is associated with future acute care utilization and costs, or hospice use, by race. To compare future acute care costs and utilization and discharge to hospice between propensity-matched cohorts of African Americans with and without PCC, and Whites with and without PCC, we conducted a secondary analysis of 35,154 seriously-ill African American and White adults who had PCC at a high-acuity hospital and were discharged 2014-2016. We found no significant difference between African Americans with or without PCC in mean future acute care costs ($11,651 vs. $15,050, P=0.09), 30-day readmissions (P=0.58), future hospital days (P=0.34), future ICU admission (P=0.25), or future ICU days (P=0.30), but found greater discharge to hospice among African Americans with PCC (36.5% vs. 2.4%, P<0.0001). We found significant differences between Whites with PCC vs. without PCC in mean future acute care costs ($8,095 vs. $16,799, P<0.001), 30-day readmissions (10.2% vs. 16.7%, P<0.0001), future days hospitalized (3.7 vs. 6.3 days, P<0.0001), and discharge to hospice (42.7% vs. 3.0%, P<0.0001). Results suggest PCC decreases future acute care costs and utilization in Whites and, directionally but not significantly, in African Americans; and increases discharge to hospice in both races (15-fold in African Americans, 14-fold in Whites). Research is needed to understand how PCC supports end-of-life decision-making and hospice use across races and how systems and policies can enable effective goals-of-care consultations across settings.

scholarly journals Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD

2019 ◽  
Vol 30 (3) ◽  
pp. 481-491 ◽  
Author(s):  
Catherine R. Butler ◽  
Margaret L. Schwarze ◽  
Ronit Katz ◽  
Susan M. Hailpern ◽  
William Kreuter ◽  
...  
Keyword(s):  
Health Care ◽  
Lower Extremity ◽  
End Of Life ◽  
End Of Life Care ◽  
Lower Extremity Amputation ◽  
Care Utilization ◽  
Life Care ◽  
Medicare Beneficiaries ◽  
Care Needs ◽  
Extremity Amputation

BackgroundLower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation.MethodsWe conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD.ResultsOverall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to—and to have had prolonged stays in—acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services.ConclusionsNearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.

Associations Between Health Literacy and End-of-Life Care Intensity Among Medicare Beneficiaries

2021 ◽  
pp. 104990912098850
Author(s):  
Qingying Luo ◽  
Kewei Shi ◽  
Peiyin Hung ◽  
Shi-Yi Wang
Keyword(s):  
Health Literacy ◽  
End Of Life ◽  
Linear Models ◽  
Hospital Death ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Low Health Literacy ◽  
Multivariable Analyses ◽  
Hospice Use ◽  
Eol Care

Background: Despite well-documented disparities in end-of-life (EOL) care, little is known about whether patients with low health literacy (LHL) received aggressive EOL care. Objective: This study examined the association between health literacy (HL) and EOL care intensity among Medicare beneficiaries. Method: We conducted a retrospective analysis of Medicare fee-for-service decedents who died in July-December, 2011. ZIP-code-level HL scores were estimated from the 2010-2011 Health Literacy Data Map, where a score of 225 or lower was defined as LHL. Aggressive EOL care measures included repeated hospitalizations within the last 30 days of life, no hospice enrollment within the last 6 months of life, in-hospital death, and any of above. Using hierarchical generalized linear models, we examined the association between HL and aggressive EOL care. Results: Of 649,556 decedents, the proportion of decedents who received any aggressive EOL care among those in LHL areas was 82.7%, compared to 72.7% in HHL areas. In multivariable analyses, decedents residing in LHL areas, compared to those in HHL areas, had 31% higher odds of aggressive EOL care (adjusted odds ratio [AOR] 1.31; 95% confidence interval [CI]:1.21-1.42), including higher odds of no hospice use (AOR 1.35; 95% CI: 1.27-1.44), repeated hospitalization (AOR 1.07; 95% CI: 1.01-1.14) and in-hospital death (AOR 1.21; 95% CI: 1.13-1.29). Conclusion: Medicare beneficiaries who resided in LHL areas were likely to receive aggressive EOL care. Tailored efforts to improve HL and facilitate patient-provider communications in LHL areas could reduce EOL care intensity.

scholarly journals Understanding Patients’ Decisions to Obtain Unplanned, High-Resource Health Care After Colorectal Surgery

2021 ◽  
pp. 104973232110024
Author(s):  
Stephanie T. Lumpkin ◽  
Eileen Harvey ◽  
Paul Mihas ◽  
Timothy Carey ◽  
Alessandro Fichera ◽  
...  
Keyword(s):  
Health Care ◽  
Colorectal Surgery ◽  
Health Care Utilization ◽  
Care Coordination ◽  
Health Care Use ◽  
Care Utilization ◽  
Discharge Instructions ◽  
Care Needs ◽  
High Resource ◽  
Optimal Health

Readmissions and emergency department (ED) visits after colorectal surgery (CRS) are common, burdensome, and costly. Effective strategies to reduce these unplanned postdischarge health care visits require a nuanced understanding of how and why patients make the decision to seek care. We used a purposefully stratified sample of 18 interview participants from a prospective cohort of adult CRS patients. Thirteen (72%) participants had an unplanned postdischarge health care visit. Participant decision-making was classified by methodology (algorithmic, guided, or impulsive), preexisting rationale, and emotional response to perceived health care needs. Participants voiced clear mental algorithms about when to visit an ED. In addition, participants identified facilitators and barriers to optimal health care use. They also identified tangible targets for health care utilization reduction efforts, such as improved care coordination with streamlined discharge instructions and improved communication with the surgical team. Efforts should be directed at improving postdischarge communication and care coordination to reduce CRS patients’ high-resource health care utilization.

scholarly journals Effect of Psychiatric Illness on Acute Care Utilization at End of Life From Serious Medical Illness

2017 ◽  
Vol 54 (2) ◽  
pp. 176-185.e1 ◽  
Author(s):  
Kyle Lavin ◽  
Dimitry S. Davydow ◽  
Lois Downey ◽  
Ruth A. Engelberg ◽  
Ben Dunlap ◽  
...  
Keyword(s):  
End Of Life ◽  
Acute Care ◽  
Psychiatric Illness ◽  
Care Utilization ◽  
Medical Illness ◽  
Acute Care Utilization

Hospice Use And End-Of-Life Spending Trajectories In Medicare Beneficiaries On Hemodialysis

2018 ◽  
Vol 37 (6) ◽  
pp. 980-987 ◽  
Author(s):  
Ann M. O’Hare ◽  
Susan M. Hailpern ◽  
Melissa Wachterman ◽  
William Kreuter ◽  
Ronit Katz ◽  
...  
Keyword(s):  
End Of Life ◽  
Medicare Beneficiaries ◽  
Hospice Use

scholarly journals Effect of Palliative Care on Aggressiveness of End-of-Life Care Among Patients With Advanced Cancer

2017 ◽  
Vol 13 (9) ◽  
pp. e760-e769 ◽  
Author(s):  
Daniel P. Triplett ◽  
Wendi G. LeBrett ◽  
Alex K. Bryant ◽  
Andrew R. Bruggeman ◽  
Rayna K. Matsuno ◽  
...  
Keyword(s):  
Health Care ◽  
Palliative Care ◽  
End Of Life ◽  
Advanced Cancer ◽  
Health Care Use ◽  
Medicare Beneficiaries ◽  
Invasive Procedures ◽  
Chemotherapy Administration ◽  
Palliative Care Consultation ◽  
Care Consultation

Purpose: Palliative care’s role in oncology has expanded, but its effect on aggressiveness of care at the end of life has not been characterized at the population level. Methods: This matched retrospective cohort study examined the effect of an encounter with palliative care on health-care use at the end of life among 6,580 Medicare beneficiaries with advanced prostate, breast, lung, or colorectal cancer. We compared health-care use before and after palliative care consultation to a matched nonpalliative care cohort. Results: The palliative care cohort had higher rates of health-care use in the 30 days before palliative care consultation compared with the nonpalliative cohort, with higher rates of hospitalization (risk ratio [RR], 3.33; 95% CI, 2.87 to 3.85), invasive procedures (RR, 1.75; 95% CI, 1.62 to 1.88), and chemotherapy administration (RR, 1.61; 95% CI, 1.45 to 1.78). The opposite pattern emerged in the interval from palliative care consultation through death, where the palliative care cohort had lower rates of hospitalization (RR, 0.53; 95% CI, 0.44-0.65), invasive procedures (RR, 0.52; 95% CI, 0.45 to 0.59), and chemotherapy administration (RR, 0.46; 95% CI, 0.39 to 0.53). Patients with earlier palliative care consultation in their disease course had larger absolute reductions in health-care use compared with those with palliative care consultation closer to the end of life. Conclusion: This population-based study found that palliative care substantially decreased health-care use among Medicare beneficiaries with advanced cancer. Given the increasing number of elderly patients with advanced cancer, this study emphasizes the importance of early integration of palliative care alongside standard oncologic care.

Trends in health care utilization, cost, and aggressive care at end of life among older cancer patients in the Deep South.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 155-155
Author(s):  
Elizabeth Ann Kvale ◽  
Gabrielle Rocque ◽  
Kerri S. Bevis ◽  
Aras Acemgil ◽  
Richard A. Taylor ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Utilization ◽  
End Of Life ◽  
Healthcare Utilization ◽  
Linear Models ◽  
Care Utilization ◽  
Deep South ◽  
Medicare Beneficiaries ◽  
Aggressive Care ◽  
The Impact

155 Background: Healthcare utilization and costs escalate near diagnosis and in the final months of life. There is a national trend toward aggressive care at end of life (EOL). We examined patterns in utilization and cost across the trajectory of care and during the last two weeks of life during implementation of a lay navigation intervention. Methods: Claims data were obtained for Medicare beneficiaries ≥ 65 years old with cancer in the UAB Health System Cancer Community Network (UAB CCN). For 10 quarters from January 2012 -June 2014, we examined healthcare utilization for the population at large, navigated patients, and decedents. All analyses included ER visits, hospitalizations, and ICU admissions and use of chemotherapy in the last 2 weeks of life, and hospice utilization (admission or less than 3 days of hospice) in the quarter of death for decedents. Descriptive analyses and linear regression were used to test trends over time; general linear models evaluated changes in health care utilization and cost. Results: Across the population reduction of 13.4% to 11% for hospitalization (18% decrease, p < 0.01), 8.0% to 7.1% for ER visits (12% decrease, p < 0.01), 2.9% to 2.5% for ICU admissions (14% decrease, p = 0.04) and an increase of 3.9% to 4.3% for hospice (9.2% increase p = 0.37) were found. Among 5,861 decedents, in the last 2 weeks of life, there were decreases in ICU admissions (14.6% decrease, p = 0.11), from 39.2% to 32.0%, ER visits (18.4% decrease, p = 0.03), and chemotherapy, from 4.7% to 3.5% (25.5% decrease, p = 0.11).Over the 10 quarters, hospice enrollment increased from 70.7% to 77.4% (9.48% increase; p = 0.06), and the proportion of patients on hospice for less than 3 days changed from 7.8% to 7.5% (3.85% decrease, p = 0.30). Costs decreased about $158 per quarter per beneficiary. A significant pre-post decrease of $952 per beneficiary (p < 0.01) led to an estimated reduction in Medicare costs of $18,406,920 for the 19,335 beneficiaries in the UAB CCN for the five quarters post-implementation. Conclusions: We observed decreased healthcare utilization and cost and trends toward decreased aggressive care at EOL in the UAB CCN. Further work is needed to determine the impact of navigation on utilization trends.

scholarly journals Palliative care for cancer patients near end of life in acute-care hospitals across Canada: a look at the inpatient palliative care code

2019 ◽  
Vol 26 (1) ◽  
Author(s):  
J. Tung ◽  
J. Chadder ◽  
D. Dudgeon ◽  
C. Louzado ◽  
J. Niu ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Acute Care ◽  
Care Delivery ◽  
Acute Care Hospital ◽  
Acute Care Hospitals ◽  
Administrative Databases ◽  
Care Hospital ◽  
Care Needs ◽  
Patients With Cancer

Hospitals play an important role in the care of patients with advanced cancer: nearly half of all cancer deaths occur in acute-care settings. The need for increasing access to palliative care and related support services for patients with cancer in acute-care hospitals is therefore growing. Here, we examine how often and how early in their illness patients with cancer might be receiving palliative care services in the 2 years before their death in an acute-care hospital in Canada. The palliative care code from inpatient administrative databases was used as a proxy for receiving, or being referred for, palliative care. Currently, the palliative care code is the only data element routinely collected from patient charts that allows for the tracking of palliative care activity at a pan-Canadian level.     Our findings suggest that most patients with cancer who die in an acute-care hospital receive a palliative designation; however, many of those patients are identified as palliative only in their final admission before death. Of the patients who received a palliative designation before their final admission, nearly half were identified as palliative less than 2 months before death. Findings signal that delivery of services within and between jurisdictions is not consistent, that the palliative care needs of some patients are being missed by physicians, and that palliative care is still largely seen as end-of-life care and is not recognized as an integral component of cancer care.     Measuring the provision of system-wide palliative care remains a challenge because comprehensive national data about palliative care are not currently reported from all sectors. To advance measurement and reporting of palliative care in Canada, attention should be focused on collecting comparable data from regional and provincial palliative care programs that individually capture data about palliative care delivery in all health care sectors.

Acute Care Utilization Is More Common in Patients with Sickle Cell Disease Who Have Chronic Complications and Chronic Pain: A Preliminary Report from the Escaped Trial

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2490-2490 ◽  
Author(s):  
Sophie Lanzkron ◽  
Carlton Haywood ◽  
Jane A Little ◽  
Joshua Field ◽  
Joseph Ryan Shows ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Sickle Cell Disease ◽  
Acute Care ◽  
Sickle Cell ◽  
Research Funding ◽  
Symptom Burden ◽  
Care Utilization ◽  
Cell Disease ◽  
Chronic Complications

Abstract Background: We undertook a large multisite observational study collecting prospective data on health care utilization of patients with sickle cell disease (SCD). No prospective examination of symptom burden has been undertaken in SCD since the Cooperative Study of Sickle Cell Disease, and none in the modern era, since the widespread adoption of hydroxyurea therapy. The ESCAPED trial aims to compare patient centered outcomes following management of acute painful vaso-occlusive (VOC) events in the emergency department or in the infusion center. Here, we examine acute care utilization patterns in the first 223 subjects who have completed at least 6 months of follow-up and test determinants of utilization. Methods: This is an ongoing, prospective cohort study that is recruiting across four sites (Baltimore, Cleveland, Milwaukee, and Baton Rouge). 500 adults with SCD who live in proximity to one of the study sites are being recruited and followed for 18 months. Data from visits for all acute, uncomplicated VOC are collected by chart review and patient interview. To ensure that acute visits are not missed, subjects are contacted on a monthly basis and where available statewide health information exchanges are queried. We tested for associations between subject characteristics upon enrollment and the number of acute visits during follow up using Poisson regression. Results: The average length of follow-up to date is 9.1 months with a range of 6.1-14.2 months for the 223 subjects who have been enrolled for at least 6 months. The mean number of acute visits per month for uncomplicated VOC by the cohort was 0.65 (SD 0.87) with a median of 0.35, minimum of 0 and maximum of 5. 43 subjects have had no acute visits. 59% of the cohort are female, the mean age is 35.6 (SD 12.1). 74.3% have sickle cell anemia, 42% are employed and 52% reported having chronic pain. In a multivariate model, factors associated with an independent decrease in likelihood of an acute visit were increasing age, a history of leg ulcers, graduating high school and being employed, while an increase in likelihood of an acute visit was associated with chronic complications (kidney disease, retinopathy, stroke, and avascular necrosis) and chronic pain. Conclusions: In this cohort, chronic complications like renal disease and AVN are associated with increased acute care visits. The association of chronic pain as an independent risk factor for acute visits, while intuitive, suggests that understanding and managing chronic pain may be central to mitigating pain and decreasing the need for acute care visits in the long term. The prevalence of chronic pain is high in this cohort, which likely well represents the contemporary US sickle cell community. The development of therapeutic strategies that address this significant complication of SCD are imperative if we are to both decrease symptom burden and the need for health care utilization in this population. Disclosures Lanzkron: NKT therapeutics: Research Funding; Prolong: Research Funding; Pfizer: Research Funding; Selexys: Research Funding; NHLBI: Research Funding; PCORI: Research Funding; GBT: Consultancy. Haywood:PCORI: Research Funding; NHLBI: Research Funding. Little:PCORI: Research Funding. Field:PCORI: Research Funding; NKT Therapeutics: Consultancy, Research Funding; Astellas Pharma: Consultancy, Research Funding. Shows:PCORI: Employment, Research Funding. Segal:PCORI funded: Research Funding. Saheed:PCORI: Research Funding. Robertson:PCORI: Research Funding. Proudford:PCORI: Research Funding. Kincaid:PCORI funded: Research Funding. Burgess:PCORI: Research Funding. Green:PCORI: Research Funding. Wang:PCORI: Research Funding. Seufert:PCORI: Research Funding. Brooks:PCORI: Research Funding. Griffin:PCORI: Research Funding. Piehet:PCORI: Research Funding. Frymark:PCORI: Research Funding. Varadhan:PCORI: Research Funding.

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