Kevin Ache

Hospice Admissions for Cancer in the Final Days of Life: Independent Predictors and Implications for Quality Measures

PURPOSE To define patient characteristics associated with hospice enrollment in the last 3 days of life, and to describe adjusted proportions of patients with late referrals among patient subgroups that could be considered patient-mix adjustment variables for this quality measure. METHODS Electronic health record-based retrospective cohort study of patients with cancer admitted to 12 hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network. RESULTS Of 64,264 patients admitted to hospice with cancer, 10,460 (16.3%) had a length of stay ≤ 3 days. There was significant variation among hospices (range, 11.4% to 24.5%). In multivariable analysis, among patients referred to hospice, patients who were admitted in the last 3 days of life were more likely to have a hematologic malignancy, were more likely to be male and married, and were younger (age < 65 years). Patients with Medicaid or self-insurance were less likely to be admitted to hospice within 3 days of death. CONCLUSION Quality measures of hospice lengths of stay should include patient-mix adjustments for type of cancer and site of care. Patients with hematologic malignancies are at especially increased risk for late admission to hospice.

Are Advance Directives Associated with Better Hospice Care

To describe individuals with advance directives at the time of hospice enrollment and to determine whether they have patterns of care and outcomes that are different from those of individuals without advance directives.

Can hospices predict which patients will die within six months

OBJECTIVE To determine whether it is possible to predict, at the time of hospice enrollment, which patients will die within 6 months. DESIGN Electronic health record-based retrospective cohort study. SETTING Patients admitted to 10 hospices in the CHOICE network (Coalition of Hospices Organized to Investigate Comparative Effectiveness). PARTICIPANTS Hospice patients. MAIN OUTCOME MEASURES Mortality at 6 months following hospice admission. RESULTS Among 126,620 patients admitted to 10 hospices, 118,532 (93.6%) died within 6 months. In a multivariable logistic regression model, five characteristics were independent predictors of 6-month mortality. For instance, patients younger than 65 years were less likely to die within 6 months (odds ratio [OR] 0.64; 95% confidence interval [CI] 0.45-0.91; p=0.014). Conversely, male patients were more likely to die within 6 months (OR 1.47; 95% CI 1.05-2.02; p=;0.036). After adjusting for other variables in this model, there were several subgroups with a low probability of 6-month probability (e.g., stroke and Palliative Performance Scale [PPS] score=50; adjusted probability of 6-month mortality=39.4%; 95% CI: 13.9%-72.5%). However, 95% confidence intervals of these 6-month mortality predictions extended above 50%. CONCLUSIONS Hospices might use several variables to identify patients with a relatively low risk for 6-month mortality and who therefore may become ineligible to continue hospice services if they fail to show significant disease progression.

Increasing inpatient hospice use versus patient preferences in the USA: are patients able to die in the setting of their choice?

Background Growth in hospice utilisation has been accompanied by an increase in the proportion of hospice patients who die in an inpatient hospice setting rather than at home. Objective To determine whether this increase in inpatient utilisation is consistent with patient preferences. Design Retrospective cohort study. Setting Seven hospices in the Coalition of Hospices Organised to Investigate Comparative Effectiveness (CHOICE) network. Patients 70 488 patients admitted between 1 July 2008 and 31 May 2012. Measurements We measured changes in patients’ stated preferences at the time of admission regarding site of death, including weights to adjust for non-response bias. We also assessed patients’ actual site of death and concordance with patients’ preferences. Results More patients died receiving inpatient care in 2012 as compared to 2008 (1920 (32.7%), 2537 (18.5%); OR 1.21; 95% CI 1.19 to 1.22; p<0.001). However, patients also expressed an increasing preference for dying in inpatient settings (weighted preferences 27.5% in 2012 vs 7.9% in 2008; p<0.001). The overall proportion of patients who died in the setting of their choice (weighted preferences) increased from 74% in 2008 to 78% in 2012 (p<0.001). Limitations This study included only seven hospices, and results may not be representative of the larger hospice population. Conclusions Although more patients are dying while receiving inpatient care, these changes in site of death seem to reflect changing patient preferences. The net effect is that patients in this sample were more likely to die in the setting of their choice in 2012 than they were in 2008.