Melissa W. Wachterman

Association of Hospice Agency Profit Status With Patient Diagnosis, Location of Care, and Length of Stay

CONTEXT Medicares per diem payment structure may create financial incentives to select patients who require less resource-intensive care and have longer hospice stays. For-profit and nonprofit hospices may respond differently to financial incentives. OBJECTIVE To compare patient diagnosis and location of care between for-profit and nonprofit hospices and examine whether number of visits per day and length of stay vary by diagnosis and profit status. DESIGN, SETTING, AND PATIENTS Cross-sectional study using data from the 2007 National Home and Hospice Care Survey. Nationally representative sample of 4705 patients discharged from hospice. MAIN OUTCOME MEASURES Diagnosis and location of care (home, nursing home, hospital, residential hospice, or other) by hospice profit status. Hospice length of stay and number of visits per day by various hospice personnel. RESULTS For-profit hospices (1087 discharges from 145 agencies), compared with nonprofit hospices (3618 discharges from 524 agencies), had a lower proportion of patients with cancer (34.1%; 95% CI, 29.9%-38.6%, vs 48.4%; 95% CI, 45.0%-51.8%) and a higher proportion of patients with dementia (17.2%; 95% CI, 14.1%-20.8%, vs 8.4%; 95% CI, 6.6%-10.6%) and other noncancer diagnoses (48.7%; 95% CI, 43.2%-54.1%, vs 43.2%; 95% CI, 40.0%-46.5%; adjusted P < .001). After adjustment for demographic, clinical, and agency characteristics, there was no significant difference in location of care by profit status. For-profit hospices compared with nonprofit hospices had a significantly longer length of stay (median, 20 days; interquartile range [IQR], 6-88, vs 16 days; IQR, 5-52 days; adjusted P = .01) and were more likely to have patients with stays longer than 365 days (6.9%; 95% CI, 5.0%-9.4%, vs 2.8%; 95% CI, 2.0%-4.0%) and less likely to have patients with stays of less than 7 days (28.1%; 95% CI, 23.9%-32.7%, vs 34.3%; 95% CI, 31.3%-37.3%; P = .005). Compared with cancer patients, those with dementia or other diagnoses had fewer visits per day from nurses (0.50 visits; IQR, 0.32-0.87, vs 0.37 visits; IQR, 0.20-0.78, and 0.41 visits; IQR, 0.26-0.79, respectively; adjusted P = .002) and social workers (0.15 visits; IQR, 0.07-0.31, vs 0.11 visits; IQR, 0.04-0.27, and 0.14 visits; IQR, 0.07-0.31, respectively; adjusted P < .001). CONCLUSION Compared with nonprofit hospice agencies, for-profit hospice agencies had a higher percentage of patients with diagnoses associated with lower-skilled needs and longer lengths of stay.

Reporting dementia on the death certificates of nursing home residents dying with end-stage dementia.

To the Editor: In 2004, the National Center for Health Statistics (NCHS) ranked Alzheimer disease as the fifth leading cause of death among US residents older than 65 years, an increase from prior years.1 NCHS data are derived from death certificates. Retrospective studies of patients who died at various stages of dementia suggest this condition is under-reported on death certificates.2,3 We prospectively observed a cohort of nursing home residents who had been diagnosed with end-stage dementia to describe which conditions were documented on their death certificates. Methods. Data were collected between 2003 and 2007 from the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study, a prospective study of 323 residents of 22 Boston-area nursing homes with advanced dementia, each followed up for up to 18 months.4 Eligibility criteria included age older than 60 years and advanced dementia (based on physician documentation of dementia in chart and Global Deterioration Scale stage 7 determined by a nurse).5 The Hebrew SeniorLife institutional review board approved this study. Written consent was provided by participants’ health care proxies. Descriptive data included age, sex, race (reported by proxies using predefined categories), dementia type (Alzheimer, vascular, or other, from medical records), nursing home length of stay, living in a dementia special care unit, location of death, and functional status at study entry (from nurses; Bedford Alzheimer Nursing Severity Subscale6). Descriptive variables, including race, were ascertained to allow for comparability with other samples. Massachusetts death certificates, obtained for all participants who died during follow-up, have 3 sections. In part 1, line A requests the “immediate cause of death.” Lines B through D request the “sequence of conditions resulting in the immediate cause of death.” Part 2 asks for “other significant conditions contributing to death” (no limit on number). Two research assistants who were unaware of the study aims independently abstracted causes of death verbatim from the death certificates. Conditions were categorized into predefined clinically relevant groups and quantified using proportions. Exact binomial 95% confidence intervals (CIs) were calculated using SAS version 9.1 (SAS Institute, Cary, North Carolina). Results. Of the 323 participants, 165 died during follow-up (Table 1). Among all decedents, dementia documentation on their death certificates was none, 37.0% (95% CI, 29.6%–44.8%); listed in part 1 line A, 15.8% (95% CI, 10.6%–22.2%); listed in part 1 lines B–D, 35.2% (95% CI, 27.9%–43.0%); and listed in part 2, 16.4% (95% CI, 11.2%–22.9%) (Table 2). Seven participants had dementia listed in parts 1 and 2. Among the 114 decedents with a premortem diagnosis of Alzheimer disease, documentation of dementia anywhere on their death certificates was none, 33.3% (95% CI, 24.8%–42.8%); Alzheimer disease, 27.2% (95% CI, 19.3%–36.8%); “dementia” without further specification, 37.7% (95% CI, 28.8%–47.3%); and vascular dementia, 0.9% (95% CI, 0.2%–4.8%). Table 1 Characteristics of Nursing Home Decedents With Advanced Dementia (N = 165) Table 2 Causes of Death of Decedents With Advanced Dementia in Nursing Homes, Recorded According to Location on Death Certificates (N = 165) Comment. In this study, dementia, and specifically Alzheimer disease, was underreported on death certificates, raising concerns about the accuracy of mortality statistics based on these documents. Despite the terminal stage of dementia in our cohort, dementia was not recorded on 37% of death certificates. The absence of Alzheimer disease on three-quarters of death certificates of decedents with this premortem diagnosis is a particular problem because among the causes of dementia, NCHS ranks only Alzheimer disease among its leading causes of death. This study is limited in that 94% of the cohort died in nursing homes where dementia is more likely to be reported on death certificates compared with hospitals.2 There may be some inaccuracies in the clinical dementia subtypes obtained from the chart. The findings may not be generalizable outside Boston; however, the study sample and nursing homes are comparable with those in the rest of the United States.4 An appreciation that patients die from and with dementia is necessary to inform end-of-life decision making. Underestimation of the burden of dementia as a major fatal illness may hamper planning of health services needed for persons dying with this condition.

The Who, What, and Why of Risk Adjustment: A Technology on the Cusp of Adoption

Risk adjustment (RA) consists of a series of techniques that account for the health status of patients when predicting or explaining costs of health care for defined populations or for evaluating retrospectively the performance of providers who care for them. Although the federal government seems to have settled on an approach to RA for Medicare Advantage programs, adoption and implementation of RA techniques elsewhere have proceeded much more slowly than was anticipated. This article examines factors affecting the adoption and use of RA outside the Medicare program using case studies in six U.S. health care markets (Baltimore, Seattle, Denver, Cleveland, Phoenix, and Atlanta) as of 2001. We found that for purchasing decisions, RA was used exclusively by public agencies. In the private sector, use of risk adjustment was uncommon and scattered and assumed informal and unexpected forms. The most common private sector use of RA was by health plans, which occasionally employed RA in negotiations with purchasers or to allocate resources internally among providers. The article uses classic technology diffusion theory to explain the adoption and use of RA in these six markets and derives lessons for health policy generally and for the future of RA in particular. For health policy generally, the differing experiences of public and private actors with RA serve as markers of the divergent paths that public and private health care sectors are pursuing with respect to managed care and risk sharing. For the future of RA in particular, its history suggests the need for health service researchers to consider barriers to use adoption and new analytic technologies as they develop them.

When Methods Meet Politics: How Risk Adjustment Became Part of Medicare Managed Care

Health-based risk adjustment has long been touted as key to the success of competitive models of health care. Because it decreases the incentive to enroll only healthy patients in insurance plans, risk adjustment was incorporated into Medicare policy via the Balanced Budget Act of 1997. However, full implementation of risk adjustment was delayed due to clashes with the managed care industry over payment policy, concerns over perverse incentives, and problems of data burden. We review the history of risk adjustment leading up to the Balanced Budget Act and examine the controversies surrounding attempts to stop or delay its implementation during the years that followed. The article provides lessons for the future of health-based risk adjustment and possible alternatives.

Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis

Importance Patients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with health care utilization and costs. Objective To examine the association between hospice length of stay and health care utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis. Design, Setting, and Participants This cross-sectional observational study was conducted via the United States Renal Data System registry. Participants were all 770 191 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were April 2016 to December 2017. Main Outcomes and Measures Hospital admission, intensive care unit (ICU) admission, and receipt of an intensive procedure during the last month of life; death in the hospital; and costs to the Medicare program in the last week of life. Results Among 770 191 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for 3 days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for 3 days or fewer were less likely to die in the hospital (13.5% vs 55.1%; P < .001) or to undergo an intensive procedure in the last month of life (17.7% vs 31.6%; P < .001) but had higher rates of hospitalization (83.6% vs 74.4%; P < .001) and ICU admission (54.0% vs 51.0%; P < .001) and similar Medicare costs in the last week of life (

Patterns of Hospice Care Among Military Veterans and Non-Veterans

10 756 vs

Obesity Among Adults With Disabling Conditions

10 871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred more than 15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were

Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses.

3221). Conclusions and Relevance Overall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population.

Relationship Between the Prognostic Expectations of Seriously Ill Patients Undergoing Hemodialysis and Their Nephrologists

CONTEXT Historically, hospice use by veterans has lagged behind that of non-veterans. Little is known about hospice use by veterans at a population level. OBJECTIVES To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization. METHODS Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression. RESULTS Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P = 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P = 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P = 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than non-veterans (one every 5.3 days vs. one every 3.7 days; P = 0.002). CONCLUSION Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist.