Thomas Christian

Volume Matters: Returning Home After Hip Fracture

To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participants fracture) and other facility characteristics on outcomes.

Examining Variation in Hospice Visits by Professional Staff in the Last 2 Days of Life

IMPORTANCE In the final days of life, symptoms are exacerbated and often families need both education and emotional support from hospice professional staff. The Medicare Hospice Benefit provides a per-diem payment with no requirements on the frequency of patient visits. OBJECTIVE To examine individual characteristics, hospice program, and geographic variation in hospice visits by professional staff during the last 2 days of life. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of 661 557 Medicare hospice beneficiaries included all patients who died in federal fiscal year 2014 (October 1, 2013-September 30, 2014) in hospice services while receiving routine home care in the last 2 days of life. Data analysis was conducted from March 9 to August 25, 2015. MAIN OUTCOMES AND MEASURES Medicare regulations require that hospice care centers report daily the frequency and duration of patient visits by professional staff, as well as the type of hospice staff who conduct these visits. We examined visit variation by hospice professional staff (physician, nursing staff, and social worker) during the last 2 days of life using a multivariable logistic model adjusting for decedent and hospice program characteristics. RESULTS Of the 661 557 patients in the study, 81 478 (12.3%) received no professional staff visits in the last 2 days of life. State variation ranged from 590 of 15 399 patients (3.8%) in Wisconsin to 97 of 492 patients (19.7%) in Alaska, and hospice program interquartile variation ranged from 3.2% (25th percentile) to 19.5% (75th percentile). Black patients were less likely to have any visits than were white patients (7352 of 48 221 [15.2%] vs 70 365 of 585 377 [12.0%]; adjusted odds ratio, 1.30; 95% CI, 1.24-1.37). Those dying in a nursing home were 1.74 times less likely to have any visits than those dying at home (30 880 of 186 649 [16.5%] vs 40 973 of 386 654 [10.6%]; 95% CI, 1.62-1.88). Those dying on a Sunday were 3.35 times less likely to have a visit compared with persons dying on a Tuesday (19 519 of 95 979 [20.3%] vs 6784 of 92 127 [7.4%]; 95% CI, 3.17-3.55). CONCLUSIONS AND RELEVANCE Hospice visits in the last 2 days of life by professional staff vary by race, hospice program, and geographic region of the country. Visits were less likely when the Medicare beneficiary was black, dying on a Sunday, and receiving care in a nursing home.

Using Predicted Therapy Visits in the Medicare Home Health Prospective Payment System

A criticism of Medicare’s home health prospective payment system is its partial reliance on cost-based reimbursement of therapy services provided by home health agencies (HHAs) to Medicare fee-for-service (FFS) beneficiaries, potentially overincentivizing the provision of therapy services. Using Medicare FFS home health claims and assessment data, we estimated a model to predict therapy use as a proxy for clinical need and replace actual therapy use with the prediction in the home health payment system. We estimated a

Hospice Visit Intensity by Physicians and Nurse Practitioners on the General Inpatient Level of Care (TH371C)

1.178 billion (95% confidence interval,

A Review of Hospice Characteristics and Patient Outcomes Associated with Exceeding the Medicare Hospice Annual Aggregate Reimbursement Cap (SA517C)

1.171-

Examining Emergency Room and Observational Stay Visits During Medicare Hospice Election (TH347-B)

1.184) decrease in home health payments relative to levels under the current system. The majority of the decrease was due to the model predicting fewer high therapy episodes than actually occurred. It may therefore be more appropriate to predict both therapy and nontherapy use, requiring an overhaul of the current system.

Characteristics of Hospice Programs With Problematic Live Discharges

and patient hope points to the mediating role that patient readiness may play. Additional research has also found that among some patients, engaging in and EOL conversation before they are ready may actually cause harm. Presently, health practitioners do not have a way to measure patient readiness. Therefore, the purpose of this study was to develop a survey assessment tool, rooted in research, to measure patient readiness to engage in an EOL discussion. The 16-item survey was initially developed by a gerontological researcher and clinical oncologist, and tested for face reliability and appropriateness among a geriatrician and three patients with chronic illness. In May 2018, the final version of the survey was pilot tested among 168 patients attending their regularly scheduled oncology appointment. On average, most participants identified as Caucasian (74%) females (61%) in partnerships (58%) and having a cancer diagnosis (64%). Bivariate analyses revealed that older age (60+, p=0.008), Caucasian race (p=0.04), and reported greater knowledge of community and supportive services (p=0.049) was significantly associated with increased readiness to engage in an EOL discussion. Additionally, a higher score on the Advance Care Planning Engagement Survey was significantly associated with increased readiness (p<0.001). Findings reveal patient groups that might be more appropriate targets for interventions, education, and resources and highlight the role of interprofessionals in outpatient health settings to “prime the pump” for these types of conversations.

What Happens to Patients When They Fracture Their Hip During a Skilled Nursing Facility Stay

physician and degree of fragmentation with referral to hospice. This model adjusted for resident characteristics, cognition, functional status and diagnosis prior to admission. Results. We captured 130,833 hospitalizations of Medicare beneficiaries with advanced cognitive impairment who were residing in NHs between 2000 and 2010 (mean patient age of 83.6, 68.0% female, 74.3% white, 70.2% one-year mortality). Of the hospitalizations that involved only one type of provider acting as the attending physician, the primary provider for that admission was a non-hospitalist general practitioner, a hospitalist, or a specialist in 67.4%, 25.6% and 7.1% of admissions respectively. Hospitalists had 1.44 increased odds of hospice referral compared to non-hospitalist generalists (95% CI 1.31-1.58). Specialists were not statistically significantly different from non-hospitalist generalist. Conclusion. Hospice referrals for NH residents with ACI are more likely when the attending physician is a hospitalist. Implications for Research, Policy, and Practice. Hospitalists, a growing class of physicians, are more likely to appropriately refer NH residents with a high 1-year mortality to hospice at hospital discharge.

A First Look at Trends in Post-Mortem Visit Rates of the Medicare Hospice Benefit: A National Study (S723)

Objectives Understand the prevalence of emergency room and observational stay utilization during Medicare hospice election. Describe provider characteristics associated with high rates of emergency room and observation stay utilization during Medicare hospice election. Original Research Background: Patients enrolled in the Medicare hospice benefit may occasionally use emergency room (ER) and observational stay (OV) services during a hospice election. Little is known about the extent and reasons behind use of these services. Research Objectives: Methods: Results: We identified a cohort of 999,711 hospice enrollment periods with admission dates in 2010; of these, 64,239