Age and Gender Differences in Medicare Expenditures and Service Utilization at the End of Life for Lung Cancer Decedents

PURPOSE: Gender and age differences in medical care are well documented. We examined age and gender differences in Medicare expenditures for lung cancer decedents in the last year of life (LYOL) through a cross-sectional study of Medicare administrative and claims data. METHODS: Participants were aged Medicare beneficiaries (>or=68) with lung cancer, who were covered by Parts A and B for 36 months before death (1996-1999; n = 13,120). Regression techniques were used to estimate age and gender differences in mean Medicare utilization and expenditures in the LYOL overall and by type of service, conditional on use: inpatient, outpatient, physician, skilled nursing facility (SNF), home health, and hospice, controlling for demographic, clinical, geographic, and supply characteristics. RESULTS: Women were more likely than men to use inpatient, SNF, home health, and hospice services. Women's average expenditures were approximately dollars 1,900 greater than men's, with differences attributed to higher average expenditures for SNF, home health, and hospice. Older cohorts used fewer inpatient and outpatient services and used more SNF and hospice services in their LYOL. Average Medicare expenditures were significantly lower in older cohorts (dollars 8,487 less for those age >or=85 at death than for those 68-74). Adjusting for age explains most of the gender differences in average Medicare expenditures. Remaining gender differences vary across age cohorts, with larger gender differences in social-supportive service expenditures among those 68-74 and 75-84 and outpatient and physician services among those 75-84 and >or=85. DISCUSSION AND CONCLUSIONS: Our findings suggest that gender disparities in expenditures are generally small at the end of life for lung cancer decedents, particularly among the older cohorts. As expected, the bigger observed differences are by age although the direction of the association is not consistent across types of service. Higher expenditures for women on social-supportive services may reflect fewer informal supports for older women compared with men.     

Assessing quality of end-of-life hospital care in a southern European regional health service

OBJECTIVES: During the final period of life, patients with cancer in the Basque Country are given treatment in different types of hospital care. This study compared the quality of care according to the type of care in one of the autonomous communities in Spain. METHODS: A retrospective study was carried out of cancer patients who died in conventional hospital services, home hospitalization services, and palliative care units. In addition to hospital stay and readmission number, variables based on the recommendations of Spanish Society for Palliative Care were studied. RESULTS: End-of-life was diagnosed in 57 percent of a sample of 486 patients, 3 days before death (median). The use of symptom control scales was only documented in the clinical records of eight patients. Sociofamily evaluation was not found. Patients in conventional hospital services were less frequently diagnosed with end-of-life and agony and were significantly different from the rest in the reasons for admission, symptoms assessed, drugs used, administration routes, and dosage forms. Pain was evaluated in 50 percent of the patients and was better controlled in palliative care units. Patients not diagnosed with agony (52 percent) were more frequently not given specific treatment. CONCLUSIONS: End-of-life in cancer patients was diagnosed too late. The quality of care in palliative care units and by home hospitalization service was better than that in conventional hospitalization. Nevertheless, there were areas for improvement in the three modalities of care.     

Hospice Care: What Services Do Patients and Their Families Receive?

OBJECTIVE: To determine the degree to which patients and families enrolled with hospice received services across key categories of palliative care, the extent of hospice-level variability in services delivered, and changes over time in services delivered. DATA SOURCE: Nationally representative sample of 9,409 discharged patients from 2,066 hospices in the National Home and Hospice Care Survey. STUDY DESIGN: Observational, cross-sectional study conducted from 1992 to 2000. The primary outcome is the receipt of services across five key categories of palliative care: nursing care, physician care, medication management, psychosocial care, and caregiver support. DATA COLLECTION: Data were obtained via interview with the hospice staff member most familiar with the patient's care, in conjunction with medical record review. PRINCIPLE FINDINGS: In 2000, 22 percent of patients enrolled with hospice received services across five key categories of palliative care. There was marked variation across hospices in service delivery. One-third of hospices provided patients and families services in one or two of the five key categories of palliative care, whereas 14 percent of hospices provided services across five key categories of palliative care. In multivariable analysis, the odds of receiving any additional hospice service was significantly greater in later compared with earlier years (odds ratio=1.10, 95 percent confidence interval 1.01-1.20). Nevertheless, the percentages of patients in 2000 receiving medication management (59 percent), respite care (7 percent), and physician services (30 percent) remained low. CONCLUSIONS: Hospice care for patients and families varies substantially across hospices. Whereas some hospices provide services across the key categories of palliative care, other hospices do not provide this breadth of services. Greater understanding of the causes of variation in service delivery as well as its impact on patient and family outcomes and satisfaction with end-of-life care is a critical subject for future research. Changes in Medicare's reimbursement policies may help hospices increase the range of services provided to patients and families.     

Disparities in End of Life Care for Elderly Lung Cancer Patients

The objective of this study was to examine geographic and race/ethnic disparities in access to end of life care among elderly patients with lung cancer. The study sample consisted of 91,039 Medicare beneficiaries with lung cancer who died in 2008. The key outcome measures included the number of emergency room visits, the number of inpatient admissions and the number of intensive care unit (ICU) days in the last 90 days of life, hospice care ever used and hospice enrollment within the last 3 days of life. Medicare beneficiaries with lung cancer residing in rural, remote rural, and micropolitan areas had more ER visits in the last 90 days of life as compared to urban residents. Urban residents however, had more ICU days in the last 90 days of life and were more likely to have ever used hospice as compared to residents of rural, remote rural and micropolitan counties. Racial minority lung cancer patients had more ICU days, ER visits and inpatient days than non-Hispanic White patients, and also were less likely to have ever used hospice care or be enrolled in hospice in the last 3 days of life. Lung cancer patients with very low socioeconomic status (SES) were less likely to ever use hospice or be enrolled in hospice care in the last 3 days of life, as compared to those who had very high SES. Geographic, racial and socioeconomic disparities in end of life care call for targeted efforts to address access barriers for these groups of patients.     

晚期癌症患者居家宁养服务与住院姑息治疗成本-效益分析

目的:分析晚期癌症患者居家与住院姑息性治疗的疗效及医疗费用支出,为晚期癌症患者居家及住院治疗提供参考。方法:统计50位居家接受宁养服务和50位住院接受姑息治疗的患者的医疗费用并进行比较分析,通过问卷调查统计他们的生活质量并进行对比分析。结果:居家接受宁养服务的患者的医疗费用明显低于住院接受姑息治疗的患者(P<0.05),两组患者的生活质量无明显差异(P>0.05)。结论:晚期癌症患者居家接受宁养服务是一种较好的选择,且可避免医疗资源的浪费和过度治疗。     

Nonclinical outcomes of hospital-based palliative care

Evidence-based outcomes are commonly used in making decisions about clinical care. For healthcare executives, evidence-based outcomes also can be useful in making decisions about hospital services. Finkler and Ward (2003) suggest a model whereby cost measurement, cost control, and value assessment can be used as nonclinical, evidence-based outcome measures to provide decision support and to guide management decisions. The Finkler and Ward framework is used to understand the financial implications of establishing an inpatient palliative care unit (PCU). A longitudinal study was conducted to examine the nonclinical outcomes associated with opening and operating an inpatient PCU at a large academic medical center during the first four years of the unit's operation. First, the cost of providing inpatient palliative care was measured. Results indicated that the cost per day to care for patients hospitalized in the last 20 days leading up to their death was significantly less on the PCU than on intensive care units and non-PCUs. Average daily total charges exceeded reimbursement on the ICU and non-PCUs, but the cost on the PCU for the same population was equal to or below the average daily total charges. Second, ways to control costs when operating an inpatient PCU were identified and measured. Evidence from one organization suggests that costs can effectively be controlled by admitting patients directly to the PCU and by appropriate use of hospital resources, including staff, ancillary services, and pharmaceuticals. Third, the study assessed the value to the institution of operating an inpatient PCU. Results indicated that the inpatient PCU yielded a cost savings of nearly 1 million dollars by the third year of operations. This study highlights the nonclinical outcomes of one institution's inpatient PCU and provides guidelines for healthcare executives and managers to use in making decisions about adopting such programs.     

The effect of inpatient hospice units on hospice use post-admission

The objective of this study was to determine whether having a hospice unit within the hospital increases the proportion of terminally ill patients who use hospice services (including home, nursing home, or inpatient hospice) post-admission. Using medical record data abstracted for 232 randomly selected patients with terminal cancer admitted to six community hospitals in Connecticut, we found that patients admitted to a hospital with a hospice unit were more likely to use hospice services (i.e., home hospice, nursing home hospice, or inpatient hospice) post-admission than patients admitted to a hospital without a hospice unit (unadjusted OR 5.7, 95% CI 3.1, 10.6). This effect persisted after adjusting for patient age, gender, marital status, documented discussions of prognosis, prior hospice use, and type of cancer.     

‘Where do I go from here’? A cultural perspective on challenges to the use of hospice services

Do hospice services as shaped by a western perspective adequately fulfil the needs of persons from non‐Western cultures? Based on a Western view of palliative care, the vision outlined in the New Zealand Palliative Care Strategy (2001) is to deliver palliative care services, including hospice services, to all patients and their families requiring them in the context of an increasingly pluralistic and multicultural society. It is predicted that over the next two decades the proportion of people identifying as Māori, Pacific and Asian will dramatically increase within New Zealand. Ministry of Health information provided through a GAP analysis identified hospices as facing access‐to‐care pressures for Māori, Pacific and Asian patients. It is therefore critical to identify the challenges to hospice service access for Māori, Asian and Pacific patients. This project involved qualitative interviews with 37 cancer patients (Māori, Pacific and Asian self‐identified ethnicities), whānau/family and bereaved whanua/family, as well as 15 health professionals (e.g. referring GPs, oncologists, allied health professionals) within one District Health Board. Patients and their families included both those who utilised hospice services, as well as those non‐users of hospice services identified by a health professional as having palliative care needs. Challenges to hospice service utilisation reported in the findings include a lack of awareness in the communities of available services, as well as continuing misconceptions concerning the nature of hospice services. Language barriers were particularly reported for Asian patients and their families. Issues concerning the ethnic representativeness of the hospice services staff were raised. The findings highlight the importance of patient and family knowledge of hospice care for utilisation of services. This information can be used for future planning to enable hospices to both provide high quality evidence based palliative care services for patients and families and provide consultative services to primary healthcare providers in the community.     

The Effect of Inpatient Hospice Units on Hospice Use Post-Admission

ABSTRACT

The objective of this study was to determine whether having a hospice unit within the hospital increases the proportion of terminally ill patients who use hospice services (including home, nursing home, or inpatient hospice) post-admission. Using medical record data abstracted for 232 randomly selected patients with terminal cancer admitted to six community hospitals in Connecticut, we found that patients admitted to a hospital with a hospice unit were more likely to use hospice services (i.e., home hospice, nursing home hospice, or inpatient hospice) post-admission than patients admitted to a hospital without a hospice unit (unadjusted OR 5.7, 95% CI 3.1, 10.6). This effect persisted after adjusting for patient age, gender, marital status, documented discussions of prognosis, prior hospice use, and type of cancer.     

A clinician's view on palliative care, terminal care and quality of life.

No more than 20-25% of cancer patients are cured and 55% need palliative treatment from the time of diagnosis. Medical and nurse training in palliative care, and pain control in particular, is poor and there is a great shortage of doctors trained in terminal care. Palliative care is detailed, complex care and includes many services both in the hospital and in the community. It should be available to all patients wherever they live. We need a network of Home Care and Hospital Support Teams throughout the country, and a limited number of specialist hospice inpatient units to deal with the difficult problems, research and training in terminal care. These services need to be co-ordinated and monitored and will require funding by governmental bodies.     

Associations Between End-of-Life Expenditures and Hospice Stay Length Vary by Clinical Condition and Expenditure Duration

ObjectivesHospice use reduces costly aggressive end-of-life (EOL) care (eg, repeated hospitalizations, intensive care unit care, and emergency department visits). Nevertheless, associations between hospice stays and EOL expenditures in prior research have been inconsistent. We examined the differential associations between hospice stay duration and EOL expenditures among newly diagnosed patients with cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and dementia.MethodsIn the Surveillance, Epidemiology, and End Results–Medicare data, we identified 240 246 decedents diagnosed with the aforementioned conditions during 2001 to 2013. We used zero-inflated negative binomial regression models to examine the differential associations between hospice length of services and EOL expenditures incurred during the last 90, 180, and 360 days of life.ResultsFor the last 360 days of expenditures, hospice stays beyond 30 days were positively associated with expenditures for decedents with COPD, CHF, and dementia but were negatively associated for cancer decedents (all P<.001) after adjusting for demographic and medical covariates. In contrast, for the last 90 days of expenditures, hospice stay duration and expenditures were consistently negatively associated for each of the 4 patient disease groups.ConclusionsLonger hospice stays were associated with lower 360-day expenditures for cancer patients but higher expenditures for other patients. We recommend that Medicare hospice payment reforms take distinct disease trajectories into account. The relationship between expenditures and hospice stay length also depended on the measurement duration, such that measuring expenditures for the last 6 months of life or less overstates the cost-saving benefit of lengthy hospice stays.     

On how increasing numbers of newer cancer therapies further delay referral to hospice: the increasing palliative care imperative

Delay in referral of cancer patients to hospice until very near the end of life may deny patients and families optimal palliative care. A variety of factors may contribute to these delays. This article describes how the proliferation of newer anticancer therapies, although desirable overall, may further increase these delays. It is important for hospice personnel to understand these changes in medical oncology and to work to optimize palliative care delivery concomitantly with disease-remitting therapies.     

Audit tools for palliative care services: identification of neglected aspects of care

The purpose of this study was to investigate the extent to which audit of palliative care service occurs nationally in Britain and Ireland. The following items were measured: (1) audit tools employed, (2) aspects of services undergoing audit, (3) changes in practice as a result of audit, and (4) obstacles to conducting some aspects of the audit. Audit practices were surveyed by means of a postal questionnaire distributed to managers of all hospice and palliative care services in the United Kingdom and Republic of Ireland. A 10 percent sample of managers (n = 40) who responded were subsequently interviewed to confirm and elaborate on questionnaire responses. The response rate was 60 percent and was highest for hospices at 68 percent. Of the respondents, 73 percent audit their services. Of those who audit their services, 79 percent changed their service as a result. Although physical aspects of care were audited frequently (61 percent), other core aspects of palliative care that rarely were audited included bereavement care (17 percent), training (13 percent), and psychological and spiritual care (12 percent). Managers indicated that some aspects of care were rarely audited because they considered clinical and organizational aspects of palliative care to be more important. They also stated that they did not have enough time, expertise, or adequate measurement tools. Until the neglected features of palliative care are audited, the full effectiveness of the services remains unknown.     

A new concept in cancer care: the supportive care program

This article describes the findings of a pilot program designed to enter advanced prostate cancer patients into the hospice benefit while they are still being actively treated, but in situations where treatment is known to be primarily palliative in nature. The supportive care program (SCP) combines the medical model's goal to prolong life with the goal of hospice to palliate symptoms and improve quality of life (QOL). The concept of a SCP was developed to create a team approach where advanced prostate cancer patients who are starting investigational chemotherapy are concurrently enrolled into a hospice program. The objectives were to identify whether SCP improved QOL and continuity of care while remaining cost-effective. Data were collected on patient quality of life, performance status, use of health care resources, and costs for the 36 enrolled patients. A comparison was made to a matched set of 23 control patients. Our findings indicate that the SCP contributes to continuity of care while being cost-effective.     

Place of death: preferences among cancer patients and their carers

The place of death of cancer patients has become an important theme in UK cancer and palliative care policy. This paper examines the place of death preferences of 41 terminally ill cancer patients and 18 of their informal carers, living in the Morecambe Bay area of north-west England. We interviewed cancer patients referred to the research team by 13 specialist palliative care professionals; patients had an estimated 3 months of life remaining. The study design involved an in-depth qualitative interview with each patient soon after referral to the study, followed by an interview some 4 weeks later and subsequent tracking interviews by telephone at 2-4 week intervals until death occurred. Interviews were also conducted with main coresident carers soon after patient referral to the study and again in the post-bereavement period. Thirteen factors were identified as shaping the place of death preference of patients and carers. These are organised into four thematic domains: the informal care resource, management of the body, experience of services, and existential perspectives. In documenting these factors, this paper adds significantly to current knowledge on the factors that shape place of death preference, a field of enquiry acknowledged to be underdeveloped (J. Palliative Med. 3 (2000) 287). More importantly, it uncovers some of the reasons that underpin these preferences. Our research revealed a much stronger preference for deaths in a hospice than had been anticipated, leading us to take a qualified stance on the current policy drive in favour of home deaths by those charged with delivering UK cancer and palliative care services.     

Comparison of hospice use and demographics among European Americans,African Americans,and Latinos

The goals of this study were to compare the rate of use of hospice services and other relevant characteristics of European American, African American, and Latino hospice patients. Information on length of stay in hospice, marital status, age, disposition at termination, living situation, caregiver, referral source, and payment method was collected on patients who used hospice care in southern New Jersey between the years 1995 and 2001 (N = 1958). African Americans and Latinos were both found to use services at significantly lower rates than European Americans. In addition, African American use of hospice declined significantly during this time period, while European American use increased. Differences were also found among the groups in marital status, living situation, caregiver, referral source, and payment method. These differences highlight the need for hospice providers to recognize issues unique to minority groups. The reasons for these disparities need to be clarified by further research.     

The Harry R. Horvitz Center for Palliative Medicine (1987-1999): development of a novel comprehensive integrated program

The Cleveland Clinic is a large multispecialty group practice. The need for a palliative care program was identified and the program started in 1987. A key concept has been that the existing structure of hospice care as defined by Medicare is insufficient to address the needs of patients with incurable disease. The field of palliative medicine implies physician expertise in several key areas: (1) communication; (2) decision-making; (3) management of complications; (4) symptom control; (5) care of the dying; and (6) psychosocial care. The development of the program (the first in the United States) since 1987 has put in place the following major services, listed consecutively: (1) hospital consultation service; (2) outpatient clinics; (3) acute care inpatient service; (4) hospice and home care service; (5) acute-care palliative medicine inpatient unit; and (6) hospice inpatient facility. Program development has meant that a new program has been introduced approximately every 18 months since the start of the program. This has considerable implications for staffing, the management of change, and competition for scarce resources within a contracting health care budget. The staffing of the program has focused on developing specialized attending physicians using a multidisciplinary approach dedicated to enhancing the role of nursing in the field. The major budgeted areas are (1) the acute-care palliative medicine unit, and (2) the hospice and home care service. Specific commitment has been made to research and education because of the desire to develop an intellectual basis for the practice of palliative medicine. This requires structured activities in both areas with a systematic approach to research and education. The complexity of developing a service should not be underestimated. There has been consistent support for the program by senior leadership within the Cleveland Clinic Foundation, including the cancer center. The major lessons learned during program development have been: (1) to focus on quality of patient care; (2) to commit to academic endeavor in research and education; (3) to secure institutional commitment to program development; (4) to establish a positive, proactive, businesslike approach; (5) to defend budget and personnel, albeit within a difficult time in health care; and (6) to commit to success, i.e., never promise anything on which you do not deliver. The future development of post-acute-care services serving predominantly the chronically ill elderly population suggest an expanded administrative and conceptual role for the future development of palliative medicine to help serve the needs of the aging population in the United States.     

Hospice and palliative care: an educational intervention for healthcare professionals in a rural community

The purpose of the study was to increase the awareness and availability of hospice care in rural communities. In Taos, New Mexico, a community of about 30,000 people, we developed an educational intervention that introduced the topic of end-of-life care and hospice to their healthcare professionals. We targeted nurses, physicians, and other related healthcare professionals. The nurses and allied health professionals received a half-day seminar. The physicians attended a grand round about hospice and palliative care lead by the local hospice medical director. This individual was an important member of the local medical staff and was certified in hospice and palliative medicine. After the intervention, we were able to demonstrate an increase in the hospice annual census by 85 percent (p < 0.001). Average length of stay was not altered (27.3 percent enrolled for six days or less preintervention, 29.5 percent enrolled for six days or less postintervention; p = 0.97). Similarly, the number of patients admitted with a non-cancer diagnosis was not affected (54.6 percent preintervention, 44.3 percent postintervention; p = 0.34). We concluded that the educational intervention significantly increased the number of patients referred for hospice care. However, it did not affect the length of stay or increase enrollment for people with a non-cancer diagnosis. The educational intervention was inexpensive, locally run, and very effective as demonstrated by the increase in hospice referrals. Exporting the model to other rural sites appears to be feasible.     

Cancer Chemotherapy Treatment Patterns and Febrile Neutropenia in the US Veterans Health Administration

BackgroundThe Veterans Health Administration (VHA) is the largest integrated health care system in the United States and a major cancer care provider.ObjectiveTo use VHA database to conduct a population-based study of patterns of myelosuppressive chemotherapy use and to assess the incidence and management of febrile neutropenia (FN) among VHA patients with lung, colorectal, or prostate cancer or non-Hodgkin lymphoma (NHL).MethodsData were extracted for the initial myelosuppressive chemotherapy course for 27,899 patients who began treatment in the period 2006 to 2011. FN-related costs were defined as claims containing FN diagnosis.ResultsMost patients were men (98.0%); most were 65 years or older (55.8%). Patients received a mean 3.4 to 3.9 chemotherapy cycles/course (median cycle duration 34–43 days). The incidence of FN among patients with lung, colorectal, or prostate cancer or NHL was 10.2%, 4.6%, 5.4%, and 17.3%, respectively. Primary or secondary prophylactic antibiotics/colony-stimulating factors were received by 21% and 12% of patients, respectively. Antibiotics were more commonly given as primary or secondary prophylaxis for patients with lung, colorectal, and prostate cancer; colony-stimulating factors were more common for patients with NHL. Among patients with FN, those with lung cancer had the highest inpatient mortality (10%); patients with NHL had the highest costs ($24,571) and the longest hospital length of stay (15.4 days).ConclusionsVHA cancer care was generally consistent with National Comprehensive Cancer Network recommendations; however, compared with the general population, chemotherapy cycles were longer, combination chemotherapy was used less, and treatment to prevent FN was used less, differences that may be attributed to the unique VHA patient population. The impact of these practices warrants further investigation.     

A comparative study of hospice services in the United States.

In order to document the implementation of the hospice concept in the United States, 24 hospices, in operation at least one year and serving at least 100 patients, were selected from the National Hospice Organization roster to participate in a survey of organization, staffing, funding, services and population served. All of the hospices offered both home care and bereavement programs but only 41.7 per cent provided an inpatient program. Ten of the hospices were institutionally based, usually in a hospital. Inpatient services were associated with institutional affliations. The average profile of patients admitted to hospice was a 60-year-old White (89 per cent), female (54.3 per cent) cancer patient (94.5 per cent) whose spouse was primary care giver (63.8 per cent). Hospices provided a wide variety of both medical and social services provided by volunteers as well as paid staff. It appears that two divergent types of hospices are developing: 1) independent, heavily volunteer hospices with a variety of professional staff delivering a wide array of social/psychological services with unstable funding; and 2) institutionally based hospices providing both inpatient and home care, greater variety of medical/nursing services, less variety of social/psychological services, using fewer types of volunteers and paid staff, and not experiencing funding problems.