Asking Patients Where They Want to Die When Admitted to Hospice Linked to Fewer Hospitalizations at End-of-Life
Patients who were asked where they wanted to die upon entering hospice had lower rates of hospitalization at the end of life, as did those in hospices that monitored symptoms more frequently, according to a new study led by researchers at the Icahn School of Medicine at Mount Sinai. Published online today in the July issue of the journal Medical Care, the study also determined that for-profit hospices have persistently high rates of hospitalization regardless of preferred practice implementation.
While the Affordable Care Act requires hospices to report quality measures across a range of processes and practices, this is the first study to examine the link between hospice preferred practices and outcomes for patients receiving hospice care.
Researchers tracked a cohort from the National Hospice Survey of 149,814 Medicare beneficiaries enrolled in a national random sample of 577 hospices across the United States and followed them from 2008-2011 until their death. Findings determined that while the hospitalization of patients after being enrolled in hospice varied considerably, two of the six preferred practices examined (namely assessing patient preferences for site of death and monitoring symptoms at least every dew days) were associated with significantly lower hospitalization rates of patients following hospice enrollment. The other four examined preferred practices were not associated with hospitalization-based outcomes.
“The substantial hospice level variation in hospitalization rates identified in this study underscores the need to better understand the drivers of inter-hospice variation, to develop quality measures based on these determinants, and to create incentives for high performance on quality measures to improve the experiences of patients and families at the end of life,” said Melissa Aldridge, PhD, MBA, Professor of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai.
Hospice services focus on palliative rather than curative care and include medical services, symptom management, spiritual counseling, social services and bereavement counseling delivered by an interdisciplinary team of professionals for patients with a prognosis of six months or less to live. Forty-five percent of terminally ill patients in the U.S. currently die under hospice, and its use has grown by more than 20 percent over the past decade. It is covered by Medicare, Medicaid, Managed Care (including HMOs), and most private insurances.
Meanwhile, researchers found that hospitalization rates at for-profit hospices were higher regardless of preferred practice implementation—suggesting that it is the organization of the hospice itself in terms of ownership that likely drive policies and decisions regarding hospitalization.
“Our results highlight the need to better understand the practices of for-profit hospices where the pattern of high hospitalization of patients is persistent,” said Dr. Aldridge. “Our data also suggests that the hospitalization of individuals who had enrolled with for-profit hospices may be a means of shifting costs of care from the hospice organization to Medicare, but more research is necessary to explore this issue. In particular, we need to understand from the perspective of patients and their caregivers, why hospitalizations at the end of life occur after hospice enrollment.”
Co-authors of the study include Elizabeth Bradley, PhD, and Emily Cherlin, PhD, MSW Department of Epidemiology and Public Health, Yale School of Public Health , Eric Lee, MPH, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai; Andrew Epstein, PhD, Perelman School of Medicine, University of Pennsylvania; and Abraham Brody, RN, PhD, New York University College of Nursing.
The study was supported by the National Institute of Nursing Research (5R01NR013499), the National Cancer Institute (1R01CA116398-01A2), and the John D. Thompson Foundation.
About the Mount Sinai Health System
The Mount Sinai Health System is an integrated health system committed to providing distinguished care, conducting transformative research, and advancing biomedical education. Structured around seven hospital campuses and a single medical school, the Health System has an extensive ambulatory network and a range of inpatient and outpatient services—from community-based facilities to tertiary and quaternary care.
The System includes approximately 7,100 primary and specialty care physicians; 12 joint-venture ambulatory surgery centers; more than 140 ambulatory practices throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and 31 affiliated community health centers. Physicians are affiliated with the renowned Icahn School of Medicine at Mount Sinai, which is ranked among the highest in the nation in National Institutes of Health funding per investigator. The Mount Sinai Hospital is in the "Honor Roll" of best hospitals in America, ranked No. 15 nationally in the 2016-2017 "Best Hospitals" issue of U.S. News & World Report. The Mount Sinai Hospital is also ranked as one of the nation's top 20 hospitals in Geriatrics, Gastroenterology/GI Surgery, Cardiology/Heart Surgery, Diabetes/Endocrinology, Nephrology, Neurology/Neurosurgery, and Ear, Nose & Throat, and is in the top 50 in four other specialties. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 10 nationally for Ophthalmology, while Mount Sinai Beth Israel, Mount Sinai St. Luke's, and Mount Sinai West are ranked regionally. Mount Sinai's Kravis Children's Hospital is ranked in seven out of ten pediatric specialties by U.S. News & World Report in "Best Children's Hospitals."