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.

SummaryBackground and objectives Textbooks report that patients with ESRD survive for 7-10 days after discontinuation of dialysis. Studies describing actual survival are limited, however, and research has not defined patient characteristics that may be associated with longer or shorter survival times. The goals of this study were to determine the mean life expectancy of patients admitted to hospice after discontinuation of dialysis, and to identify independent predictors of survival time.Design, setting, participants, & measurements Data for demographics, clinical characteristics, and survival were obtained from 10 hospices for patients with ESRD who discontinued dialysis before hospice admission. Data were collected for patients admitted between January 1, 2008 and May 15, 2012. All hospices were members of the Coalition of Hospices Organized to Investigate Comparative Effectiveness network, which obtains de-identified data from an electronic medical record.Results Of 1947 patients who discontinued dialysis, the mean survival after hospice enrollment was 7.4 days (range, 0-40 days). Patients who discontinued dialysis had significantly shorter survival compared with other patients (n=124,673) with nonrenal hospice diagnoses (mean survival 54.4 days; hazard ratio, 2.96; 95% confidence interval, 2.82 to 3.09; P,0.001). A Cox proportional hazards model identified seven independent predictors of earlier mortality after dialysis discontinuation, including male sex, referral from a hospital, lower functional status (Palliative Performance Scale score), and the presence of peripheral edema.Conclusions Patients who discontinue dialysis have significantly shorter survival than other hospice patients. Individual survival time varies greatly, but several variables can be used to predict survival and tailor a patient's care plan based on estimated prognosis.

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.