A national study of disenrollment from hospice among people with dementia

Abstract

Background: People with dementia (PWD) are at high risk for hospice disenrollment, yet little is known about patterns of disenrollment among the growing number of hospice enrollees with dementia. Design: Retrospective, observational cohort study of 100% Medicare beneficiaries with dementia aged 65 and older enrolled in the Medicare Hospice Benefit between July 2012 and December 2017. Outcome measures included hospiceinitiated disenrollment for patients whose rate of decline ceased to meet the Medicare hospice eligibility guideline of "expected death within 6 months" (extended prognosis) and patient-initiated disenrollment (revocation). Hospice, regional, and patient risk factors and variation were assessed with multilevel mixed-effects logistic regression models. Results: Among 867,695 hospice enrollees with dementia, 70,945 (8.2%) were disenrolled due to extended prognosis and 43,133 (5.0%) revoked within 1-year of their index admission. There was substantial variation in hospice provider disenrollment due to extended prognosis (10th-90th percentile 4.5%-14.6%, adjusted median odds ratio (MOR) 1.86, 95% confidence interval (CI) 1.82, 1.91) and revocation (10th-90th percentile 2.5%-10.1%, MOR 2.09, 95% CI 2.03, 2.14). Among hospital referral regions (HRR), there was more variation in revocation (10th-90th percentile 3.5%-7.6%, MOR 1.4, 95% CI 1.34, 1.47) than extended prognosis (10th-90th percentile 7.0%-9.5%, MOR 1.23, 95% CI 1.18, 1.27), with much higher revocation rates noted in HRRs located in the Southeast and Southern California. A number of patient and hospice characteristics were associated with higher odds of both types of disenrollment (younger age, female sex, minoritized race and ethnicity, Medicaid dual eligibility, Medicare Part C enrollment), while some were associated with revocation only (more comorbidities, newer, smaller, and for-profit hospices). Conclusions:In this nationally representative study of hospice enrollees with dementia, hospice disenrollment varied by type of hospice, geographic region, and patient characteristics including age, sex, race, and ethnicity. These findings raise important questions about whether and how the Medicare Hospice Benefit could be adapted to reduce disparities and better support PWD.

Functional and clinical needs of older hospice enrollees with coexisting dementia

“…Differences in hospice use patterns between enrollees with coexisting and principal diagnoses of dementia likely stem from differences in how NHATS and HRS characterize settings, and the fact that that HRS includes nursing home residents in baseline assessments. A recent study using 100% Medicare claims found that 8% of enrollees with principal dementia were disenrolled for extended prognosis 33 (compared to 5% identified in this study).…”

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice

“…6 Type 2 burdensome transitions identifies individuals who are hospitalized within 2 days after hospice live discharge and die while hospitalized. 6 Early and late live discharges are associated with racial and ethnic minoritized status, [7][8][9][10][11] younger age, 7,8,12,13 dual Medicare and Medicaid enrollment, [7][8][9] fewer comorbidities, 7,14 increased functional status, 7,15 and for-profit hospice status. 10,16 However, type 1 and 2 burdensome transitions have not been as well studied (a 2016 study by Prsic et al 16 is an exception), despite being potentially related to poor assessment of patient stability prior to live discharge 6 or nonsystematic approaches to live discharge planning 17,18 that may result in postdischarge care fragmentation.…”