Breaking the Link Between Enrollment in Hospice and Discontinuation of Dialysis

Romero, K. Renata Flores; Widera, Eric; Wachterman, Melissa

doi:10.1001/jamainternmed.2022.6390

Cited by 5 publications

(5 citation statements)

References 6 publications

(11 reference statements)

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“…These metrics have been demonstrated in prior studies to be associated with better value of care [27]. Therefore, policies that would encourage continuation of dialysis for comfort and symptom management at the end of life should be promoted.…”

Section: Hospice Utilization and Duration Of Hospice Care Among The E...mentioning

confidence: 93%

Current Trends in Hospice Care Usage for Dialysis Patients in the Usa

Soipe

Leggat

Abioye

et al. 2023

Preprint

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Background: This study examined the predictors and latest trends in hospice utilization, adequate duration of hospice care, and dialysis discontinuation without hospice enrollment among patients with end stage renal disease (ESRD). Methods: Data from the United States Renal Data System (USRDS) for ESRD patients who died between January 1, 2012, and December 31, 2019, were analyzed. Chi square and logistic regression were used to evaluate associations between outcomes of interest and predictors while Joinpoint regression was used to examine trends. Results: Among 803,049 patients, the median (IQR) age was 71 (17) years, 57% were male, 27% enrolled in hospice, 8% discontinued dialysis before death without hospice enrollment, and 7% remained in hospice for ≥15 days. Patients older than 64 years (adjusted odds ratio [aOR]: 2.75, 95% CI: 2.71-2.79) and white race (aOR: 1.79, 95% CI: 1.77-1.81) were more likely to enroll in hospice. White patients (aOR: 0.75, 95% CI: 0.73-0.76) and those who never received a kidney transplant (aOR: 0.75, 95% CI: 0.73-0.78) were less likely to have adequate duration of hospice care. Hospice enrollment and standardized duration of hospice care increased over time, with an average annual percentage change (AAPC) of 1.1% (95% CI:0.6-1.6) and 5% (95% CI:2.6-7.4) respectively. Conclusions: Approximately one in every four ESRD patients who died between 2012 and 2019 had a history of hospice enrollment, while one in every 12 discontinued dialysis before death without hospice enrollment. There was an upward trend in the standardized duration of hospice care.

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Section: Hospice Utilization and Duration Of Hospice Care Among The E...mentioning

confidence: 93%

Current Trends in Hospice Care Usage for Dialysis Patients in the Usa

Soipe

Leggat

Abioye

et al. 2023

Preprint

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“…As patients approach the end of life, they often experience less clinical benefit and more discomfort from dialysis . Nonetheless, even in end-stage disease, dialysis continues to prolong life: discontinuation leads to death within 2 weeks . Discontinuing this treatment can prove to be a nearly insurmountable shift in patients’ and families’ perspectives about dialysis as life sustainment .…”

Section: Hospice Access Limitations: a Case Study In Eskdmentioning

confidence: 99%

“…27 Nonetheless, even in end-stage disease, dialysis continues to prolong life: discontinuation leads to death within 2 weeks. 28 Discontinuing this treatment can prove to be a nearly insurmountable shift in patients' and families' perspectives about dialysis as life sustainment. 29 Therefore, functionally requiring discontinuation of dialysis before hospice enrollment may artificially limit access to hospice.…”

Section: Hospice Access Limitations: a Case Study In Eskdmentioning

confidence: 99%

Concurrent Care as the Next Frontier in End-of-Life Care

Ernecoff,

Anhang Price

2023

JAMA Health Forum

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ImportanceHospice care is a unique type of medical care for people near the end of life and their families, with an emphasis on providing physical and psychological symptom management, spiritual care, and family caregiver support to promote quality of life. However, many people in the US who could benefit from hospice have very short stays or do not enroll at all due to current hospice policy. Changing policy to allow for concurrent availability of disease-directed therapy and hospice care—known as concurrent care—offers an opportunity to increase hospice use and lengths of stay.ObservationsUnder Medicare payment policy, hospices are responsible for covering all costs related to patients’ terminal conditions under a per diem rate. This payment structure has led to a de facto requirement that patients forgo costly therapies (including life-prolonging treatments or those with palliative intent) on enrollment in hospice because they are prohibitively expensive. In other countries, in Medicaid for children, and in the Veterans Health Administration in the US, there is greater flexibility in providing hospice services alongside life-prolonging care. Often paired with innovative payment models, concurrent care smooths practical, psychological, and physical care transitions when patient goals prioritize comfort. For example, allowing simultaneous receipt of hospice care and dialysis for people living with end-stage kidney disease—a group with relatively low hospice enrollment—can act as a bridge to hospice and potentially promote longer lengths of stay.Conclusions and RelevanceMedicare and health care delivery systems are increasingly testing payment and care delivery models to improve hospice use via concurrent care, offering an important opportunity for innovation to better meet the needs of people living with serious illness and their families.

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“…24 One cited barrier to timely access to hospice for patients with ESKD is Medicare hospice policy, which pays hospice agencies a per diem rate of approximately $200 and requires hospices to bear financial responsibility for all costs related to a patient's primary hospice diagnosis. 25 Because dialysis is cost-prohibitive, patients dying of ESKD may face a uniquely difficult choice between hospice and dialysis. Yet this policy cannot explain the low rates of hospice use among those with ESKD not on dialysis 26 or those on dialysis financed by the Veterans Health Administration, which pays for concurrent hospice and dialysis.…”

Section: Introductionmentioning

confidence: 99%

“…One cited barrier to timely access to hospice for patients with ESKD is Medicare hospice policy, which pays hospice agencies a per diem rate of approximately $200 and requires hospices to bear financial responsibility for all costs related to a patient's primary hospice diagnosis 25 . Because dialysis is cost‐prohibitive, patients dying of ESKD may face a uniquely difficult choice between hospice and dialysis.…”

Section: Introductionmentioning

confidence: 99%

Nephrologists' perspectives and experiences with hospice among older adults with end‐stage kidney disease

Wachterman,

Sinha,

Leveille

et al. 2024

J American Geriatrics Society

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BackgroundHospice care leads to improved patient and family outcomes. Hospice use among older adults with end‐stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high‐quality hospice care for older adults with ESKD.MethodsUtilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi‐structured interviews with 20 nephrologists in the United States focused on treatment decision‐making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high‐quality hospice.ResultsWith a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high‐quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD.ConclusionsOur findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.

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Breaking the Link Between Enrollment in Hospice and Discontinuation of Dialysis

Abstract: This Viewpoint discusses Medicare coverage regarding hospice care for patients receiving dialysis at the end of life.

Cited by 5 publications

References 6 publications

Current Trends in Hospice Care Usage for Dialysis Patients in the Usa

Current Trends in Hospice Care Usage for Dialysis Patients in the Usa

Concurrent Care as the Next Frontier in End-of-Life Care

Nephrologists' perspectives and experiences with hospice among older adults with end‐stage kidney disease

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