Examining Variation in Hospice Visits by Professional Staff in the Last 2 Days of Life

Abstract

IMPORTANCE In the final days of life, symptoms are exacerbated and often families need both education and emotional support from hospice professional staff. The Medicare Hospice Benefit provides a per-diem payment with no requirements on the frequency of patient visits. OBJECTIVE To examine individual characteristics, hospice program, and geographic variation in hospice visits by professional staff during the last 2 days of life. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of 661 557 Medicare hospice beneficiaries included all patients who died in federal fiscal year 2014 (October 1, 2013-September 30, 2014) in hospice services while receiving routine home care in the last 2 days of life. Data analysis was conducted from March 9 to August 25, 2015. MAIN OUTCOMES AND MEASURES Medicare regulations require that hospice care centers report daily the frequency and duration of patient visits by professional staff, as well as the type of hospice staff who conduct these visits. We examined visit variation by hospice professional staff (physician, nursing staff, and social worker) during the last 2 days of life using a multivariable logistic model adjusting for decedent and hospice program characteristics. RESULTS Of the 661 557 patients in the study, 81 478 (12.3%) received no professional staff visits in the last 2 days of life. State variation ranged from 590 of 15 399 patients (3.8%) in Wisconsin to 97 of 492 patients (19.7%) in Alaska, and hospice program interquartile variation ranged from 3.2% (25th percentile) to 19.5% (75th percentile). Black patients were less likely to have any visits than were white patients (7352 of 48 221 [15.2%] vs 70 365 of 585 377 [12.0%]; adjusted odds ratio, 1.30; 95% CI, 1.24-1.37). Those dying in a nursing home were 1.74 times less likely to have any visits than those dying at home (30 880 of 186 649 [16.5%] vs 40 973 of 386 654 [10.6%]; 95% CI, 1.62-1.88). Those dying on a Sunday were 3.35 times less likely to have a visit compared with persons dying on a Tuesday (19 519 of 95 979 [20.3%] vs 6784 of 92 127 [7.4%]; 95% CI, 3.17-3.55). CONCLUSIONS AND RELEVANCE Hospice visits in the last 2 days of life by professional staff vary by race, hospice program, and geographic region of the country. Visits were less likely when the Medicare beneficiary was black, dying on a Sunday, and receiving care in a nursing home.

Effects of Caregiver and Decedent Characteristics on CAHPS Hospice Survey Scores

“…Decedent race/ethnicity was not tested because of sensitivities around such adjustment. With respect to setting of care, prior studies have suggested substantially different care processes and reports of care experiences by setting 5,21 and have demonstrated associations between both hospice profit status and setting as well as profit status and care processes. 22 True differences in quality of care across c Note that, as is often the case, bivariate and multivariate regression coefficients differ in sign in several instances, so that unadjusted RRs may be higher for a group (e.g., caregivers of male decedents) associated with a lower adjusted (multivariate) odds ratio of responding.…”

Nursing Support of Home Hospice Caregivers on the Day of Patient Death

“…Unfortunately not all caregivers and patients receive a visit on the day of patient death, despite the fact that the hospice Medicare benefit does not restrict visit number and that patient symptoms are often exacerbated as death approaches (Teno, Plotzke, Christian, & Gozalo, 2016). This study reported on patients who did not receive a hospice visit within 48 hours of death, finding concerning disparities using an analysis of hospice administrative data (Teno et al, 2016).…”

“…This study reported on patients who did not receive a hospice visit within 48 hours of death, finding concerning disparities using an analysis of hospice administrative data (Teno et al, 2016). Patients who were black were 30% less likely to get visits, one in five persons dying in a nursing home did not get a hospice visit, and one in five dying on a Sunday did not get a visit (Teno et al, 2016). This precludes supporting caregivers and patients during a particularly vulnerable time.…”

The Affordable Care Act and End-of-Life Care for Patients With Cancer

“…44,45 Hospice visits in the last days of life vary substantially by race, hospice program, and geographic region of the country. 46 …”