Hospice Enrollment and Evaluation of Its Causal Effect on Hospitalization of Dying Nursing Home Patients

Abstract

Objective. To examine the patient, nursing home (NH), hospice provider, and local market factors associated with the selection of the Medicare hospice benefit by eligible NH residents, and evaluate the causal effect of hospice on end-of-life hospitalization rates. Data Sources/Study Setting. Secondary data for 1995-1997 for NH residents. Study Design. This retrospective cohort study includes NH residents in five states (Kansa, Maine, New York, Ohio, South Dakota) who died in the years 1995-1997. Medicare claims identified hospice enrollment and hospitalizations. Geocoding of NHs, hospice providers, and hospitals was used to identify local markets. The two outcome measures are hospice enrollment and hospitalization of NH residents in their last 30 days of life. Data Collection/Extraction Method. A file was constructed linking MDS assessments to Medicare claims and denominator files, NH provider files (OSCAR), hospice provider of service files, and the area resource file. Principal Findings. Twenty-six percent of hospice and 44 percent of nonhospice residents were hospitalized in their last 30 days of life (odds ratio [OR] 0.45; 95 percent confidence interval [CI]: 0.42-0.48). Adjusting for confounders, hospice patients were less likely than nonhospice residents to be hospitalized (OR 0.47; 95 percent CI: 0.45-0.50). Adding inverse propensity score weighting, hospice patients were still less likely than nonhospice residents to be hospitalized (OR 0.56; 95 percent CI: 0.53-0.61). Conclusions. Hospice selection introduces some bias in the evaluation of the causal effect of hospice on end-of-life hospitalization rates. However, even after adjusting for selection bias, hospice does have a powerful effect in reducing end-of-life hospitalization rates.

Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

“…As in other studies, 9,35 we found the presence of DNR and DNH orders to be associated with a much lower risk of a hospital death. Of interest, approximately three-fourths of SNF residents with and without hospice had DNR orders, whereas approximately 10% of each group had DNH orders (documented on the MDS).…”

“…8,9 To identify residents who died with advanced dementia a diagnosis of ''Alzheimer's'' or ''Dementia other than Alzheimer's'' had to be documented on the MDS closest to death or on any Medicare Part-A claim (i.e., home health, hospice, hospital, outpatient, or SNF claim) in the last 12 months of life. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes we used to capture dementia have been used by others 24,25 (290.xx, 291.2, 292.82, 294.1x, 294.8, 331.0-331.2, and 332.83).…”

“…Hospitals are generally not the preferred location for the site of death among the frail elderly, and in many cases hospitalizations are potentially avoidable. 21 Hospice enrollment is known to be associated with lower hospital use for dying NH residents 9 and previous research has shown that 33.5% of NH residents dying within 30 days of a SNF admission die in a hospital. 22 Unknown is how hospice use (and timing of referrals) may differ when SNF admission occurs near death and how hospice use subsequent to SNF may influence the probability of a terminal hospitalization.…”

“…2-7 NH hospice care has been found to provide benefits to dying NH residents, including better pain management, 8 fewer hospitalizations, 9 and greater family satisfaction with end-of-life (EoL) care, [10][11][12] and the benefits of hospice have been shown to extend to residents with dementia. 8,9,13 Although the proportion of dying NH residents with advanced dementia accessing hospice almost tripled between 1999 and 2006 (to approximately 40%), 14 there remain important barriers to greater and timelier hospice access.…”

“…8,9,13 Although the proportion of dying NH residents with advanced dementia accessing hospice almost tripled between 1999 and 2006 (to approximately 40%), 14 there remain important barriers to greater and timelier hospice access. 15,16 A major barrier is the Medicare policy disallowing simultaneous access to Medicare Part A hospice care for NH residents receiving Medicare skilled nursing facility (SNF) care (when SNF care is for the terminal condition).…”