Increasing Veterans’ Hospice Use: The Veterans Health Administration’s Focus On Improving End-Of-Life Care

Miller, Susan C.; Intrator, Orna; Scott, Winifred; Shreve, Scott; Phibbs, Ciaran S.; Kinosian, Bruce; Allman, Richard M.; Edes, Thomas E.

doi:10.1377/hlthaff.2017.0173

Cited by 37 publications

(28 citation statements)

References 11 publications

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“…8,9 Indeed, Medicare-enrolled veterans are more likely to use hospice than are general Medicare beneficiaries. 24 This VA policy enables the concurrent receipt of hospice care and disease-modifying treatment, and the present study suggests that as hospice use increased, there was an associated increase in the concurrent receipt of radiation therapy and chemotherapy and hospice care. 2 Consistent with our finding of greater concurrent care among veterans in high HEQs, we found that nearly 75% of patients with newly diagnosed stage IV NSCLC received chemo-therapy in the first 6 months after diagnosis or until death, but even in the highest HEQ VAMCs, only 6% of patients received chemotherapy after hospice initiation.…”

Section: Discussionsupporting

confidence: 51%

Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

et al. 2019

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IMPORTANCE Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans’ end-of-life care is unknown. OBJECTIVE To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. DESIGN, SETTING, AND PARTICIPANTS A modified difference-in-difference study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non–small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. EXPOSURES Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. MAIN OUTCOMES AND MEASURES Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis. RESULTS Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67–3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53–0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62–0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, −$358 to −$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. CONCLUSIONS AND RELEVANCE Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.

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Section: Discussionsupporting

confidence: 51%

Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

et al. 2019

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“…While some medical centers established dedicated hospice/palliative care wards in acute care facilities, CLCs became the locus of hospice and palliative care in the majority of VA medical centers. An article recently published by Miller et al (2017) found that male Veterans aged 66 and older had increases in their rates of hospice use within the last year of life following the CELC initiative. Therefore, the findings from these two studies, taken together, suggest that the CELC initiative was successful in increasing the number of Veterans who had access to hospice services.…”

Section: Discussionmentioning

confidence: 99%

Change in VA Community Living Centers 2004–2011: Shifting Long-Term Care to the Community

Thomas

Coté

Makineni

et al. 2018

Journal of Aging & Social Policy

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The United States Department of Veterans Affairs (VA) is facing pressures to rebalance its long-term care system. Using VA administrative data from 2004-2011, we describe changes in the VA's nursing homes (called Community Living Centers [CLCs]) following enactment of directives intended to shift CLCs' focus from providing long-term custodial care to short-term rehabilitative and post-acute care, with safe and timely discharge to the community. However, a concurrent VA hospice and palliative care expansion resulted in an increase in hospice stays, the most notable change in type of stay during this time period. Nevertheless, outcomes for Veterans with non-hospice short and long stays, such as successful discharge to the community, improved. We discuss the implications of our results for simultaneous implementation of two initiatives in VA CLCs.

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“…Our finding that rural residents were less likely than urban residents to die in an inpatient hospice unit is similar to findings on overall hospice use outside of the VA. 4,5,7,8 However, it is important to note that veterans who died while receiving hospice care at home or in non-VA settings-freestanding hospice units, other hospitals, or facilities-were not included in our study. 48 Our study adds to previous research by identifying a similar trend in a clinically diverse population and examining death in an inpatient hospice unit as an indicator across multiple inpatient settings. Comparing odds ratios between rural categories, our findings depart from previous research outside the VA, which found that isolated and remote rural residents were the least likely of all to use the service.…”

Section: Discussionmentioning

confidence: 76%

Does Quality of End‐of‐Life Care Differ by Urban‐Rural Location? A Comparison of Processes and Family Evaluations of Care in the VA

Rosario

Kutney‐Lee

Sochalski

et al. 2019

The Journal of Rural Health

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Purpose Several studies have identified differences in end‐of‐life (EOL) care between urban and rural areas, yet little is known about potential differences in care processes or family evaluations of care. The purpose of this study was to examine the relationship between rurality of residence and quality of EOL care within the Veterans Affairs health care system. Methods This study was a retrospective, cross‐sectional analysis of 126,475 veterans who died from October 2009 through September 2016 in inpatient settings across 151 facilities. Using unadjusted and adjusted logistic regression, we compared quality of EOL care between urban and rural veterans using family evaluations of care and 4 quality of care indicators for receipt of (1) palliative care consult, (2) a chaplain visit, (3) death in an inpatient hospice unit, and (4) bereavement support. Findings Veterans from rural areas had lower odds of dying in an inpatient hospice unit compared to veterans from urban areas, before and after adjustment (large rural OR 0.73, 95% CI: 0.70‐0.77; P < .001, small rural OR 0.81, 95% CI: 0.77‐0.86; P < .001, isolated rural OR 0.87, 95% CI: 0.81‐0.93; P < .001). Differences in comparisons of other quality of care indicators were small and of mixed significance. No significant differences were found in family ratings of care in fully adjusted models. Conclusion Receipt of some EOL quality indicators differed with urban‐rural residence for some comparisons. However, family ratings of care did not. Our findings call for further investigation into unmeasured individual characteristics and facility processes related to rurality.

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Increasing Veterans’ Hospice Use: The Veterans Health Administration’s Focus On Improving End-Of-Life Care

Cited by 37 publications

References 11 publications

Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

Change in VA Community Living Centers 2004–2011: Shifting Long-Term Care to the Community

Does Quality of End‐of‐Life Care Differ by Urban‐Rural Location? A Comparison of Processes and Family Evaluations of Care in the VA

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