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Hospice care may lower end-of-life hospitalizations
Study looks thoroughly at all factors
Hospice care has a strong impact on reducing end-of-life hospitalization rates among nursing home residents, according to a recent study that examined a variety of factors that could affect hospitalization rates in this population.
The study provides solid data for hospice directors to use when promoting hospice care in nursing homes, suggests Susan C. Miller, PhD, an associate professor of community health (research) at Brown Medical School in Providence, RI. Miller was a co-author of the study, which was published in Health Services Research.
"I've talked with people before about studies that weren't as sophisticated as this one, and they sometimes take the information to a meeting with nursing home administrators, using it to talk about the benefits of hospice care," Miller says. "Hospice care improves the quality of a patient's end of life, so it's an issue that most nursing home administrators want to know about."
The study looked specifically at the last month of life for nursing home residents in five states, including Kansas, Maine, New York, Ohio, and South Dakota.
"It was a convenience sample of states because they had nursing home minimum data set information for residents, and we looked at those who died between 1995 and 1997," Miller explains.
"Then we combined the resident assessments with nursing home information, the claim information for Medicare, and hospitalization information," she adds.
Often, hospitalizations among nursing home patients are more about the facility's policy, a state's policy, and other factors that are not necessarily related to a specific patient, Miller notes.
For example, some studies have shown that when there are more hospital beds in a particular market, then there are more hospitalizations, Miller explains.
"So we tried to control for all confounding factors so we could really isolate the hospice effect," Miller says. "So, we have found a causal effect."
Investigators also looked for selection bias, meaning they adjusted the study to account for people who were in hospice care because they chose to be in hospice care, and were less likely to desire being hospitalized in the first place, she adds.
"And there are different kinds of nursing homes, with some sending residents to the hospital more than others," Miller says.
"What we found is there is some bias if you don't have the sophisticated adjustment that we used," Miller says.
Adjusting for selection bias, the study found that significantly fewer nursing home residents who received hospice care had been hospitalized when compared with similar residents who did not receive hospice care.
While 44 percent of residents who received no hospice services had been hospitalized in their last 30 days of life, only 26 percent of residents who received hospice care had been hospitalized in their last month of life.1
"The estimate is conservative because we included anyone who had hospice care — whether it was one day or 30 days," Miller adds.
Some of the factors that impacted whether or not a nursing home resident received hospice care were these, Miller says:
Researchers also concluded that the increased availability of palliative care management services used by hospice was preventing end-of-life hospitalizations.
The biggest challenge for hospices will be to convince Medicare to get rid of the biggest barrier to hospice enrollment among nursing home residents, which is the skilled nursing benefit, Miller says.
Nursing home patients who are enrolled in skilled nursing care cannot simultaneously enroll in hospice care, Miller says.
"You can't be in hospice care for care of the same condition as the skilled nursing benefit, and that's a huge barrier to hospice care," Miller says.
But it's also a shortsighted policy on Medicare's part because if hospice care can reduce hospitalization rates, then allowing hospice enrollment among these patients will save, not cost, more money, she adds.
"There are a lot of people who can never get into hospice if they want to remain on the Medicare Part A benefit," Miller says.
For example, a patient who is dying of lung disease and is receiving care in the nursing home under the skilled nursing benefit would have to pay privately for the nursing home care if he or she wanted to be enrolled in hospice care, Miller explains.
"There are financial disincentives to enrolling patients in hospice care, and maybe this subject should be revisited [by policymakers] because it looks like hospice has a powerful effect and can reduce hospitalizations," Miller says.
There is too little incentive for nursing homes to change the way they classify these patients because their budgets are so tight that the skilled nursing benefit is needed, she adds.
[Editor's note: For more information on nursing home-hospice collaborations, visit this Web site: www.nhpco.org/nursinghomes.]
1. Gozalo PL, Miller SC. Hospice enrollment and evaluation of its causal effect on hospitalization of dying nursing home patients. Health Serv Res. 2007;42:587-610. online at: www.hret.org/hret/publications/volume42/issuetwo.html.
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