Associations Between Health Literacy and End-of-Life Care Intensity Among Medicare Beneficiaries

2021 ◽  
pp. 104990912098850
Author(s):  
Qingying Luo ◽  
Kewei Shi ◽  
Peiyin Hung ◽  
Shi-Yi Wang
Keyword(s):  
Health Literacy ◽  
End Of Life ◽  
Linear Models ◽  
Hospital Death ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Low Health Literacy ◽  
Multivariable Analyses ◽  
Hospice Use ◽  
Eol Care

Background: Despite well-documented disparities in end-of-life (EOL) care, little is known about whether patients with low health literacy (LHL) received aggressive EOL care. Objective: This study examined the association between health literacy (HL) and EOL care intensity among Medicare beneficiaries. Method: We conducted a retrospective analysis of Medicare fee-for-service decedents who died in July-December, 2011. ZIP-code-level HL scores were estimated from the 2010-2011 Health Literacy Data Map, where a score of 225 or lower was defined as LHL. Aggressive EOL care measures included repeated hospitalizations within the last 30 days of life, no hospice enrollment within the last 6 months of life, in-hospital death, and any of above. Using hierarchical generalized linear models, we examined the association between HL and aggressive EOL care. Results: Of 649,556 decedents, the proportion of decedents who received any aggressive EOL care among those in LHL areas was 82.7%, compared to 72.7% in HHL areas. In multivariable analyses, decedents residing in LHL areas, compared to those in HHL areas, had 31% higher odds of aggressive EOL care (adjusted odds ratio [AOR] 1.31; 95% confidence interval [CI]:1.21-1.42), including higher odds of no hospice use (AOR 1.35; 95% CI: 1.27-1.44), repeated hospitalization (AOR 1.07; 95% CI: 1.01-1.14) and in-hospital death (AOR 1.21; 95% CI: 1.13-1.29). Conclusion: Medicare beneficiaries who resided in LHL areas were likely to receive aggressive EOL care. Tailored efforts to improve HL and facilitate patient-provider communications in LHL areas could reduce EOL care intensity.

scholarly journals Hospice Utilization and Its Effect on Acute Care Needs at the End of Life in Medicare Beneficiaries With Hepatocellular Carcinoma

2017 ◽  
Vol 13 (3) ◽  
pp. e197-e206 ◽  
Author(s):  
Hanna K. Sanoff ◽  
YunKyung Chang ◽  
Melissa Reimers ◽  
Jennifer L. Lund
Keyword(s):  
Hepatocellular Carcinoma ◽  
End Of Life ◽  
Acute Care ◽  
Symptom Burden ◽  
Health Care Use ◽  
Care Utilization ◽  
Hospital Death ◽  
Medicare Beneficiaries ◽  
Care Needs ◽  
Hospice Use

Introduction: Hepatocellular carcinoma (HCC) is a poor-prognosis cancer with a high symptom burden. Multidisciplinary HCC care is complex and unique in cancer medicine. We sought to determine whether the distinct process affects hospice use and how hospice affects end-of-life acute care utilization. Patients and Methods: Patients dying after HCC diagnosed from 2004 to 2011 were identified within SEER-Medicare. Hospice use and associated factors were described using logistic regression. Coarse exact and propensity score matching created groups of hospice and nonhospice comparators balanced on clinical characteristics. Health care use from first hospice claim to death and the matched duration in the nonhospice group were compared. Results: Of 7,992 decedent patients with HCC, 63% used hospice before death, with a median duration of 18 days (interquartile range, 5-51 days). Initial treatment with surgery and ablation (odds ratio [OR], 0.63; 95% CI, 0.53 to 0.74) or chemoembolization/radioembolization (OR, 0.71; 95% CI, 0.62 to 0.80) was associated with decreased odds of subsequent hospice use compared with untreated patients. Hospice use was more likely in those consulting hematology/oncology (OR, 1.33; 95% CI, 1.13 to 1.56) but not in those consulting gastroenterology (OR, 0.79; 95% CI, 0.65 to 0.95). Hospice patients had lower rates of hospitalization (7.9% v 47.8%; risk ratio [RR], 0.16; 95% CI, 0.14 to 0.19), intensive care unit stay (2.8% v 25.3%; RR, 0.11; 95% CI, 0.09 to 0.14), and in-hospital death (3.5% v 58.4%; RR, 0.06; 95% CI, 0.05 to 0.07). Conclusion: Processes of care influence which patients with HCC are referred to hospice. Hospice use has a marked effect on acute care use at the end of life in patients with HCC. Efforts to incorporate cancer-focused palliative care might improve the quality of end-of-life care in HCC.

scholarly journals End-of-life care quality outcomes among Medicare beneficiaries with hematologic malignancies

2020 ◽  
Vol 4 (15) ◽  
pp. 3606-3614
Author(s):  
Pamela C. Egan ◽  
Thomas W. LeBlanc ◽  
Adam J. Olszewski
Keyword(s):  
End Of Life ◽  
Hospital Setting ◽  
Hematologic Malignancies ◽  
Care Quality ◽  
Lower Probability ◽  
Medicare Beneficiaries ◽  
Quality Outcomes ◽  
Adjusted Means ◽  
Hospice Use ◽  
Eol Care

Abstract Patients with hematologic malignancies are thought to receive more aggressive end-of-life (EOL) care and have suboptimal hospice use compared with patients with solid tumors, but descriptions of EOL outcomes from comprehensive cohorts have been lacking. We used the population-based Surveillance, Epidemiology, and End Results–Medicare dataset to describe hospice use and indicators of aggressive EOL care among Medicare beneficiaries who died of hematologic malignancies in 2008-2015. Overall, 56.5% of decedents used hospice services for median 9 days (interquartile range, 3-27), 33.0% died in an acute hospital setting, 36.8% had an intensive care unit (ICU) admission in the last 30 days of life, and 13.3% received chemotherapy within the last 14 days of life. Hospice use was associated with 96% lower probability of inpatient death (adjusted risk ratio [aRR], 0.038; 95% confidence interval [CI], 0.035-0.042), 44% lower probability of an ICU stay in the last 30 days of life (aRR, 0.56; 95% CI, 0.54-0.57), and 62% decrease in chemotherapy use in the last 14 days of life (aRR, 0.38; 95% CI, 0.35-0.41). Hospice enrollees spent on average 41% fewer days as inpatient during the last month of life (adjusted means ratio, 0.59; 95% CI, 0.57-0.60) and had 38% lower mean Medicare spending in the last month of life (adjusted means ratio, 0.62; 95% CI, 0.61-0.64). These associations were consistent across histologic subgroups. In conclusion, EOL care quality outcomes and hospice enrollment were suboptimal among older decedents with hematologic cancers, but hospice use was associated with a consistent decrease in aggressive care at EOL.

scholarly journals Discussions Between People With Dementia and Care Partners About End-of-Life Care Planning

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 162-162
Author(s):  
Megan Shepherd-Banigan ◽  
Cassie Ford ◽  
Emmanuelle Belanger ◽  
Courtney Van Houtven
Keyword(s):  
End Of Life ◽  
Linear Models ◽  
Positive Association ◽  
Living Will ◽  
Amyloid Pet ◽  
Care Planning ◽  
Care Plans ◽  
People With Dementia ◽  
Care Partners ◽  
Eol Care

Abstract Advanced care planning (ACP) leads to better end-of-life (EoL) care. Yet, some care-partners are unaware of the person with dementia’s (PwD) preferences. Care-partners play an important role in urging PwD to consider their EoL care wishes early in their disease course and to document those wishes. However, it is unknown whether discussions between care-partners and PwD are associated with documenting EoL care plans. We apply generalized linear models to baseline data from the CARE-IDEAS study which includes a sample of patients who received an amyloid PET scan and their care-partners (n=1,672). We examine the association between PwD report of having discussed EoL care with their care-partner and PwD report of having documented their plans through an advanced directive, a living will, or designating a health care proxy. PwD who reported speaking with their care-partners about EoL care were 10% (marginal probability (MP) 0.10; 95% CI: 0.8, 0.13) more likely to have documented their EoL care wishes. Furthermore, if PwD and care-partners agreed that they had discussed EoL care, PwD were 7% (MP 0.7; 95% CI 0.04, 0.10) more likely to report that they documented their EoL care plans. The positive association between communicating with care-partners about EoL care and having formal EoL care plans suggests that the ACP process could be a systematic approach to increase the care-partner’s knowledge of PwD EoL wishes. These results also suggest that increasing involvement of care partners in ACP may encourage patients to document their wishes at end of life.

Hospice Use And End-Of-Life Spending Trajectories In Medicare Beneficiaries On Hemodialysis

2018 ◽  
Vol 37 (6) ◽  
pp. 980-987 ◽  
Author(s):  
Ann M. O’Hare ◽  
Susan M. Hailpern ◽  
Melissa Wachterman ◽  
William Kreuter ◽  
Ronit Katz ◽  
...  
Keyword(s):  
End Of Life ◽  
Medicare Beneficiaries ◽  
Hospice Use

scholarly journals Economic Burden of Osteoporosis-Related Fractures in the US Medicare Population

2020 ◽  
pp. 106002802097051 ◽  
Author(s):  
Setareh A. Williams ◽  
Shanette G. Daigle ◽  
Richard Weiss ◽  
Yamei Wang ◽  
Tarun Arora ◽  
...  
Keyword(s):  
Economic Burden ◽  
Linear Models ◽  
Hospice Care ◽  
Skilled Nursing Facility ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
Public Health Burden ◽  
Osteoporosis Related Fracture

Background Osteoporosis-related fractures are an important public health burden. Objective To examine health care costs in Medicare patients with an osteoporosis-related fracture. Methods Medicare fee-for-service members with an osteoporosis-related fracture between January 1, 2010, to September 30, 2014 were included. A nonfracture comparator group was selected by propensity score matching. Generalized linear models using a gamma distribution were used to compare costs between fracture and nonfracture cohorts. Results A total of 885 676 Medicare beneficiaries had fracture(s) and met inclusion criteria. Average age was 80.5 (±8.4) years; 91% were White, and 94% female. Mean all-cause costs were greater in the fracture vs nonfracture cohort ($47 163.25 vs $16 034.61) overall and for men ($52 273.79 vs $17 352.68). The highest mean costs were for skilled nursing facility ($29 216), inpatient costs ($24 190.19), and hospice care ($20 996.83). The highest incremental costs versus the nonfracture cohort were for hip ($71 057.83 vs $16 807.74), spine ($37 543.87 vs $16 860.49), and radius/ulna ($24 505.27 vs $14 673.86). Total medical and pharmacy costs for patients who experienced a second fracture were higher compared with those who did not ($78 137.59 vs $44 467.47). Proportionally more patients in the fracture versus nonfracture cohort died (18% vs 9.3%), with higher death rates among men (20% vs 11%). Conclusion and Relevance The current findings suggest a significant economic burden associated with fractures. Early identification and treatment of patients at high risk for fractures is of paramount importance for secondary prevention and reduced mortality.

End-of-Life Orders, Resource Utilization, and Costs Among Injured Older Adults Requiring Emergency Services

2020 ◽  
Author(s):  
Amber L Lin ◽  
Craig Newgard ◽  
Aaron B Caughey ◽  
Susan Malveau ◽  
Abby Dotson ◽  
...  
Keyword(s):  
Older Adults ◽  
End Of Life ◽  
Resource Utilization ◽  
Emergency Services ◽  
Patient Characteristics ◽  
Vital Statistics ◽  
Fee For Service ◽  
Post Discharge ◽  
Index Event ◽  
Hospice Use

Abstract Background: Portable Orders for Life-Sustaining Treatment (POLST) are increasingly utilized to assist patients approaching the end of life in documenting goals of care. We evaluated the association of POLST, resource utilization, and costs to 1 year among injured older adults requiring emergency services.Methods: This was a retrospective cohort of injured older adults ≥65 years with continuous Medicare fee-for-service coverage transported by emergency medical services (EMS) in 2011 across 4 counties in Oregon. Data sources included EMS, Medicare claims, vital statistics, and state POLST, inpatient and trauma registries. Outcomes included hospital admission, receipt of aggressive medical interventions, costs, and hospice use. We matched patients on patient characteristics and comorbidities to control for bias.Results: We included 2116 patients of which 484 (22.9%) had a POLST form prior to 911 contact. Of POLST patients, 136 (28.1%) had orders for full treatment, 194 (40.1%) for limited interventions, and 154 (31.8%) for comfort measures. There were no significant associations for care during the index event. However, in the year after the index event, patients with care limitations had higher adjusted hospice use (limited interventions OR 1.7 [95% CI: 1.2–2.6]; comfort OR, 2.0 [95% CI: 1.3–3.0]) and lower adjusted post-discharge costs (no POLST, $32,399 [95% CI: 30,041–34,756]; limited interventions, $18,729 [95% CI: 12,913–24,545]; and comfort $15,593 [95% CI: 12,091–19,095]). There were no significant associations for all other outcomes.Conclusions: Care limitations specified in POLST forms among injured older adults transported by EMS are associated with increased use of hospice and decreased costs to 1 year.

Trends in health care utilization, cost, and aggressive care at end of life among older cancer patients in the Deep South.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 155-155
Author(s):  
Elizabeth Ann Kvale ◽  
Gabrielle Rocque ◽  
Kerri S. Bevis ◽  
Aras Acemgil ◽  
Richard A. Taylor ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Utilization ◽  
End Of Life ◽  
Healthcare Utilization ◽  
Linear Models ◽  
Care Utilization ◽  
Deep South ◽  
Medicare Beneficiaries ◽  
Aggressive Care ◽  
The Impact

155 Background: Healthcare utilization and costs escalate near diagnosis and in the final months of life. There is a national trend toward aggressive care at end of life (EOL). We examined patterns in utilization and cost across the trajectory of care and during the last two weeks of life during implementation of a lay navigation intervention. Methods: Claims data were obtained for Medicare beneficiaries ≥ 65 years old with cancer in the UAB Health System Cancer Community Network (UAB CCN). For 10 quarters from January 2012 -June 2014, we examined healthcare utilization for the population at large, navigated patients, and decedents. All analyses included ER visits, hospitalizations, and ICU admissions and use of chemotherapy in the last 2 weeks of life, and hospice utilization (admission or less than 3 days of hospice) in the quarter of death for decedents. Descriptive analyses and linear regression were used to test trends over time; general linear models evaluated changes in health care utilization and cost. Results: Across the population reduction of 13.4% to 11% for hospitalization (18% decrease, p < 0.01), 8.0% to 7.1% for ER visits (12% decrease, p < 0.01), 2.9% to 2.5% for ICU admissions (14% decrease, p = 0.04) and an increase of 3.9% to 4.3% for hospice (9.2% increase p = 0.37) were found. Among 5,861 decedents, in the last 2 weeks of life, there were decreases in ICU admissions (14.6% decrease, p = 0.11), from 39.2% to 32.0%, ER visits (18.4% decrease, p = 0.03), and chemotherapy, from 4.7% to 3.5% (25.5% decrease, p = 0.11).Over the 10 quarters, hospice enrollment increased from 70.7% to 77.4% (9.48% increase; p = 0.06), and the proportion of patients on hospice for less than 3 days changed from 7.8% to 7.5% (3.85% decrease, p = 0.30). Costs decreased about $158 per quarter per beneficiary. A significant pre-post decrease of $952 per beneficiary (p < 0.01) led to an estimated reduction in Medicare costs of $18,406,920 for the 19,335 beneficiaries in the UAB CCN for the five quarters post-implementation. Conclusions: We observed decreased healthcare utilization and cost and trends toward decreased aggressive care at EOL in the UAB CCN. Further work is needed to determine the impact of navigation on utilization trends.

Use of hospice services among Medicare beneficiaries with acute and chronic leukemias.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 68-68
Author(s):  
Thomas William LeBlanc ◽  
Adam J. Olszewski
Keyword(s):  
Quality Measures ◽  
Hematologic Malignancies ◽  
Time Of Death ◽  
Medicare Beneficiaries ◽  
Annual Percent Change ◽  
Percent Change ◽  
Binomial Regression ◽  
Hospice Use ◽  
Eol Care ◽  
Over Time

68 Background: Studies show lower rates of hospice use among patients (pts) with hematologic malignancies. Our objective was to describe trends in hospice use and in quality measures for end-of-life (EOL) care among Medicare beneficiaries with leukemias. Methods: From the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we selected pts with acute (myeloid or lymphoblastic) or chronic (lymphocytic, myeloid, or myelomonocytic) leukemias diagnosed in 1996-2011 who died in 2001-2011. We identified hospice enrollment at death, duration of hospice enrollment, inpatient deaths, intensive care unit (ICU) admissions within 30 days of death, and chemotherapy use in the last 14 days of life. We summarized linearized trends by year of death using log-binomial regression, reporting average annual percent change (APC). Results: Among 38,038 leukemia pts (41% acute, median age 78 years) 81% died, after median 2.8 months from diagnosis (95%CI, 2.7-2.9) for acute and 49.1 months (95%CI, 47.9-50.1) for chronic leukemias. Among pts who died in 2001-2011 ( N= 23,941), 42% were enrolled in hospice at the time of death. This proportion significantly increased between 2001 and 2011, from 33% to 48% (APC +4.1%, P< .001), both for acute and chronic leukemias ( Pinteraction= .25). Median time on hospice was 8 days, and the proportion of pts with < 3 days on hospice increased from 20% to 24% between 2001 and 2001 (APC +1.2%, P= .05). Inpatient deaths significantly decreased from 54% to 39%, respectively (APC -3.2%, P< .001), but ICU use at EOL increased from 34% to 41% (APC +2.4%, P< .001). Chemotherapy use at EOL was more frequent in acute (17%) than chronic (6%) leukemia, and decreased for both (overall from 15% to 10%, APC -3.2%, P< .001). Conclusions: The use of hospice services among older pts with leukemia has increased, suggesting its wider acceptance over time. However, the increasing proportion of brief, terminal hospice admissions, and increasing rate of ICU use at EOL reflect persistent barriers to early enrollment in this population. Some measures of aggressiveness of care (inpatient deaths, chemotherapy at EOL) are lower in the community than previously reported from academic centers (El-Jawahri, Cancer 2015).

Aggressive care at end-of-life in the Veteran’s Health Administration versus fee-for-service Medicare among patients with advanced lung cancer.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. 12025-12025
Author(s):  
Carolyn J Presley ◽  
Kiranveer Kaur ◽  
Ling Han ◽  
Pamela R. Soulos ◽  
Weiwei Zhu ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Hospice Care ◽  
Regional Level ◽  
Advanced Lung Cancer ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Health Administration ◽  
Veteran's Health Administration ◽  
Aggressive Care ◽  
Hospice Use

12025 Background: The Veteran’s Health Administration (VHA) allows simultaneous receipt of cancer treatment and hospice care, termed concurrent care, while fee-for-service Medicare does not. Although many physicians who care for patients in the VHA also care for private sector patients, it is unclear whether there is a “spillover” relation between end of life (EOL) care in the VHA and Medicare systems at the regional level. We examined temporal trends, as well as regional-level associations between Medicare and VHA EOL practice for patients with advanced lung cancer. Methods: We conducted a retrospective study on VHA and SEER-Medicare (SM) decedents from 2006-2012 with stage IV non-small cell lung cancer (NSCLC) who received any lung cancer care. Aggressive care (AC) at EOL was defined as any of the following within 30 days of death– intensive care unit (ICU) admission, no-hospice care, cardiopulmonary resuscitation(CPR), mechanical ventilation (MV), > 1 inpatient admission and receipt of chemotherapy. Descriptive statistics were used to compare outcomes. We also analyzed the association between Medicare hospital referral region (HRR) hospice admissions, Medicare HRR EOL spending, and VHA AC use adjusted for patient’s characteristics using a random intercept mixed effect logistic regression model after matching VHA facilities with Medicare facilities in a particular HRR. Results: AC use significantly decreased during the study period, from 46% to 31% among 18,371 Veterans and from 42% to 38% among 25,283 in the SM cohort, (t-test P < .05). Hospice use significantly increased within both cohorts (p < .001). The receipt of chemotherapy at EOL was similar for both cohorts throughout the study period. Veterans who received care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive AC at EOL (adjusted Odds Ratio (aOR): 0.13 95%CI: 0.08-0.23, P < .001) than veterans in regions with lower Medicare hospice use. Medicare HRR spending at the EOL was not associated with receipt of AC among Medicare beneficiaries (aOR): 1.004 95%CI: 1.00-1.009, P = 0.07). Conclusions: Perhaps due to availability of concurrent care, VHA patients received less aggressive care at EOL as compared to SM patients. At the regional level, greater hospice use among Medicare beneficiaries was significantly associated with reduced AC within the VHA.

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