Abstract
Wachterman MW, Marcantonio ER, Davis RB, McCarthy EP: Association of hospice agency profit status with patient diagnosis, location of care, and length of stay. JAMA 2011;305:472–479.
Throughout the existence of the Medicare Hospice Benefit, there have been arguments that either for-profit or nonprofit status provided better care, and that for-profit and nonprofit hospices may respond differently to underlying financial incentives. That said, Medicare's per diem payment structure may create financial incentives to select patients who require less resource-intensive care and have longer hospice stays. In this study, the authors attempted to compare patient diagnosis and location of care between for-profit and nonprofit hospices and examine whether number of visits per day and length of stay vary by diagnosis and profit status. Cross-sectional study of 4705 nationally represented patients discharged from hospice using data from the 2007 National Home and Hospice Care Survey were utilized. The main outcome measures of this study were diagnosis and location of care (home, nursing home, hospital, residential hospice, or other) by hospice profit status, as well as hospice length of stay and number of visits per day by various hospice personnel. Results demonstrated that for-profit hospices (1087 discharges from 145 agencies), compared with nonprofit hospices (3618 discharges from 524 agencies), had a lower proportion of patients with cancer (34.1%; 95% confidence interval [CI], 29.9%–38.6%, vs. 48.4%; 95% CI, 45.0%–51.8%) and a higher proportion of patients with dementia (17.2%; 95% CI, 14.1%–20.8%, vs. 8.4%; 95% CI, 6.6%–10.6%) and other noncancer diagnoses (48.7%; 95% CI, 43.2%–54.1%, vs. 43.2%; 95% CI, 40.0%–46.5%; adjusted p < 0.001). After the authors adjusted for demographic, clinical, and agency characteristics, there was no significant difference in location of care by profit status. For-profit hospices compared with nonprofit hospices had a significantly longer length of stay (median, 20 days; interquartile range [IQR], 6–88, vs. 16 days; IQR, 5–52 days; adjusted p = 0.01) and were more likely to have patients with stays longer than 365 days (6.9%; 95% CI, 5.0%–9.4%, vs. 2.8%; 95% CI, 2.0%–4.0%) and less likely to have patients with stays of fewer than 7 days (28.1%; 95% CI, 23.9%–32.7%, vs. 34.3%; 95% CI, 31.3%–37.3%; p = 0.005). Compared with cancer patients, those with dementia or other diagnoses had fewer visits per day from nurses (0.50 visits; IQR, 0.32–0.87, vs. 0.37 visits; IQR, 0.20–0.78, and 0.41 visits; IQR, 0.26–0.79, respectively; adjusted p = 0.002) and social workers (0.15 visits; IQR, 0.07–0.31, vs. 0.11 visits; IQR, 0.04–0.27, and 0.14 visits; IQR, 0.07–0.31, respectively; adjusted p < 0.001). The authors conclude that compared with nonprofit hospice agencies, for-profit hospice agencies had a higher percentage of patients with diagnoses associated with lower-skilled needs and longer lengths of stay. That said, there are several limitations of the study as noted by the authors. First, National Home and Hospice Care Survey includes only patients who were discharged from hospice and therefore underestimates length of stay because patients with longer lengths of stay have a lower likelihood of having been discharged and are therefore underrepresented in the sample. Nonetheless, the authors found that for-profit hospices weremore likely than nonprofit hospices to have prolonged lengths of stay (i.e., >1 year). Second, the authors lacked data on important agency characteristics beyond metropolitan statistical area and chain status, such as the hospices' geographic location, which may explain the observed differences in racial composition. The authors acknowledged that they also do not knowwhether hospices were part of a larger system of care, which could facilitate coordination of and transitions in care and thus increase hospice lengths of stay. Third, the authors lacked data on costs and revenue, and therefore, did not demonstrate that differences in the diagnostic composition of hospices resulted in lower costs or greater revenue. Fourth, diagnosis is an imperfect measure of disease severity. Fifth, and perhaps most importantly, the authors were unable to assess the relationship between profit status and quality of care. Although this studyimproves on previous research by assessing the number of visits per day by various hospice personnel, the authors lacked important information on the length of each visit and care provided. Finally, the authors noted that clinicians caring for patients considering hospice can be reassured that for-profit hospices appear to provide as many nursing visits and more homehealth aide visits (although fewer social work visits) than nonprofit hospices.
Kim DY, Song HS, Ahn JS, Ryoo BY, Shin DB, Yim CY, Kim SY: The dosing frequency of sustained-release opioidsand the prevalence of end-of-dose failure in cancer pain control: A Korean multicenter study. Support Care Cancer 2011;19: 297–301.
End-of-dose failure is commonly observed as therapeutic levels of sustained-release opioids decline. To determine the dosing frequency of sustained-release opioids (morphine, oxycodone, and transdermal fentanyl) and the prevalence of end-of-dose failure in clinical practice, a patient-reported survey was performed. A multicenter survey was conducted in 56hospitals in South Korea between June and November 2008. One-thousand ninety-seven cancer outpatients who were prescribed oral sustained-release opioids (morphine or oxycodone) or transdermal fentanyl were enrolled in the study. Results demonstrated that of the oral sustained-release opioid patients, 67.0% took oral sustained-release opioids twice daily, whereas 26.2% took them more than twice daily. Of the transdermal fentanyl patients, 88.8% wore the patch for 72 hours. Of the enrolled patients, 48.3% experienced worsening pain just before the next sustained-release opioid dose, and 36.8% of these patients took medication earlier than the prescribed dosing schedule. Patients felt that oral sustained-release opioids gave adequate pain control lasting an average of 9.6 hours, versus an average of 62.9 hours fortransdermal fentanyl. The authors conclude that their survey demonstrated that sustained-releaseopioids are used by patients in a manner that is inconsistent with standard recommendations. End-of-dose failure is suggested to explain increased dosing frequency, and patientsreported that adequate pain relief lasted for less time than was stated in the manufacturers' prescription recommendation.
Abdo AS, Basu A, Geraci SA: Managing chronic heart failure patient in chronic kidneydisease. Am J Med 2011;124:26–28.
Management of systolic heart failure can be particularly challenging in patients with chronic kidney disease, especially in patients who are not yet receiving hemodialysis. Moreover, few clinical trials have been performed in this particular population, so management is directed by evidence from studies of patients with limited or no renal impairment. Their heightened risk for many treatment complications mandates additional considerations regarding drug selection, dosing, and monitoring. Subspecialty consultation is driven by patient instability or disease progression, intolerance of standard treatment, or need for device placement. This article provides a brief review of the use of angiotensive-coverting enzyme inhibitors and angiotensin receptor-blockers, beta blockers, aldosterone receptors antagonists, digoxin, volume management, potassium management, and subspecialty consultation.
Curtis JR, Nielsen EL, Treece PD, Downey L, Dotolo D, Shannon SE, Back AL, Rubenfeld GD, Engelberg RA: Effect of a quality-improvement interventionon end-of-life care in the intensive care unit. A randomized trial. Am J Respir Crit Care Med 2011;183:348–355.
As noted by the authors, the intensive care unit (ICU) is a common setting for death, with conversations frequently held to discuss withholding or withdrawing life-sustaining therapy at the end-of-life.
In this study, the authors evaluated the effectiveness of a quality-improvement intervention to improve ICU end-of-life care. They conducted a cluster-randomized trial randomizing 12hospitals. The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports. Outcomes were assessed for patients dying in the ICU or within 30 hours of ICUdischarge using surveys and medical record review. Families completed Quality of Dying and Death (QODD) and satisfaction surveys. Nurses also completed the QODD. Data were collected during baseline and follow-up at each hospital (May 2004 to February 2008). The authors used robust regression models to test for intervention effects, controlling for site, patient, family, and nurse characteristics. Results demonstrated that all hospitals completed the trial with2318 eligible patients and target sample sizes obtained for family and nurse surveys. The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a nonsignificant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change intime from admission to withdrawal (hazard ratio = 1.0; P = 0.81). The authors conclude that this intervention was associated with no improvement in quality of dying and no change in ICU length of stay before death or time from ICU admission to withdrawal of life-sustainingmeasures. Improving ICU end-of-life care will require interventions with more direct contact with patients and families.