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The Impact of Reported Hospice Preferred Practices on Hospital Utilization at the End of Life

Aldridge, Melissa D. PhD, MBA; Epstein, Andrew J. PhD; Brody, Abraham A. RN, PhD; Lee, Eric J. MPH; Cherlin, Emily PhD, MSW; Bradley, Elizabeth H. PhD

doi: 10.1097/MLR.0000000000000534
Original Articles

Background: The Affordable Care Act requires hospices to report quality measures across a range of processes and practices. Yet uncertainties exist regarding the impact of hospice preferred practices on patient outcomes.

Objective: Assess the impact of 6 hospice preferred practices and hospice organizational characteristics on hospital utilization and death using the first national data on hospice preferred practices.

Design: Longitudinal cohort study (2008–2011) of Medicare beneficiaries (N=149,814) newly enrolled in a national random sample of hospices (N=577) from the National Hospice Survey (84% response rate) and followed until death.

Outcome Measures: The proportion of patients at each hospice admitted to the hospital, emergency department (ED), and intensive care unit (ICU), and who died in the hospital after hospice enrollment.

Results: Hospices that reported assessing patient preferences for site of death at admission had lower odds of being in the highest quartile for hospital death (AOR=0.36; 95% CI, 0.14–0.93) and ED visits (AOR=0.27; 95% CI, 0.10–0.76). Hospices that reported more frequently monitoring symptoms had lower odds of being in the highest quartile for ICU stays (AOR=0.48; 95% CI, 0.24–0.94). In adjusted analyses, a higher proportion of patients at for-profit compared with nonprofit hospices experienced a hospital admission (15.3% vs. 10.9%, P<0.001), ED visit (21.8% vs. 15.6%, P<0.001), and ICU stay (5.1% vs. 3.0%, P<0.001).

Conclusions: Hospitalization of patients following hospice enrollment varies substantially across hospices. Two of the 6 preferred practices examined were associated with hospitalization rates and for-profit hospices had persistently high hospitalization rates regardless of preferred practice implementation.

*Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York

Geriatrics Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY

Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

§New York University College of Nursing, New York, NY

Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, CT

Supported by the National Institute of Nursing Research 5R01NR013499 (M.D.A.), the National Cancer Institute 1R01CA116398-01A2 (E.B.), and the John D. Thompson Foundation (E.B.).

The results of this study were reported at the AcademyHealth Annual Research Meeting in June as part of a panel, “The Evolution of Medicare’s Hospice Benefit: Implications for Service Use, Quality Measurement, and Payment Reform” and at the American Academy of Hospice and Palliative Medicine’s Annual Research Meeting in February 2015.

The authors declare no conflict of interest.

Reprints: Melissa D. Aldridge, PhD, MBA, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, P.O. Box 1070, New York, NY 10029. E-mail:

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