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Making the Rounds

Hospice Referrals for Advanced Dementia Patients Increase

02/14/2018

Referrals MTR Vol 9

The rate of hospice referrals for hospitalized patients with advanced dementia transferred from nursing homes increased over the past decade, particularly among those whose attending physician was a hospitalist rather than a non-hospitalist generalist or specialist, according to a report published in the Journal of the American Geriatrics Society.

“The increased likelihood of hospice referral for admissions where hospitalists are the attending physician is encouraging, given the growing role of hospitalists in the care of hospitalized older adults,” write the authors. “This ... has implications for how hospice referrals for high-risk patients might be increased.”

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Benefits of Hospice for Dementia Patients

Research has shown that patients with advanced cognitive impairment, many of whom reside in nursing homes, derive significant benefits from enrollment in hospice, the authors point out.  Patient and family benefits include:

  • Fewer unmet needs compared with advanced dementia patients not in hospice
  • Fewer hospitalizations and other burdensome transitions 
  • Improved symptom management 
  • Greater family satisfaction and higher ratings for the quality of end-of-life care their loved ones received 

“Despite the benefits of hospice care, there is significant variation in who is enrolled in hospice that is not driven by patient preferences for care,” the authors write. They add that while patient and system characteristics contribute to the occurrence of hospice enrollment, physician characteristic have been shown to be a major predictor. 

“This work contributes an additional example of the role of the physician and the health system in determining the care that patients receive at the end of life,” the report says.  Investigators analyzed hospice referral patterns in a 20% sample of Medicare nursing home residents with advanced dementia and four or more impairments in activities of daily living who were hospitalized between 2000 and 2010 (n = 128,989). Rates of hospice referral of patients within one day post-discharge were compared among three groups of attending physicians: general practitioners, specialists and hospitalists.

Overall Findings

  • The rate of hospice referral among hospitalized advanced dementia patients increased from 2.8% in 2000 to 11.2% in 2010.
  • 10.6% of patients died while hospitalized; the mortality rate in the year post-hospitalization was 66.6%.
  • Over time, all three physician groups had increasing hospice referral rates, from 2.7%, 2.6% and 3.6% in 2000 to 9.9%, 10.2% and 13.8% in 2010 for generalists, specialists and hospitalists, respectively.

Key Role of Hospitalists

  • Hospitalists were more likely than generalist physicians to refer patients to hospice at discharge (adjusted odds ratio [AOR] 1.27; 95% confidence interval [CI] 1.20–1.40) in bivariate analysis.
  • Adjustment for the increasing prevalence of hospitalist utilization by facilities over time revealed an even stronger likelihood of hospice referral for patients cared for by hospitalists (OR 1.75; 95% CI 1.50–1.86). 
  • Continuity of care from outpatient setting to hospital (i.e., having cared for the patient within 120 days prior to admission) was linked to lower likelihood of hospice referral (AOR 0.78; 95% CI 0.73–0.85). 

“It is interesting that generalists with continuity were less likely to refer persons to hospice, indicating that the presence of fresh eyes might be important to re-evaluate a patient’s clinical course,” note the authors. 

Suggested Reasons for Higher Rate of Hospitalist Referrals: 

  • Hospitalists probably care for greater numbers of seriously ill inpatients than do generalists, and may thus have become more comfortable discussing advance care planning and suggesting hospice. 
  • A lack of care continuity with patients may reduce hospitalists’ fears of inducing patient-perceived abandonment and may also improve prognostication. 
  • Hospitalists may be practicing in health systems in which they have greater exposure to palliative care teams, or in systems that encourage hospice referral as a means of reducing readmissions and inpatient deaths. 
  • Due to the relative newness of the hospitalist specialty, these physicians are likely to have benefited in their medical training from the increased emphasis on education in palliative medicine in recent years. 

Hospitalist care is also associated with shorter length of hospital stays and other quality outcomes, making it a good target for improving rates of hospice referral, the authors note. 

“Understanding the increasingly common hospitalist role as well as hospital-level factors associated with hospitalist utilizations is necessary to understand how we might ensure that the hospice benefit is available for all patients and families who might benefit,” they write. 

“Efforts to increase generalist and specialist education around palliative care and collaboration with palliative specialists could mimic some of this exposure and training that hospitalists have,” suggest the authors. In the clinical setting, “interventions such as electronic medical record triggers or triggered palliative care consults could provide this benefit regardless of attending type.” 

Source: “Association of Physician Specialty with Hospice Referral for Hospitalized Nursing Home Patients with Advanced Dementia,” Journal of the American Geriatrics Society; August 2017; 65(8):1784-1788. Ankuda CK, Mitchell SL, Teno JM et al; Robert Wood Johnson Clinical Scholars Program, University of Michigan, Ann Arbor; Hebrew Senior Life, Institute for Aging Research, Boston; and Division of Gerontology and Geriatric Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle.