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Original Investigation |

Examining Variation in Hospice Visits by Professional Staff in the Last 2 Days of Life

Joan M. Teno, MD, MS1; Mike Plotzke, PhD2; Thomas Christian, PhD2; Pedro Gozalo, PhD3
[+] Author Affiliations
1Division of Gerontology and Geriatric Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle
2Abt Associates, Cambridge Massachusetts
3Health Services, Policy, and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island
JAMA Intern Med. 2016;176(3):364-370. doi:10.1001/jamainternmed.2015.7479.
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Importance  In the final days of life, symptoms are exacerbated and often families need both education and emotional support from hospice professional staff. The Medicare Hospice Benefit provides a per-diem payment with no requirements on the frequency of patient visits.

Objective  To examine individual characteristics, hospice program, and geographic variation in hospice visits by professional staff during the last 2 days of life.

Design, Setting, and Participants  This retrospective cohort study of 661 557 Medicare hospice beneficiaries included all patients who died in federal fiscal year 2014 (October 1, 2013–September 30, 2014) in hospice services while receiving routine home care in the last 2 days of life. Data analysis was conducted from March 9 to August 25, 2015.

Main Outcomes and Measures  Medicare regulations require that hospice care centers report daily the frequency and duration of patient visits by professional staff, as well as the type of hospice staff who conduct these visits. We examined visit variation by hospice professional staff (physician, nursing staff, and social worker) during the last 2 days of life using a multivariable logistic model adjusting for decedent and hospice program characteristics.

Results  Of the 661 557 patients in the study, 81 478 (12.3%) received no professional staff visits in the last 2 days of life. State variation ranged from 590 of 15 399 patients (3.8%) in Wisconsin to 97 of 492 patients (19.7%) in Alaska, and hospice program interquartile variation ranged from 3.2% (25th percentile) to 19.5% (75th percentile). Black patients were less likely to have any visits than were white patients (7352 of 48 221 [15.2%] vs 70 365 of 585 377 [12.0%]; adjusted odds ratio, 1.30; 95% CI, 1.24-1.37). Those dying in a nursing home were 1.74 times less likely to have any visits than those dying at home (30 880 of 186 649 [16.5%] vs 40 973 of 386 654 [10.6%]; 95% CI, 1.62-1.88). Those dying on a Sunday were 3.35 times less likely to have a visit compared with persons dying on a Tuesday (19 519 of 95 979 [20.3%] vs 6784 of 92 127 [7.4%]; 95% CI, 3.17-3.55).

Conclusions and Relevance  Hospice visits in the last 2 days of life by professional staff vary by race, hospice program, and geographic region of the country. Visits were less likely when the Medicare beneficiary was black, dying on a Sunday, and receiving care in a nursing home.

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Figure 1.
State-Level Variation in Medicare Beneficiaries Not Receiving Visits From Hospice Professional Staff During the Last 2 Days of Life1

Variation between states ranged from those in the lowest quartile, with 9.2% or less, to 10 states that had a rate of greater than 15.0%. The second quartile ranged from 9.3% to 11.4%, while the third quartile was 11.5% to 14.9%. Map drawn by one of us (T.C.) using Stata software (StataCorp).

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Figure 2.
Variation of Visits From Hospice Professional Staff by Days of Week the Patient Died

Visits by professional staff during the last 2 days of life varied based on the day of the week that the patient died. For persons who died on a Tuesday, 7.4% did not have a visit, while 20.3% of those who died on a Sunday did not receive a visit.

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