How Effective are Hospices in Spreading the Science of Palliative Care?

 Medicare-certified hospices are the principal organizational model delivering palliative care to those with life-limiting illnesses.  A close look at NHPCO's Annual Facts and Figures (2020 version recently published) reveals much about the hospice industry and the spread of the science of palliative care.

The industry continues to be subscale, hindering the development of clinical proficiency. For example, more than half of US hospices admit fewer than 2 patients per week (same as five years earlier). See here for previous blog post arguing the case that proficiency in health care is related to volume. Furthermore, more than 25% of hospices have been newly certified in the last few years, another important consideration in the development of proficiency. One might argue that the number of people utilizing the hospice benefit to receive palliative care has been growing (in 2018, more than 50% of Medicare decedents received palliative care through a certified hospice), thus justifying a greater number of hospices in the country, but the % growth in the number of hospices in the US exceeds the growth in the number of Americans utilizing the Medicare hospice benefit.  I suggest  that the large variations in late-life care will continue until the hospice industry gains in scale. (read here for more on clinical variations in late-life care).

On a more promising note from the 2020 NHPCO report, the  percentage of short-stay patients (those receiving palliative care through the hospice benefit for seven days or less) dropped to 27.9%, from 35% five years ago.  So an issue (timely use of hospice benefit) some thought intractable 10 years ago (read here) may be gradually improving.

As always, your insights and feedback are invited.

Improving Late-Life Care - Do We Know Exemplary Performance?

We're starting to learn more about late-life care, thanks in large measure to the Dartmouth Atlas Project.


For example, in a recent report  Trends and Variation in End-of-Life Care for Medicare Beneficiaries
with Severe Chronic Illness (read here),  we learned more about the final 30 days of life of a patient with cancer. More than half (54.7%) were hospitalized during that period. 5.6% received life-sustaining procedures. Half of the final month was spent in hospice (11 days) and an acute-care hospital bed (4 days). Interesting, but without context. Likely, the past 10 years has seen considerable improvement in these measures. How much more improvement should we expect? Can hospitalizations be cut in half? If so, what might be the most effective methods? A transitional care document , like POLST? A provider reimbursement structure where collaboration, rather than procedures, is more highly valued? A community palliative care officer who's accountable  for late-life care across settings within a specific community or region? Any of these, or all of them?

And how much better can the health care system do to encourage earlier referral to palliative services, so that greater than 11 days out of the final 30 can be spent under hospice care?  As always, your ideas and opinions are invited.

Variations in Late-Life Care Persist - What Can Be Done? And By Whom?

A recent blog post commented on the enormous clinical variation in late-life care. Another blog post remarked on the difficulty of "spreading the science of palliative care" because of the fragmented system delivering palliative care. And this week The Dartmouth Atlas Project  issued a study - "Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness" - which further documented the enormous clinical variations across the nation as late-life (final six months) care is provided. The differences among communities is staggering, and these variations persist. For example, in 2007, chronically-ill patients in Manhattan spent, on average, 20.6 days in the hospital during their last six months of life, almost four times more than patients in Ogden, UT, where the average was 5.2 days. Chronically ill patients in Fort Lauderdale were half as likely to die in a hospital than similar patients in and around New York City. Is there a question as to which region's late-life care practices better comply with patient and family preferences?
The report documents trends from 2003 to 2007 in the use of medical resources to treat Medicare patients at the end of life at hospital referral regions and at 94 academic medical centers. The study found that Medicare patients diagnosed with severe chronic illness were less likely to die in a hospital and more likely to receive hospice care. They also had many more visits from physicians, particularly medical specialists, and spent more days in ICUs. The overall picture, one could say, is mixed; although patients experienced fewer hospital days and more hospice care, at the same time therre was an increase in the intensity of care for patients who were hospitalized.

"In addition to its effects on patients' quality of life, unnecessarily aggressive care carries a high
financial cost. About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease," said David C. Goodman, MD, lead author of the report, in a media release. Elliott S. Fisher, MD, report author and co-principal investigator of the Dartmouth Atlas Project, perhaps put it best, "While current trends demonstrate that change is occurring in many regions and at many institutions, it is not always in the direction that patients may prefer." Dr. Fisher went on to say more work needs to be done "to ensure that future variation in care reflects the well-informed preferences of patients."

Chronically ill patients were significantly more likely to be treated by 10 or more doctors in the last six months of life in 2007 than they were in 2003. Visiting such a number of physicians certainly must place a premium on effective care transitions. Is our current system well structured to enable effective and coordinated patient transitions?

Future posts on this blog will take a closer look at the findings of this Dartmouth study, and examine those regions, and academic medical centers, that may offer promising approaches. In other words, we'll identify exemplars.

We need to be better at disseminating the science and art of palliative care to reduce these clinical variations. But how to do that, and who should be leading the effort? Should we take a closer look at a national campaign to improve late-life care, like the 30/30/30 Campaign described in a previous post on this blog. Your thoughts are invited.

30/30/30 Campaign to Improve Late-Life Care

A Palliative Care Summit was recently convened in Philadelphia by the School of Population Health at Thomas Jefferson University. It was described as the “First National” and the “Leading Forum on Palliative and End-of-Life Care”.


An impressive array of speakers over the two days. Diane Meier,MD, Sean Morrison, MD, Don Schumacher, David Wennberg, MD, Christine Richie, MD, Terri Maxwell, PhD,APRN, James Cleary, MD.,Todd Hultman,PhD,APRN to name but a few. A roster of thought leaders in the field. Compelling cases were made during the presentations on why hospice and palliative care (is/are?) the solution to many of the health care industry’s woes. Meanwhile, just next door, other industry thought leaders were offering compelling cases on why “medical homes” or ‘expanded chronic care models” or “mobile technology” were desirable solutions for transformation of the health care system.

In other words, competing, or one might say, conflicting visions. These competing/conflicting visions exist across specialties, and within them. Dr. Morrison addressed this issue when he stated that the public and professionals are confused by references to hospice and palliative care , as if these were two distinct fields or sectors.

While my training is as a health executive, I’ve spent much of my professional career advancing the work of palliative care/hospice professionals and organizations. So I pay closer attention to the hospice/palliative care field, and how it may best fit into the larger health care system. And as Dr. Morrison stated directly, and others commented more indirectly, while progress has been made over the past 15 years, the institutional culture of dying in the US has not dramatically changed. I refer to palliative care as one parts accomplishment for every three parts of potential. Yes, we have a long way to go, indeed.

At the end of the Summit, I was left with a nagging question: If hospice and palliative care are such an obvious solution, then why hasn’t the “art” and “science” of hospice and palliative care spread more quickly and widely than it has? No simple answers to be sure. Yes, many of the speakers offered calls (some powerful) to action. Yet calls for action have been sounded for the past 15 years, with some, but most would argue, insufficient progress. Why? The promise of palliative care to improve late-life care has been stymied by a highly fragmented field of hospice and palliative care where stakeholders are perpetually “staking” out their ground.

Some suggestions for the Second National Palliative Care Summit. Let’s have discussions around:

• How nursing AND medicine can best collaborate to improve access to palliative care in all settings across the community.

• What NEW organizational models might best bring together key stakeholders in late-life care within a community?

• What can be learned from communities whose late-life care practices make them exemplars?

Finally, we need a unifying campaign to improve late-life care in the US. Here’s a suggestion. The 30/30/30 Campaign. A national campaign carried out locally/regionally.

Something like the following:

• No more than 30% of deaths occur in hospitals.
• At least 30% of deaths in hospital are consulted by palliative care specialists.
• No more than 30% of patients who die will be enrolled in hospice for 10 days or less.

Your comments, ideas, feedback are, as usual, invited.

Staggering Gaps in Late-Life Care Makes News

A recent post on this blog (read here) commented on the Dartmouth Atlas Project findings of variation in late-life care for advanced cancer patients. While the findings of variation are  not surprising to those who have been following the Project's studies over the past two decades, what did  leave me open-mouthed was the  enormity of these variations. In some communities, more than 70% of patients with advanced cancer did NOT receive hospice care, staggering even when one considers that nationally 45% did not receive hospice care. If hospice care is not provided to nearly half of patients with advanced cancer, what must those figures be for patients with other advanced illnesses for which prognostication is more difficult. Conversely, in some communities, more than 70% of  patients with advanced cancer DID receive hospice care.

I'm encouraged, nonetheless, by the widespread attention given to this study, in both national and regional publications. It's almost as if these study findings have sounded an alert, one that says WE CAN DO BETTER. Much better.

The Los Angeles Times commented  that "the study found that patients in Minneapolis were four times less likely than those in Los Angeles to receive aggressive life-sustaining treatment during their last weeks on earth."  The article went on to bluntly say "In other words, unless people strongly assert their preferences, their end-of-life care will largely be determined by the prevailing customs of their communities."

An article in the Chicago Tribune commented, "the gap was even greater for frail, seriously ill cancer patients who received CPR, mechanical ventilation and feeding tubes — interventions deemed of little value as the end of life approaches. Some 16 percent of these patients got these therapies in Chicago, compared with 9 percent across the U.S."  More from the Tribune, "that analysis reveals some stark differences among Illinois hospitals. Notably, for Evanston Hospital, Glenbrook Hospital and Highland Park Hospital — all part of NorthShore University HealthSystem — only 19 percent of Medicare patients with advanced cancer died in the hospital, compared with 38 percent at Northwestern Memorial Hospital."

The Milwaukee Journal-Sentinel headline read bluntly that late-life care "needs improving".  It offered the following example of variations within the state: "At Columbia St. Mary's two hospitals in Milwaukee, which have since been consolidated, 11.2% of patients with advanced cancer died in the hospital. At St. Mary's Hospital in Madison, it was 16%. In contrast, an average of 37.3% of patients with advanced cancer at Wheaton Franciscan Healthcare-St. Joseph Campus died in the hospital, although this may be because the hospital has an area designed for patients near the end of life who want to be in a residential setting." Perhaps.

Not all of the local news reports focused on laggards. The St. Petersburg Times found that study results in that community were generally better than national averages. And the Globe Gazette (Iowa) highlighted  the exemplary performance of Mason City, Iowa in most indicators.

Future posts will take closer looks at communities and hospitals with exemplary performance in an effort to answer the question:  How Did they Do That? In the meantime, I invite your thoughts.

Can Hospice and Palliative Care Escape the R Word?

The question Why are Referrals to Hospice Slowing? seems to be making the rounds these days.
Misconceptions about hospice and palliative care have abounded well before the latest efforts to refrom the health care system. How else to explain the persistent and continuing reticence to refer to, and accept hospice services, in most US communities. What's different today is that the skeptics of hospice and palliative medicine are more vitriolic than their predecessors, and their talking points (arguments) are more vivid - "death panels, socialized medicine".
I served as the chief executive of a hospice affiliated with a highly-regarded academic health center in the 90s, and the reasons then were abundant for the low referral rate to hospice: patients were referred to academic health centers because they wanted to avail themselves of the most sophisticated medical care for cure; the attending physicians were providing palliative care; the patients' religious/cultural beliefs made them unready for hospice, etc. We've all heard them before, and we still hear these reasons now.
It's just that now, in the context of health reform, palliative care, for some, is considered 'rationing."
And it gains credence because there is so much money in late-life care.