Dataset Information

End-of-Life Care Transition Patterns of Medicare Beneficiaries.

ABSTRACT: OBJECTIVES:To characterize the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132). DESIGN:Retrospective study. SETTING:United States. PARTICIPANTS:Medicare beneficiaries aged 66 and older who died from July to December 2011. MEASUREMENTS:Transitions between healthcare settings (e.g., hospital, skilled nursing facility, inpatient hospice, home hospice, home without hospice) in the last 6 months of life. A count variable for number of transitions was summarized, and Sankey diagrams were produced to illustrate the sequences of healthcare transitions. Multivariable analyses were used to identify factors associated with likelihood of having four or more transitions. RESULTS:More than 80% decedents (n = 556,437) had at least one transition within the last 6 months of life; 218,731 had four or more transitions within the last 6 months of life. The most-frequent transition pattern (19.3% of all decedents; n = 127,435) was home to hospital, back to home or skilled nursing facility, to hospital again, and then to settings other than hospital, ending with four or more transitions. The average number of transitions in the last 6 months of life varied substantially across states, ranging from 1.8 in Alaska to 3.1 in New Jersey. Transitions became more intensive for decedents approaching death. In multivariable analyses, women, blacks, individuals younger than 85, and individuals without dementia were more likely to have four or more transitions (all P < .05). CONCLUSION:Approximately one-third of the Medicare beneficiaries who died in 2011 had four or more transitions within their last 6 months of life. Identifying interventions that can facilitate care transitions consistent with beneficiaries' preferences is warranted.

SUBMITTER: Wang SY

PROVIDER: S-EPMC5507734 | biostudies-literature | 2017 Jul

REPOSITORIES: biostudies-literature

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End-of-Life Care Transition Patterns of Medicare Beneficiaries.

Wang Shi-Yi SY Aldridge Melissa D MD Gross Cary P CP Canavan Maureen M Cherlin Emily E Bradley Elizabeth E

Journal of the American Geriatrics Society 20170403 7

<h4>Objectives</h4>To characterize the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132).<h4>Design</h4>Retrospective study.<h4>Setting</h4>United States.<h4>Participants</h4>Medicare beneficiaries aged 66 and older who died from July to December 2011.<h4>Measurements</h4>Transitions between healthcare settings (e.g., hospital, skilled nursing facility, inpatient hospice, home hospice, home without hospic ...[more]

PMID: 28369785

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Project description:ImportanceMedicare beneficiaries with end-stage renal disease (ESRD) are a medically complex group accounting for less than 1% of the Medicare population but more than 7% of Medicare fee-for-service payments.ObjectiveTo evaluate the association of the Comprehensive End-Stage Renal Disease Care (CEC) model with Medicare payments, health care use, and quality of care.Design, setting, and participantsIn this economic evaluation, a difference-in-differences design estimated the change in outcomes for 73 094 Medicare fee-for-service beneficiaries aligned to CEC dialysis facilities between the baseline (from January 2014 to March 2015) and intervention periods (from October 2015 to December 2017) relative to 60 464 beneficiaries at matched dialysis facilities. In the CEC model, dialysis facilities, nephrologists, and other providers partner to form ESRD Seamless Care Organizations (ESCOs), specialty-oriented accountable care organizations that coordinate care for beneficiaries with ESRD. ESCOs with expenditures below a benchmark set by the Centers for Medicare & Medicaid Services are eligible to share in savings if they meet quality thresholds. A total of 685 dialysis facilities affiliated with 37 ESCOs participated in the CEC model as of January 2017. Thirteen ESCOs joined the CEC model on October 1, 2015 (wave 1), and 24 ESCOs joined on January 1, 2017 (wave 2). Patients with ESRD who were aligned with CEC dialysis facilities were compared with patients at matched dialysis facilities.Main outcomes and measuresMedicare total and service-specific payments per beneficiary per month; hospitalizations, readmissions, and emergency department visits; and select quality measures.ResultsRelative to the comparison group (n = 60 464; 55% men; mean [SD] age, 63.5 [14.4] years), total Medicare payments for CEC beneficiaries (n = 73 094; 56% men; mean [SD] age, 63.0 [14.4] years) decreased by $114 in payments per beneficiary per month (95% CI, -$202 to -$26; P = .01), associated primarily with decreases in payments for hospitalizations and readmissions. Payment reductions were offset by shared savings payments to ESCOs, resulting in net losses of $78 in payments per beneficiary per month (95% CI, -$8 to $164; P = .07). Relative to the comparison group, CEC beneficiaries had 5.01 fewer hospitalizations per 1000 beneficiaries per month (95% CI, -8.45 to -1.56; P = .004), as well as fewer catheter placements (CEC beneficiaries with catheter as vascular access for periods longer than 90 days decreased by 0.78 percentage points [95% CI, -1.36 to -0.19; P = .01]) and fewer hospitalizations for ESRD complications (CEC beneficiaries were 0.11 percentage points less likely [95% CI, -0.20 to -0.02; P = .01] to be hospitalized in a given month). Total dialysis sessions and payments increased, suggesting improved adherence to dialysis treatments.Conclusions and relevanceEarly findings from the CEC model demonstrate that a specialty accountable care organization model focused on a particular population was associated with reduced payments and improved quality of care. Future research can assess the longer-term outcomes of the CEC model and its applicability to populations with other complex chronic conditions.

Project description:Importance:Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population. Objective:To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use. Design, Setting, and Participants:This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively. Exposures:Sepsis hospital discharge and 1 or more home health assessments within 1 week. Main Outcomes and Measures:Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use. Results:Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P?<?.001), multiple dependencies of activities of daily living or instrumental activities of daily living (OR, 2.80; 95% CI, 2.57-3.05; P?<?.001), and an overall poor health status (OR, 2.21; 95% CI, 2.01-2.44; P?<?.001) documented on home health assessment. Among the decedents, cancer was associated with hospice use (OR, 2.25; 95% CI, 2.11-2.41; P?<?.001), patients aged 85 years or older (OR, 1.49; 95% CI, 1.37-1.61; P?<?.001), and living in an assisted living setting (OR, 1.93; 95% CI, 1.69-2.19; P?<?.001). Conclusions and Relevance:The findings of this study suggest that death within 1 year after sepsis discharge may be common among Medicare beneficiaries discharged to home health care. Although 1 in 2 decedents used hospice, aggressive care near the end of life and late hospice referral were common. Readily identifiable risk factors suggest opportunities to target efforts to improve palliative and end-of-life care among high-risk sepsis survivors.

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End-of-Life Care Transition Patterns of Medicare Beneficiaries.

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End-of-Life Care Transition Patterns of Medicare Beneficiaries.

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