Work

Factors associated with preventable hospitalizations after hospice live discharge among Medicare patients with Alzheimer's disease and related dementias

Year: 2023

Type: article

Abstract: Patients with Alzheimer's disease and related dementias (ADRD) are at higher risk of live discharge from hospice compared to those without ADRD.1, 2 Live discharge is often followed by burdensome transitions to acute care settings,3 which can be distressing to patients and caregivers.4 Although previous studies have identified risk factors for hospice live discharge,5 little is known about patient outcomes after discharge. As hospices move towards value-based care, improving post-discharge outcomes has important policy and clinical implications. We examined patient and hospice characteristics associated with preventable hospitalizations (PHs) among Medicare beneficiaries with ADRD who were discharged alive from hospice. This retrospective cohort study used Medicare claims data of a 20% random sample of 2014–2019 fee-for-service (FFS) beneficiaries. We assessed patient ADRD status based on principal and secondary diagnoses during a hospice stay and diagnoses in other care settings up to 3 years before hospice admission.6 We used hospice claims files to identify live discharges based on discharge status codes.7 We required patients to have continuous enrollment in Medicare Parts A and B after live discharge until death or the end of the follow-up period (December 31, 2019). We employed the Agency for Healthcare Research and Quality's Prevention Quality Indicators algorithm8 to identify PHs after hospice live discharge (Supplemental Table S1). We calculated rates of patients with at least one PH and by conditions of PHs. We modeled associations between patient and hospice characteristics and time from live discharge to the first PH using a multivariable Cox proportional hazards model. Patient characteristics included demographics (i.e., age, gender, race/ethnicity), number of chronic conditions, dual-enrollment in Medicaid, end-stage renal disease, and advance care planning. Hospice characteristics included early live discharge (within 7 days of hospice admission), late live discharge (on or after 180 days of admission), location of hospice services (e.g., home or nursing home), services provided during hospice stay, hospice ownership, and status of live discharge (e.g., patient revocation or condition stabilization). Patients were censored if they died or reached the end of the follow-up period. The Institutional Review Board at Weill Cornell Medicine approved this study. Among 100,286 ADRD patients who were discharged alive from hospice (65,990 women [65.8%]; mean [SD] age, 84.9 [9.4] years), 9972 (9.9%) had at least one PH after live discharge. The most prevalent condition of PH was heart failure (3.4%), followed by urinary tract infection (3.2%), community acquired pneumonia (2.1%), and chronic obstructive pulmonary disease or asthma (1.5%). PHs for other conditions were relatively rare, including diabetes long-term complications (0.4%), uncontrolled diabetes (0.3%), lower-extremity amputation among patients with diabetes care (0.2%), diabetes short-term complications (0.2%), and hypertension (0.2%). In multivariable Cox regression (Table 1), patient characteristics including minority race/ethnicity (e.g., Black patient, adjusted hazard ratio [aHR], 1.12; 95% confidence interval [CI]: 1.04–1.21), higher number of chronic conditions (e.g., 3–5, aHR, 2.21; 95% CI: 1.83–2.82), end-stage renal disease (aHR, 1.22; 95% CI: 1.01–1.48), discharged due to patient revocation of hospice benefit (aHR, 1.20; 95% CI: 1.14–1.26), and discharged alive within a 7-day hospice stay (aHR, 1.17; 95% CI: 1.08–1.27) were associated with a higher risk of having at least one post-discharge PH. Older age (e.g., 75–84, aHR, 0.84; 95% CI: 0.75–0.95) and receiving hospice care in a facility, such as assisted living (aHR, 0.66; 95% CI: 0.61–0.70) and nursing facility (aHR, 0.44; 95% CI: 0.41–0.47) were associated with a lower risk of having at least one post-discharge PH. Approximately 10% of ADRD patients had at least one PH after hospice live discharge. Racial/ethnic minority patients were at a higher risk of PH after live discharge, potentially due to their limited primary care access.9 Patients discharged alive within 7 days had a higher risk for PH, which may indicate that the patient was not in hospice long enough to identify and address their needs. Finally, patients who received hospice care in facilities had a lower risk for PH. These patients might be more likely to receive care and support after a live discharge compared with those who received hospice care at home. Hospices should coordinate care transitions after live discharge with primary and specialty care providers to maintain care continuity and reduce unnecessary hospitalizations. Although this study is limited by its focus on Medicare FFS population, it provides the first examination, to our knowledge, on PHs among ADRD patients after hospice live discharge. As recent policy changes started to hold hospice providers accountable for post-discharge outcomes,10 these findings will be important to identify patients at high risk for unnecessary hospitalizations after hospice live discharge and improve end-of-life care for ADRD patients. Yongkang Zhang and Elizabeth A. Luth were responsible for the conceptualization and design of this study. Yongkang Zhang contributed to the preparation of the first draft of the manuscript. Yongkang Zhang, Wodan Ling, and Manyao Zhang contributed to the data cleaning, management, and analysis. Veerawat Phongtankuel and Hui Shao contributed to the interpretation of the results. All authors critically reviewed and revised the manuscript. All authors have approved the final version of this manuscript. The authors declare no conflicts of interest. This study was supported by the National Institute on Aging of the National Institutes of Health (grant No. AG064030 to Yongkang Zhang, AG065624 to Elizabeth A. Luth, and AG059997 to Veerawat Phongtankuel) and the Physicians Foundation Center for the Study of Physician Practice and Leadership at Weill Cornell Medical College. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH or the Physicians Foundation. This study was supported by the National Institute on Aging (grant No. AG064030 to Yongkang Zhang, AG065624 to Elizabeth A. Luth, and AG059997 to Veerawat Phongtankuel) and the Physicians Foundation Center for the Study of Physician Practice and Leadership at Weill Cornell Medical College. Supplemental Table S1. Definition of outcomes and key patient and hospice characteristics. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Source: Journal of the American Geriatrics Society

DOI: 10.1111/jgs.18505

Authors: Yongkang Zhang, Elizabeth A. Luth, Veerawat Phongtankuel, Wodan Ling, Manyao Zhang, Hui Shao