Objectives
To model the steps involved in preparing for and carrying out propensity score analyses by providing step‐by‐step guidance and Stata code applied to an empirical dataset.
Study Design
...Guidance, Stata code, and empirical examples are given to illustrate (1) the process of choosing variables to include in the propensity score; (2) balance of propensity score across treatment and comparison groups; (3) balance of covariates across treatment and comparison groups within blocks of the propensity score; (4) choice of matching and weighting strategies; (5) balance of covariates after matching or weighting the sample; and (6) interpretation of treatment effect estimates.
Empirical Application
We use data from the Palliative Care for Cancer Patients (PC4C) study, a multisite observational study of the effect of inpatient palliative care on patient health outcomes and health services use, to illustrate the development and use of a propensity score.
Conclusions
Propensity scores are one useful tool for accounting for observed differences between treated and comparison groups. Careful testing of propensity scores is required before using them to estimate treatment effects.
Health care reform debate in the United States is largely focused on the highly concentrated health care costs among a small proportion of the population and policy proposals to identify and target ...this "high-cost" group. To better understand this population, we conducted an analysis for the Institute of Medicine Committee on Approaching Death using existing national data sets, peer-reviewed literature, and published reports. We estimated that in 2011, among those with the highest costs, only 11% were in their last year of life, and approximately 13% of the $1.6 trillion spent on personal health care costs in the United States was devoted to care of individuals in their last year of life. Public health interventions to reduce health care costs should target those with long-term chronic conditions and functional limitations.
Objectives
To determine whether there is racial variation in hospice enrollees in rates of hospitalization and hospice disenrollment and, if so, whether systematic differences in hospice provider ...patterns explain the variation.
Design
Longitudinal cohort study.
Setting
Hospice.
Participants
Medicare beneficiaries (N = 145,038) enrolled in a national random sample of hospices (N = 577) from the National Hospice Survey and followed until death (2009–10).
Measurements
We used Medicare claims data to identify hospital admissions, emergency department (ED) visits, and hospice disenrollment after hospice enrollment. We used a series of hierarchical models including hospice‐level random effects to compare outcomes of blacks and whites.
Results
In unadjusted models, black hospice enrollees were significantly more likely than white enrollees to be admitted to the hospital (14.9% vs 8.7%, odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.74–1.95), visit the ED (19.8% vs 13.5%, OR = 1.58, 95% CI = 1.50–1.66), and disenroll from hospice (18.1% vs 13.0%, OR = 1.48, 95% CI = 1.40–1.56). These results were largely unchanged after accounting for participant clinical and demographic covariates and hospice‐level random effects. In adjusted models, blacks were at higher risk of hospital admission (OR = 1.75, 95% CI = 1.64–1.86), ED visits (OR = 1.61, 95% CI = 1.52–1.70), and hospice disenrollment (OR = 1.54, 95% CI = 1.45–1.63).
Conclusion
Racial differences in intensity of care at the end of life are not attributable to hospice‐level variation in intensity of care. Differences in patterns of care between black and white hospice enrollees persist within the same hospice.
In 2015 an estimated 2.7 million people in the United States (1 percent of the population) died. Although decedents' illness experience varies substantially, important trends in care at the end of ...life are evident. To identify the most pressing health care policy issues related to end-of-life care, we present a comprehensive picture of the epidemiology and care patterns of people in the last stage of life. We identify three key trends in end-of-life care: increasing diversity in the primary diagnoses of decedents, increases in multimorbidity and illness complexity among people with terminal illnesses, and shifts in patterns of care at the end of life and in sites of death. This changing epidemiology of those in the last phase of life puts new pressures on the Medicare hospice benefit to ensure the availability of high-quality end-of-life care. In addition, health care policy makers must grapple with the fact that even with increasing use of hospice care, care intensity increases at the end of life. We highlight and discuss tensions that must be managed to ensure that high-quality care is accessible for people at the end of life.
Background:
Early integration of palliative care into the management of patients with serious disease has the potential to both improve quality of life of patients and families and reduce healthcare ...costs. Despite these benefits, significant barriers exist in the United States to the early integration of palliative care in the disease trajectory of individuals with serious illness.
Aim:
To provide an overview of the barriers to more widespread palliative care integration in the United States.
Design and data sources:
A literature review using PubMed from 2005 to March 2015 augmented by primary data collected from 405 hospitals included in the Center to Advance Palliative Care’s National Palliative Care Registry for years 2012 and 2013. We use the World Health Organization’s Public Health Strategy for Palliative Care as a framework for analyzing barriers to palliative care integration.
Results:
We identified key barriers to palliative care integration across three World Health Organization domains: (1) education domain: lack of adequate education/training and perception of palliative care as end-of-life care; (2) implementation domain: inadequate size of palliative medicine–trained workforce, challenge of identifying patients appropriate for palliative care referral, and need for culture change across settings; (3) policy domain: fragmented healthcare system, need for greater funding for research, lack of adequate reimbursement for palliative care, and regulatory barriers.
Conclusion:
We describe the key policy and educational opportunities in the United States to address and potentially overcome the barriers to greater integration of palliative care into the healthcare of Americans with serious illness.
Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53-105 days before ...death. Using data from the Health and Retirement Study, 2002-08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53-105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1-7, 8-14, and 15-30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.
Rapid implementation of telehealth has become a hallmark of our healthcare system's response to the COVID‐19 pandemic. Telehealth has demonstrated feasibility and efficacy in the care of older adults ...including vulnerable homebound populations.1, 2
BACKGROUND/OBJECTIVES
Hospice care confers well‐documented benefits to patients and their families, but it is underutilized. One potential reason is inadequate family support to make end‐of‐life ...decisions and care for older adults on hospice at home. We assessed the association between amount of family support and hospice use among a population of decedents and among specific illness types.
DESIGN
Prospective cohort study using the National Health and Aging Trends Study waves 2011 to 2017, linked to Medicare claims data.
SETTING
Contiguous United States.
PARTICIPANTS
A total of 1,868 NHATS decedents.
MEASUREMENTS
Outcome variable was 1 day or longer of hospice. Family caregiving intensity was measured by self‐reported hours of care per week and number of caregivers. Covariates included probable dementia status and other demographic, clinical, and functional characteristics.
RESULTS
At the end of life, hours of family caregiving and numbers of helpers vary widely with individuals with dementia receiving the most hours of unpaid care (mean = 64.5 hours per week) and having 2.4 unpaid caregivers on average. In an adjusted analysis, older adults with cancer receiving 40 hours and more of unpaid care/week as compared with fewer than 6 hours per week were twice as likely to receive hospice care at the end of life (odds ratio = 2.0; 95% confidence interval = 1.0–4.1). This association was not seen among those with dementia or among decedents in general. No significant association was found between number of caregivers and hospice use at the end of life.
CONCLUSION
Older adults at the end of life receive a high number of hours of help at the end of life, many from more than one caregiver, which may shape hospice access. Better understanding of disparities in hospice use can facilitate timely access to care for older adults with a serious illness. J Am Geriatr Soc 68:2288–2296, 2020.
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