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Improving the Use of Hospice Services in Nursing Homes
A Randomized Controlled Trial
David Casarett, MD, MA;
Jason Karlawish, MD;
Knashawn Morales, ScD;
Roxane Crowley, BA;
Terre Mirsch, RN, BSN, CHPN;
David A. Asch, MD, MBA
JAMA. 2005;294:211-217.
Context Hospice care may improve the quality of end-of-life care for nursing home residents, but hospice is underutilized by this population, at least in part because physicians are not aware of their patients’ preferences.
Objective To determine whether it is possible to increase hospice utilization and improve the quality of end-of-life care by identifying residents whose goals and preferences are consistent with hospice care.
Design, Setting, and Participants Randomized controlled trial (December 2003-December 2004) of nursing home residents and their surrogate decision makers (N=205) in 3 US nursing homes.
Intervention A structured interview identified residents whose goals for care, treatment preferences, and palliative care needs made them appropriate for hospice care. These residents’ physicians were notified and asked to authorize a hospice informational visit.
Main Outcome Measures The primary outcome measures were (1) hospice enrollment within 30 days of the intervention and (2) families’ ratings of the quality of care for residents who died during the 6-month follow-up period.
Results Of the 205 residents in the study sample, 107 were randomly assigned to receive the intervention, and 98 received usual care. Intervention residents were more likely than usual care residents to enroll in hospice within 30 days (21/107 [20%] vs 1/98 [1%]; P<.001 [Fisher exact test]) and to enroll in hospice during the follow-up period (27/207 [25%] vs 6/98 [6%]; P<.001). Intervention residents had fewer acute care admissions (mean: 0.28 vs 0.49; P = .04 [Wilcoxon rank sum test]) and spent fewer days in an acute care setting (mean: 1.2 vs 3.0; P = .03 [Wilcoxon rank sum test]). Families of intervention residents rated the resident’s care more highly than did families of usual care residents (mean on a scale of 1-5: 4.1 vs 2.5; P = .04 [Wilcoxon rank sum test]).
Conclusion A simple communication intervention can increase rates of hospice referrals and families’ ratings of end-of-life care and may also decrease utilization of acute care resources.
Author Affiliations: Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center, Philadelphia, Pa (Drs Casarett and Asch); the Division of Geriatric Medicine (Drs Casarett and Karlawish), Center for Bioethics (Drs Casarett, Karlawish, and Asch), Leonard Davis Institute of Health Economics (Drs Casarett, Karlawish, and Asch), and the Center for Clinical Epidemiology and Biostatistics (Dr Morales) at the University of Pennsylvania, Philadelphia; Temple University Law School, Philadelphia, Pa (Ms Crowley); and Holy Redeemer Home Health and Hospice Care, Philadelphia, Pa (Ms Mirsch).
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