NH residents who died in 2006 with advanced dementia and enrolled in hospice concurrent with or post Medicare SNF care received fewer invasive treatments and had a significantly lower likelihood of a hospital death than did comparable residents without hospice care. Additionally, compared to nonhospice decedents, those with hospice post SNF had a significantly lower likelihood of having persistent dyspnea while decedents with hospice concurrent with SNF had a significantly higher
likelihood of having persistent pain. This study is the first to our knowledge to attempt to understand how treatments and outcomes vary for NH residents with advanced dementia who use Medicare SNF care near the end of life, and who do or do not enroll in Medicare hospice. This understanding is particularly important given that nearly half of all NH residents dying with advanced dementia receive Medicare SNF care in the last 90 days of life, and those with Medicare SNF care are less likely to enroll in hospice.2
As in numerous other studies11, 12, 16
we found hospice enrollment was associated with a lower likelihood of dying in a hospital. Unique to this study we found that this association holds even for decedents who received hospice concurrent with SNF. While causality cannot be established from this cross-sectional study, the finding that hospice decedents had an 87% lower likelihood of a hospital death compared to nonhospice decedents lends plausible support to the notion that dual access to Medicare SNF and hospice care may reduce the rates of end-of-life hospitalizations.
For some treatments and for persistent pain and dyspnea, the effect of hospice care differed by the timing of hospice. Decedents with hospice post SNF (but not hospice concurrent with SNF) had a lower likelihood than nonhospice decedents of having persistent dyspnea. This finding is consistent with research by Kiely and colleagues16
showing hospice versus nonhospice residents with advanced dementia and dyspnea had a three times greater likelihood of receiving dyspnea treatment, and with family reports of fewer unmet dyspnea needs with hospice.28
Also, the use of therapy services for residents with hospice concurrent with SNF was more similar to nonhospice decedents than to decedents with hospice post SNF. On one hand, it is possible that the greater use of certain therapy services (i.e., physical and occupational therapy) by decedents with hospice concurrent with SNF reflects a preference for more aggressive care. On the other hand, these therapy services while consistent with the restorative goals of Medicare SNF may not align with the palliative care goals of hospice. More in depth research on the use of therapy services by NH residents with advanced dementia is needed to more fully understand the factors driving this use.
The divergent hospice effects relating to persistent pain are puzzling. Decedents with hospice concurrent with SNF had a greater
likelihood of persistent pain than did nonhospice decedents while no significant difference was found between decedents with hospice post SNF and nonhospice decedents. Previous research has suggested that there is differential pain assessment performed for hospice versus nonhospice residents, resulting in hospice residents having greater pain severity assessed and documented.17, 25
We addressed this assessment bias by only considering the presence of daily pain rather than its severity when constructing our pain measure. 25
However, as a result it is likely that our outcome measure lacked the sensitivity to adequately capture changes that may occur with hospice enrollment. Rather than measuring persistent pain we would have preferred to examine pain management since its measurement is more objective and has been shown to be superior for hospice versus nonhospice NH residents.10
However, we were unable to do so since analgesic drug data were unavailable. These measurement issues provide likely explanations for our inability to find a significant difference in the persistence of pain between decedents with hospice post SNF compared to nonhospice decedents, but they do not adequately address the greater likelihood of persistent pain found among decedents with hospice concurrent with SNF compared to their nonhospice counterparts. As speculated a priori and shown in our descriptive comparisons, decedents with hospice concurrent with SNF are different from those with hospice post SNF. For example, they may have more severe and intractable pain. While we controlled for comorbidities commonly associated with pain (arthritis, fractures, other) it is likely there were unmeasured confounding factors for which we could not control. In relation to this, since Medicare payment policy requires SNF care concurrent with hospice to be unrelated to the terminal condition, it may be that Medicare SNF residents had a qualifying event which triggered referral. One such event may have been a fracture, and we did find that 14% of residents with hospice concurrent with SNF had a principal diagnosis of fracture on their final Medicare SNF claim; this compares with a prevalence of 3% generally on the Medicare SNF claims studied. Finally, it may also be that hospices are less able to affect outcomes when care is concurrent with SNF, given the divergent goals of hospice and Medicare SNF care. To test whether this is the case, a prospective study with primary data collection is needed. Also, such a study would need to control for selection bias (i.e., for differences in hospice/nonhospice residents and between residents receiving hospice concurrent with or post SNF).
This study has other limitations that deserve comment. First, the diagnosis of advanced dementia was determined indirectly using secondary data contained in MDS and Medicare claims. However, using our methodology, our NH dementia prevalence estimates were very similar to those from a Maryland study which used an expert panel and DMS-III-R criteria.2, 22
Also, other resident-level demographic and clinical data were obtained from the MDS, and the possibility of inaccuracies must be considered. Additionally, we are unable to comment on the decision-making around Medicare-SNF and hospice use and on factors associated with referral other than those represented in our secondary data sources. Last, this research had a retrospective cohort design since we examined the care received by persons with advanced dementia who had died in NHs. Important concerns about bias with the use of a retrospective study design have been noted.30
However, by limiting our cohort to NH decedents identified as having advanced dementia (using diagnosis and
CPS score) and by examining care only in the last 90 days of life we have attempted to minimize this bias.
In conclusion, regardless of whether hospice enrollment was concurrent with or post Medicare SNF care, NH decedents with advanced dementia and SNF care in the last 90 days of life received fewer aggressive treatments and had substantially lower odds of a hospital death when they received hospice care compared to when they did not. Also, while we found associations between hospice use and persistent pain and dyspnea differed by the timing of hospice enrollment, our understanding of the hospice effect when hospice was concurrent with SNF care is limited by our study design and data sources. Through the Affordable Care Act’s required Medicare Hospice Concurrent Care demonstration project (which will allow concurrent hospice and other Medicare Part-A care)31
the benefits and costs of Medicare-SNF/hospice concurrent care will be studied. To assure valid comparisons it is essential this research relies on primary data collection for the measurement of pain and other outcomes and controls for potential differences between nonhospice residents and those who receive hospice concurrent with SNF care versus hospice post SNF.