Recent research findings are increasingly getting to the root causes of varying hospice outcomes among diverse patient populations and health care settings.

Quality inequities among special needs, dually-eligible beneficiaries

Dually-eligible Medicare and Medicaid beneficiaries may have a lower likelihood of receiving care from high-quality hospice providers, according to a recent analysis.

Dual eligible beneficiaries are covered under Medicare Advantage special needs plans that cover patients with serious and chronic conditions such as dementia, HIV/AIDS, diabetes, or those who require long-term, facility-level care.

These beneficiaries were found to be significantly more likely to use lower-quality hospices compared to others, according to recent research findings from the University of Pennsylvania’s (UPenn) Leonard Davis Institute of Health Economics. Racial, ethnic and lower socioeconomic groups are overrepresented in special needs plans and tend to have poorer outcomes, the researchers indicated.

“The disparities may result from the geographic availability of high-quality hospices or the referrals that beneficiaries receive from their plans’ contracted hospitals and nursing homes,” the researchers wrote in the study. “The results support incentivizing referrals to high-quality hospices and improving consumer information about hospice quality. Consumers need better information on hospice quality.”

Researchers analyzed quality assessment using nine measures from hospice reports. The analysis spanned claims data for Medicare fee-for-service decedents through quality scores from the Hospice Item Set (HIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. The analysis included claims and enrollment data of more than 2.2 million decedents from January 2018 through December 2019, and hospice quality data from November 2020 through August 2022.

Dually-eligible and special needs decedents had an increased probability of receiving hospice services from providers with lower quality HIS scores and greater likelihood of low family satisfaction, the research found. Systematic changes are needed to improve outcomes, including greater and more transparent education for patients and families about their end-of-life care options, they stated.

Disparities in hospice quality can exacerbate existing inequities for beneficiaries enrolled in special needs Medicare Advantage plans, the researchers indicated.

Quality reporting requirements may be a contributing factor, according to the researchers.

“Quality ratings are reported at the level of insurance contracts and may include a mix of high- and low-quality plans,” the researchers wrote. “Reporting at the plan level would encourage all Medicare Advantage plans to improve care quality, including special needs plans.”

Low hospice utilization among advanced cancer patients

Patients with advanced cancer have lower hospice utilization rates compared to others.

This is according to a recent study that included 33,744 Medicare fee-for-service advanced cancer decedents 66 and older between 2014 and 2019, published in the Journal of American Medical Association (JAMA) Network. Patient populations included those diagnosed with distant-stage breast, prostate, pancreatic or lung cancers.

Nearly half (45%) of the decedents experienced a claims-based indicator of potentially aggressive end-of-life treatment, the study found, which was led by the American Cancer Society. This trend was driven by an increase in acute care and low receipt of supportive services such as hospice and palliative care or advanced care planning near death.

“This study found persistent patterns of potentially aggressive care, but low uptake of supportive care, among Medicare decedents with advanced cancer,” the study authors stated. “A multifaceted approach targeting patient-, physician- and system-level factors associated with potentially aggressive care is imperative for improving quality of care at the end of life. Considerable efforts have been dedicated to improving the quality of end-of-life care among patients with advanced cancer in the past decade. Whether the quality has shifted in response to these efforts remains unknown.”

Advanced cancer patients were found to have a higher number of multiple acute care visits within one-to-six months prior to death, the study found. Additionally, these patients experienced more in-hospital mortalities, late hospice entry or late receipt of systematic therapies such as hospice, palliative care and advance care planning services, the findings indicated.

Only one-quarter of patients with advanced cancer received palliative care during the last six months of life, the study found.

The findings suggest that greater educational efforts are needed to improve access to high quality hospice and palliative care, according to the study’s senior author Dr. Robin Yabroff, scientific vice president of health services research at the American Cancer Society.

“This research highlights the need for interventions to improve quality of care for patients with advanced cancers, especially those helping to remove barriers to better access palliative care,” Yabroff said in a press release. “It also suggests the importance of clear, proactive communication between providers and patients and their families regarding advanced care planning to better guide end-of-life care efforts. Even though clinicians and professional health care organizations have recommended early integration of supportive and palliative care for all patients with advanced cancers, it remains underused.”

4 keys to improving care among Native Hawaiians

Recent research has unveiled some strategies to improve culturally competent end-of-life care delivery among Native Hawaiian elders, or kūpuna.

End-of-life care preferences kūpuna center around four key themes, according to a study from the University of Hawaiʻi (UH) at Mānoa’s Hā Kūpuna. The themes include cultural perspectives on death, integration of traditional healing practices, family-centered decision-making and home-based care preferences, the study found.

Researchers from UH and ALU LIKE Inc. collaborated on the project, which was recently published in the Journal of Palliative Medicine. Culture has a direct impact on health care decisions and end-of-life preferences among Native Hawaiian elders, according to researcher UH Assistant Professor Miquela Ibrao.

“Death is not an end but a transition that honors relationality, ancestors and the land,” Ibrao told the National Indigenous Times. “Decolonizing end-of-life care means respecting cultural beliefs and embracing Indigenous wisdom about healing and living well.”

Hā Kūpuna is one of three National Resource Centres for Native Elders supported by the U.S. Administration on Ageing and operates within the Thompson School of Social Work & Public Health. Fueling the research was a drive to learn more about the health care preferences among Native Hawaiian seniors and identify cultural themes impacting quality at the end of life.

Much of the data that exists around care preferences is gathered in medical settings where Native Hawaiian elders are less likely to complete formalized documentation compared to others, the researchers indicated.

The study examined the outcomes and goals of 20 participants 60 and older living in rural Hawai‘i. Themes specifically found to align with Native Hawaiian participants’ centered on the criticality of incorporating cultural traditions into health care delivery, involving family in health and end-of-life decisions, supporting home-based care and building strong patient-provider relationships.

Understanding how kūpuna view the dying process is crucial, researchers indicated. These elders view death as a transition that acknowledges relationships with ancestors and the land. Insight into traditional healing practices that integrate herbal medicine and massage are also essential components of end-of-life care delivery for this population, the study found.

Communicating how hospice services can help alleviate caregiver burden and stress can go a long way toward improved end-of-life outcomes among Native Hawaiian seniors, the research found. Many kūpuna expressed a wish to age and die at home, but fear burdening their families amid sparse resources for care in rural areas.

The concept of “Ohana,” which means family, plays a central role in health care choices among kūpuna, as deceased ancestors and the “āina” (or land) are seen as sources of guidance and healing.