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Background Hospitals across the United States are pursuing strategies to reduce avoidable readmissions but the evidence on how best to accomplish this goal is mixed, with no specific clinical practice shown to reduce readmissions consistently. Changes to hospital organizational practices, a key component of context, also may be critical to improving performance on readmissions, but this has not been studied. Objective The aim of this study was to understand how high-performing hospitals improved risk-stratified readmission rates, and whether their changes to clinical practices and organizational practices differed from low-performing hospitals. Design This was a qualitative study of 10 hospitals in which readmission rates had decreased (n=7) or increased (n=3). Participants A total of 82 hospital staff drawn from hospitals that had participated in the State Action on Avoidable Readmissions quality improvement initiative. Results High-performing hospitals were distinguished by several organizational practices that facilitated readmissions reduction, that is, collective habits of action or interpretation shared by organization members. First, high-performing hospitals reported focused efforts to improve collaboration across hospital departments. Second, they helped postacute providers improve care by sharing the hospital's clinical and quality improvement expertise and data. Third, high performers enthusiastically engaged in trial and error learning to reduce readmissions. Fourth, they emphasized that readmissions represented bad outcomes for patients, de-emphasizing the role of financial penalties. Both high-performing and low-performing hospitals had implemented most clinical practice changes commonly recommended to reduce readmissions. Conclusions Our findings highlight several organizational practices that hospitals may be able to use to enhance the effectiveness of their readmissions reduction efforts.

Hospice use has increased substantially during the past decade by an increasingly diverse patient population; however, little is known about patterns of hospice use and how these patterns have changed during the past decade.To characterize Medicare hospice users in 2000 and 2010 and estimate the prevalence of (1) very short (≤1 wk) hospice enrollment; (2) very long (6 mo) hospice enrollment; and (3) hospice disenrollment and how these utilization patterns have varied over time and by patient and hospice characteristics.Cross-sectional analysis of Medicare hospice claims data from 2000 and 2010.All US Medicare Hospice Benefit enrollees in 2000 (N=529,573) and 2010 (N=1,150,194).As of 2010, more than half (53.4%) of all Medicare decedents who used hospice had either very short (≤1 wk, 32.4%) or very long (6 mo, 13.9%) hospice enrollment or disenrolled from hospice before death (10.6%). This represents an increase of 4.9 percentage points from 2000. In multivariable analysis, patients with noncancer diagnoses, the fastest growing group of hospice users, were approximately twice as likely as those with cancer to have very short or long enrollment periods and to disenroll from hospice.The substantial proportion of hospice users with very short or long enrollment, or enrollments that end before death, underscores the potential for interventions to improve the timing and appropriateness of hospice referral so that the full benefits of hospice are received by patients and families.

Objectives To examine rates of hospice disenrollment and posthospice hospitalization among patients who are enrolled in hospices that provide continuous home care (CHC) (CHC hospices) compared with patients who are enrolled in hospices that do not offer CHC (non-CHC hospices). Methods We performed a retrospective cohort study among Medicare fee-for-service decedents between July and December 2011, who were 66 years and older and had used hospice in their last 6 months of life. We used propensity score matching to account for potential confounding characteristics of hospices. Generalized estimating equation models were applied to estimate between CHC hospices and non-CHC hospices the associations of hospice disenrollment/hospitalization, adjusted for patient characteristics. We also conducted subgroup analyses to examine how the association might have differed by hospice size, and by the percentage of enrollees who received CHC. Results After matching, we identified 936 pairs of CHC and non-CHC hospices, well balanced in terms of organizational characteristics. In fully adjusted models, compared with non-CHC hospices, CHC hospices had significantly lower disenrollment rates (adjusted rate ratio, 0.73; 95% confidence interval, 0.60-0.87), and lower hospitalization rates (adjusted rate ratio, 0.79; 95% confidence interval, 0.66-0.95). These associations were significantly more pronounced among larger hospices (those with >175 enrollees during study period), and among hospices in which at least 7.3% of enrollees used CHC. Conclusions CHC hospices had significantly lower rates of hospice disenrollment and posthospice hospitalization, suggesting CHC service available may enable higher quality of end-of-life care.

Reducing readmissions is a national priority, but many hospitals lack practical tools to identify patients at increased risk of unplanned readmission.To estimate the association between a composite measure of patient condition at discharge, the Rothman Index (RI), and unplanned readmission within 30 days of discharge.Adult medical and surgical patients in a major teaching hospital in 2011.The RI is a composite measure updated regularly from the electronic medical record based on changes in vital signs, nursing assessments, Braden score, cardiac rhythms, and laboratory test results. We developed 4 categories of RI and tested its association with readmission within 30 days, using logistic regression, adjusted for patient age, sex, insurance status, service assignment (medical or surgical), and primary discharge diagnosis.Sixteen percent of the sample patients (N=2730) had an unplanned readmission within 30 days of discharge. The risk of readmission for a patient in the highest risk category (RI70) was1 in 5 while the risk of readmission for patients in the lowest risk category was about 1 in 10. In multivariable analysis, patients with an RI70 (the highest risk category) or 70-79 (medium risk category) had 2.65 (95% confidence interval, 1.72-4.07) and 2.40 (95% confidence interval, 1.57-3.67) times higher odds of unplanned readmission, respectively, compared with patients in the lowest risk category.Clinicians can use the RI to help target hospital programs and supports to patients at highest risk of readmission.

The Affordable Care Act requires hospices to report quality measures across a range of processes and practices. Yet uncertainties exist regarding the impact of hospice preferred practices on patient outcomes.Assess the impact of 6 hospice preferred practices and hospice organizational characteristics on hospital utilization and death using the first national data on hospice preferred practices.Longitudinal cohort study (2008-2011) of Medicare beneficiaries (N=149,814) newly enrolled in a national random sample of hospices (N=577) from the National Hospice Survey (84% response rate) and followed until death.The proportion of patients at each hospice admitted to the hospital, emergency department (ED), and intensive care unit (ICU), and who died in the hospital after hospice enrollment.Hospices that reported assessing patient preferences for site of death at admission had lower odds of being in the highest quartile for hospital death (AOR=0.36; 95% CI, 0.14-0.93) and ED visits (AOR=0.27; 95% CI, 0.10-0.76). Hospices that reported more frequently monitoring symptoms had lower odds of being in the highest quartile for ICU stays (AOR=0.48; 95% CI, 0.24-0.94). In adjusted analyses, a higher proportion of patients at for-profit compared with nonprofit hospices experienced a hospital admission (15.3% vs. 10.9%, P0.001), ED visit (21.8% vs. 15.6%, P0.001), and ICU stay (5.1% vs. 3.0%, P0.001).Hospitalization of patients following hospice enrollment varies substantially across hospices. Two of the 6 preferred practices examined were associated with hospitalization rates and for-profit hospices had persistently high hospitalization rates regardless of preferred practice implementation.

Despite increased hospice use over the last decade, end-of-life care intensity continues to increase. To understand this puzzle, we sought to examine regional variation in intensive end-of-life care and determine its associations with hospice use patterns.Using Medicare claims for decedents aged 66 years and above in 2011, we assessed end-of-life care intensity in the last 6 months of life across hospital referral regions (HRRs) as measured by proportion of decedents per HRR experiencing hospitalization, emergency department use, intensive care unit (ICU) admission, and number of days spent in hospital (hospital-days) and ICU (ICU-days). Using hierarchical generalized linear models and adjusting for patient characteristics, we examined whether these measures were associated with overall hospice use, very short (≤7 d), medium (8-179 d), or very long (≥180 d) hospice enrollment, focusing on very short stay.End-of-life care intensity and hospice use patterns varied substantially across HRRs. Regional-level end-of-life care intensity was positively correlated with very short hospice enrollment. Comparing HRRs in the highest versus the lowest quintiles of intensity in end-of-life care, regions with more intensive care had higher rates of very short hospice enrollment, with adjusted odds ratios (AOR) 1.14 [99% confidence interval (CI), 1.04-1.25] for hospitalization; AOR, 1.23 (CI, 1.12-1.36) for emergency department use; AOR, 1.25 (CI, 1.14-1.38) for ICU admission; AOR, 1.10 (CI, 1.00-1.21) for hospital-days; and AOR, 1.20 (CI, 1.08-1.32) for ICU-days.At the regional level, increased end-of-life care intensity was consistently associated with very short hospice use.

One of the fundamental guiding principles of hospice is that the patient and family is the unit of care,1 reflecting the critical importance of including surviving family in the care of people with terminal illnesses. Consistent with this principle, services for family members, both before and following the patient’s death, are recognized as core components of high quality palliative care.2 This holistic model of caring for grieving family members dates back to the historical roots of the hospice movement in the United Kingdom, and was adopted by American hospices.3,4 Medicare, the primary payer of hospice care in the U.S., defines bereavement counseling as emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss and adjustment.5 Centers for Medicare & Medicaid Services (CMS) (2010) specifically require hospices to provide an initial and ongoing bereavement assessment of the needs of the patient’s family members and these assessments must be incorporated into the plan of care (§418.54(c)(7)). In addition, hospices must have an organized program established to provide bereavement services to family members for up to a year following the patient’s death (§418.64(d)).6 Evidence indicates that supportive services for grieving families can improve their post-loss adjustment,7,8,9 particularly if provided soon after a loss7 and to those at risk for prolonged or complicated grief.10,11,12,13,8 Despite the importance of serving families, we know little about the scope and intensity of hospice services provided to family members. Although Medicare certified hospice programs are required to provide support to bereaved family members, services are not separately billable, and the specific services provided are left to the discretion of the hospice. Because Medicare reimbursement is not tied to the level or quality of services provided to family members, limited financial incentives exist to provide more than a minimal level of care. One prior study by Carlson (2007) examined caregiver support services provided by hospices and found that although 59% of hospices provided personal care services, only 13% provided homemaker/household services and 7% provided respite care.14 A second study conducted with California hospices found substantial variation in the types of bereavement services provided.15 However, both of these studies focus on only a subset of family services and used data from more than a decade ago. Thus, we have limited information on the degree to which hospices provide care to families and how hospices may differ in their provision of family services. Accordingly, we conducted a national survey of hospices to better understand the scope and intensity of services provided to family members. We examined whether family services differed by hospice ownership status or by other organizational characteristics including: hospice chain affiliation, vertical integration with non-hospice health care facilities, age, region of the country, urbanicity, size (i.e., patients per day), patient-to-staff ratio, religious affiliation, concern about losing market share to competitors, and proportion of revenue from Medicare. We hypothesized that non-profit hospices would provide a richer array of services compared with for-profit hospices given the strong historical commitment to family-based care as hospice first emerged (under almost exclusively not-for-profit auspices) in the 1970s. Prior research indicated that hospice ownership affects length of stay, patient diagnosis, and other important outcomes,16,17,18 but no information is currently available on how ownership affects the scope of care provided to family members. In addition to the research on ownership, prior research has indicated that hospice organizational capacity including size, chain affiliation, years providing hospice care, nd share of revenue from Medicare are associated with hospice enrollment and disenrollment practices.19,20,21 Thus, we hypothesized that the organizational capacity of the hospice might be associated with available resources for providing services to family members. To test these hypotheses, we examined whether larger hospices, chain hospices, vertically integrated hospices, hospices with lower patient-to-staff ratios, older hospices and hospices in urban areas were more likely to provide comprehensive services to family member. Alternatively, financial constraints might prompt some hospices to provide a minimum level of bereavement care. Those with a smaller share of revenue from Medicare may provide fewer services to family members, in an effort to conserve scarce resources. In addition, we expected that religiously affiliated hospices might be predisposed toward providing more comprehensive bereavement services for families due to their greater emphasis on spirituality in the face of death. In prior work, researchers have speculated that religious affiliation might be associated with quality of care differences.22 Finally, we hypothesized that hospices reporting a concern about losing market share would provide more services to families. Findings from this study may be important to highlight key gaps in family services.

The number of for-profit hospices increased nearly 4-fold over the past decade, more than 6 times the growth of nonprofit hospices. Despite this growth, the impact of ownership on hospice care is largely unknown. We sought to assess differences in the provision of services to patients of for-profit and nonprofit hospices.Using the 1998 National Home and Hospice Care Survey, we examined services used by patients (N = 2080) cared for by 422 hospices nationwide. We used multivariable ordered logistic and logistic regression to assess the effect of profit status on service use, adjusting for potentially confounding patient and organizational characteristics. We calculated point estimates adjusted for sampling weights and standard errors adjusted for the clustering of patients within hospices.In ordered logistic models controlling for organizational and patient factors, patients of for-profit hospices received a significantly narrower range of services (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.22-0.92) than patients of nonprofit hospices. This result is driven by patients of for-profit hospices receiving significantly fewer types of hospice services that federal regulations term "noncore" or more discretionary services (adjusted OR, 0.34; 95% CI, 0.15-0.75).The pattern of care differs in for-profit and nonprofit hospices. As the industry develops a substantial for-profit presence, it is critical for clinicians and other healthcare professionals to be alert to the potential impact of profit status on the care their patients receive.

The National Quality Forum (NQF) identified hospice services as a national priority area for health care quality improvement and endorsed a set of preferred practices for quality palliative and hospice care. This study reports the first national data regarding hospices' self-reported implementation of the NQF preferred practices and identifies hospice characteristics associated with more comprehensive implementation.We conducted a national cross-sectional survey of a random sample of hospices (n=591; response rate, 84%) from September 2008 to November 2009. We evaluated the reported implementation of NQF preferred practices in the care of both patients and families.The range of reported implementation of individual NQF preferred practices among hospices was 45% to 97%. Twenty-one percent of hospices reported having implemented all patient-centered preferred practices, 26% all family-centered preferred practices, and 10% all patient and family-centered preferred practices. In adjusted analyses, large hospices (100 or more patients per day) were significantly more likely than small hospices (20 patients per day) to report having implemented all patient-centered preferred practices [odds ratio (OR)=2.46; 95% CI, 1.24, 4.90] and all family-centered preferred practices (OR=1.88; 95% CI, 1.02, 3.45). Similarly, chain-affiliated hospices were significantly more likely than free-standing hospices to report having implemented all patient-centered preferred practices (OR=2.45; 95% CI, 1.23, 4.87) and all family-centered preferred practices (OR=1.85; 95% CI, 1.01, 3.41).Hospices' reported implementation of individual preferred practices for palliative and hospice care quality was high; however, reported comprehensive implementation of preferred practices was rare and may be difficult to achieve for small, free-standing hospices.

Background: Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited. Objective: We sought to identify quality improvement efforts that were associated with hospitals' beta-blocker prescription rates after acute myocardial infarction (AMI). Research Design: This was a cross-sectional study using data from a telephone survey of quality management directors at participating hospitals linked with patient-level data from the National Registry of Myocardial Infarction (NRMI) during the study period, October 1997 to September 1999. Subjects: A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included. Measures: Hospital performance based on beta-blocker rates characterized as the top 20%, lower 20%, and middle 40% of hospitals; reported quality improvement efforts, including system interventions, physician leadership, administrative support for quality improvement efforts, and data feedback; hospital teaching status, AMI volume, geographic location, and ownership type. Results: The mean hospital-specific beta-blocker rate was 60.2%; however, the variation in beta-blocker use across hospitals was marked (range, 19.4–89.3%, standard deviation, 12.7% points), and quality improvement efforts used varied greatly. None of the quality improvement efforts distinguished higher from medium performers; the higher and the medium performers together were distinguished from the lower performers in organizational support for quality improvement efforts (fully adjusted odds ratio [OR] 1.89, 95% confidence interval [CI] 1.17–3.06) and physician leadership (fully adjusted OR 9.88, 95% CI 2.64–37.02). Among the specific quality improvement interventions, only standing orders were associated with having higher/medium versus lower performance, and their effect had borderline significance (fully adjusted OR 2.26, 95% CI 0.97–5.30, P = 0.07). Conclusions: Our findings highlight the organizational environment, specifically the absence of administrative support or physician leadership for quality improvement, as an important correlate of poor beta-blocker rates after AMI. Future studies are needed to isolate hospital quality improvement efforts that are associated with superior performance.

Background: National surveys indicate improvement in beta-blocker use after acute myocardial infarction (AMI) over time; however, these data could obscure important variation in improvement at individual hospitals. Our objective was to characterize the hospital-level variation in the improvements in beta-blocker prescription rates after AMI and to identify hospital characteristics that were associated with hospital improvement rates after adjustment for patient demographic and clinical characteristics. Methods and Results: We used data (n = 335,244 patients with AMI discharged from 682 hospitals) from the National Registry of Myocardial Infarction (NRMI) and from the American Hospital Association Annual Survey of Hospitals and hierarchical modeling to examine the associations between hospital characteristics and hospital-level rates of change in beta-blocker use during 1996-1999. On average, hospital rates of beta-blocker use for patients with AMI increased 5.9 percentage points (standard deviation, 9.7 percentage points) from the premidpoint time period (April 1996-February 1998) to the postmidpoint time period (March 1998-September 1999) of the study. The range in hospital-level changes in beta-blocker rates was substantial, from a decline of - 50.0 percentage points to an increase of +35.7 percentage points. AMI volume and teaching status, geographic region, and initial beta-blocker use rates were associated with rate of improvement, but the magnitude of these effects was modest. Conclusions: The study reveals marked hospital-level variation in improvement in beta-blocker use after AMI. Several hospital characteristics were associated with this improvement, but they are weak predictors of hospital-based improvement in the use of beta-blockers.