Hospice Characteristics and the Disenrollment of Patients with Cancer

Authors

  • Melissa D. A. Carlson,

    1. Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1070, New York, NY 10029,
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    • Address correspondence to Melissa D.A. Carlson, Ph.D., Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1070, New York, NY 10029; e-mail: Melissa.Carlson@mssm.edu. Jeph Herrin, Ph.D., is with the Department of Medicine, Yale University School of Medicine, New Haven, CT. Qingling Du, M.S., and R. Sean Morrison, M.D., are with the Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York. Andrew J. Epstein, Ph.D., Emily Cherlin, M.S.W., and Elizabeth H. Bradely, Ph.D., are with the Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT. R. Sean Morrison, M.D., is with the Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY.

  • Jeph Herrin,

    1. Department of Medicine, Yale University School of Medicine, New Haven, CT,
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  • Qingling Du,

    1. Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York,
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  • Andrew J. Epstein,

    1. Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT,
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  • Emily Cherlin,

    1. Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT,
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  • R. Sean Morrison,

    1. Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York,
    2. Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY.
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  • Elizabeth H. Bradley

    1. Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT,
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Abstract

Objective. To characterize the types of hospices with higher rates of patient disenrollment from the Medicare Hospice Benefit and the markets in which these hospices operate.

Data Source. Secondary analyses of Surveillance, Epidemiology and End Results-Medicare data. Analyses included patients who died of cancer from 1998 to 2002 and who used hospice (n=90,826).

Study Design. We used generalized estimating equations to estimate the association of patient disenrollment with hospice size, years since Medicare certification, ownership, staff mix, competition, urban/rural status, region, and fiscal intermediary. Other covariates included patient demographic and clinical characteristics.

Principal Findings. Patients were more likely to disenroll from hospice if they were served by newer hospices (OR=1.14; 95 percent CI 1.03, 1.26), by smaller hospices (OR=1.11; 95 percent CI 1.02, 1.20), or by hospices in more competitive markets (OR=1.17; 95 percent CI 1.03, 1.35). There was an independent effect of the hospice's fiscal intermediary on disenrollment, particularly disenrollment after 6 months with hospice (Wald χ2=21.2, p=.007).

Conclusions. The reasons for higher disenrollment rates for newer hospices, for smaller hospices, and for hospices in highly competitive markets are likely complex; however, results suggest that there are organizational-level barriers to keeping patients with cancer enrolled with hospice. Variation across fiscal intermediaries may indicate that regulatory oversight, particularly of long-stay patients, influences hospice disenrollment.

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