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Compared to Medicare, Veterans with VA-Financed Care are More Likely to Receive Dialysis and Hospice for Kidney Disease
In contrast to Medicare, VA is committed to ensuring that Veterans have access to hospice services regardless of whether they are still receiving disease-modifying treatments, such as dialysis for end-stage kidney disease (ESKD). This study sought to answer the question: Does the frequency of concurrent hospice and dialysis (“concurrent care”) among Veterans with ESKD vary by hospice payer? Findings showed that rates of concurrent care were substantially higher among Veterans receiving VA-financed, compared with Medicare-financed, hospice services. The proportion of Veterans receiving concurrent care was lower for those receiving Medicare-financed hospice (25%) than for those receiving VA-financed hospice, either under VA Community Care (42%) or in VA inpatient hospice (55%). Regardless of hospice payer, VA paid for the majority (87%) of dialysis treatments after Veterans were enrolled in hospice. Veterans who received concurrent care had a median hospice length-of-stay of 43 days, compared with 4 days for those who did not. Findings suggest that there is probably a substantial unmet need for concurrent care among the large majority of Veterans with ESKD receiving hospice services under Medicare.
Date: October 7, 2022
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Receiving Hospice Services Improved Ratings of End-of-Life Care for Veterans in VA Home-Based Primary Care
This study sought to describe Veterans’ use of community-based hospice services while enrolled in home-based primary care (HBPC) and their associations with bereaved families’ perceptions of care. Findings showed that overall, 53% of family members reported that the care received by Veterans receiving HBPC in the last 30 days of life was excellent. Families of Veterans who received hospice services gave higher global ratings of end-of-life care quality than those who did not (56% vs. 47%). The highest scoring secondary Bereaved Family Survey (BFS) outcomes were related to providers always being kind, caring and respectful (87%) and managing PTSD symptoms among Veterans experiencing stress (85%). The lowest scoring items were related to receiving enough information about survivor (38%) and burial and memorial (43%) benefits following the Veteran’s death. On 12 of the 14 secondary BFS outcomes, Veterans who received hospice services scored higher than those that did not. Findings suggest that increased referrals to community hospice partners for qualifying Veterans may result in more favorable perceptions of the overall end of life care experience.
Date: September 29, 2021
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Timing of Palliative Care for VA Patients with Advanced Lung Cancer is Associated with Survival
Palliative care is often underutilized – or delivered too late to provide meaningful benefit. This study sought to determine whether the early use of palliative care – received soon after diagnosis – is associated with improved survival, if referral did not occur as part of the dying process. Findings showed that palliative care was associated with survival among patients with advanced lung cancer; however, the timing of palliative care receipt was an important component of this benefit. Palliative care received 31 to 365 days after cancer diagnosis was associated with increased survival, while palliative care received within 30 days of diagnosis was associated with decreased survival. Most of the patients who received palliative care within 30 days of diagnosis only survived a few weeks after diagnosis, suggesting palliative care referral occurred to ease the dying process. Palliative care also was associated with a reduced risk of dying in an acute care setting compared to Veterans who did not receive palliative care. Given the benefits, palliative care should be considered a complementary approach in patients with advanced lung cancer, and it should be integrated with disease-modifying therapies earlier in the treatment plan.
Date: September 19, 2019
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Increased Hospice Care for Veterans Associated with Less Aggressive Medical Treatment and Lower Medical Costs
This study sought to determine if increased availability of hospice for Veterans is associated with reduced aggressive treatments and medical care costs at the end of life. Findings showed that Veterans with newly diagnosed end-stage lung cancer treated at VAMCs with the most expansion in hospice use had a significantly greater likelihood of receiving chemotherapy or radiation therapy after hospice enrollment – but a lower likelihood of having aggressive treatment or intensive care unit use, compared with similar Veterans treated in VAMCs with low hospice growth. Thus, increasing hospice availability – without restricting treatment access for Veterans with advanced lung cancer – was associated with less aggressive medical treatment and significantly lower medical costs, while still enabling Veterans to receive cancer treatment. Veterans treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care. Radiation therapy was more common than chemotherapy. The six-month costs were lower by an estimated $266 per day for the high-quintile group vs. the low-quintile group. There was no survival difference through 180 days post-diagnosis. The substantial reduction in healthcare costs suggests that the investment in hospice care that VA made has paid off, and will likely continue to pay off without restricting Veterans’ access to radiation and chemotherapy.
Date: March 28, 2019
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Veterans with Cancer Received Higher Quality, Lower Intensity End-of Life Care in VA Compared to Medicare
This study evaluated the quality of end-of-life cancer care provided by Fee-for-Service (FFS) Medicare and VA, using well-accepted quality-of-care metrics. Findings showed that Veterans treated under FFS Medicare were more likely to get unduly intensive healthcare at end-of-life compared to those treated by VA. For example, Medicare-reliant Veterans were significantly more likely to receive chemotherapy, as well as experience a hospital stay, more hospital days, ICU admission, and death in hospital. Compared to Veterans in highly urban settings, Veterans living in rural areas were less likely to have a hospital admission or ICU stay, spend a greater number of their last 30 days of life in hospital, and were less likely to die in hospital. Compared with white Veterans, black Veterans were more likely to have two or more ED visits, a hospital admission, an ICU stay, or to die in hospital.
Date: January 1, 2018
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Hospice Enrollment for Veterans with Advanced Stage Lung Cancer Increases
This study examined the use of hospice care by Veterans with advanced stage lung cancer enrolled in VA healthcare. Findings showed that overall, hospice enrollment among VA patients with advanced stage lung cancer increased from 65% in 2007 to 71% in 2013. Early hospice enrollment also increased, with time from cancer diagnosis to hospice enrollment decreasing by 65 days (32% relative decrease). There was statistically significant regional variability in overall hospice enrollment across the VA healthcare system, ranging from 64% in the Northeast to 77% in the Southeast. Regional variability in the timing of hospice enrollment also was significant; for example, enrollment in the last 3 days of life ranged from 18% in the Northeast to 12% in the Southeast. Significant regional variability in hospice enrollment and patient characteristics associated with the use and timing of enrollment suggest a framework for focused efforts to enhance utilization.
Date: October 10, 2017
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Easy-to-Use Advance Care Planning (ACP) Tools Increase Planning among Older Veterans
Study investigators created the PREPARE website, which has been shown to empower older adults to engage in advance care planning (ACP) through the use of a simple 5-step process and “how-to” videos. In addition, the team created an easy-to-read advance directive (AD) that has significantly increased patient documentation of ACP. The objective of this randomized clinical trial was to compare the efficacy of PREPARE plus the easy-to-read AD vs. the AD alone to increase ACP documentation and engagement. Findings showed that PREPARE plus an easy-to-read AD resulted in statistically significant higher advance care planning documentation (35%) compared with an easy-to-read AD alone (25%). Both tools were rated highly in terms of ease-of-use, satisfaction, helpfulness, and the likelihood Veterans would recommend the guide to others.
Date: August 1, 2017
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VA End-of-Life Initiative Increases Veterans’ Use of Hospice
This study sought to determine whether substantial VA investment in palliative care led to increased use of hospice for older male enrolled Veterans. Findings showed that the Comprehensive End of Life Care (CELC) Initiative was shown to be effective in increasing hospice use for older male Veterans beyond that observed for non-Veteran Medicare decedents. These differentials increased over time and were even larger among Veterans who had stays in hospitals – where substantial CELC Initiative investment occurred – in the last year of life.
Date: July 1, 2017
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Timing and Duration of Hospice and Palliative Care across VA, Medicare, and VA-Purchased Care
This study examined the real-world timing of palliative care in VA, and how timing and duration of hospice care varied across Medicare, VA, and VA-purchased care. Findings showed that most Veterans received hospice care, while fewer received palliative care. Taken together, 86% of Veterans had some exposure to hospice or palliative care in the approximately 180 days before death. Median first exposure to hospice care was slowest in VA (more days before receipt of care) and fastest in VA-purchased environments (fewer days before receipt of care). Patients with VA hospice care first received it a median of 14 days before death, compared with VA-purchased hospice care (median of 28 days before death) and Medicare hospice care (median of 16 days before death). After adjusting for patient age and cancer type, Veterans who received VA hospice care were significantly less likely to receive it for at least three days compared with Veterans who received it through VA-purchased or Medicare environments. Medicare was the largest payer of hospice care for Veterans (61%) followed by VA (44%) and VA-purchased care (10%). There remains a gap between recommended timing of supportive services and real-world practice of care. This is especially true for palliative care, which is recommended for all patients with advanced cancer regardless of terminal status.
Date: May 26, 2016
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Surgical Patients Less Likely to Receive Hospice or Palliative Care Compared to Medical Patients
This study examined the use of end-of-life care in the VA healthcare system among surgical and medical patients at the end of life. Findings showed that VA surgical patients were less likely to receive either hospice or palliative care in the year prior to death compared with medical patients (38% vs. 41%, respectively). This difference also was present in a separate analysis of palliative care (37% surgical vs. 39% medical) and hospice care (21% surgical vs. 24% medical). Moreover, differences in the use of palliative or hospice care were intensified after adjusting for patient characteristics. However, among Veterans who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (median of 26 days versus 23 days). The use of palliative services increased over the study period – from 29% to 47% for medical patients and from 27% to 45% for surgical patients. Likewise, hospice use increased from 21% to 27% and from 19% to 24% for medical and surgical patients, respectively. The median time between palliative or hospice initiation and death increased over the study period – from 22 to 25 days for medical patients and from 22 to 30 days for surgical patients.
Date: September 24, 2014
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Systematic Frailty Screening may Lead to Reduced Post-Operative Mortality in Frail Veterans
Investigators in this study implemented a quality improvement initiative to screen Veterans scheduled for elective surgery for frailty in order to identify those at high risk for post-operative mortality and morbidity. This systematic frailty-screening program effectively identified at-risk surgical patients and was associated with a significant reduction in mortality in Veterans undergoing palliative care consultation. Implementation of the screening program was associated with a 33% reduction in 180-day mortality even after controlling for age, frailty, and whether the patients had surgery. Further, given the high risk of dying in this frail cohort, study models suggest that for every four patients screened, one death was prevented or delayed at 180 days. After implementation of the frailty-screening program, palliative care consultations were more frequently ordered by surgeons, and they were more likely to take place before the index operation. Moreover, pre-operative palliative care consultations ordered by a surgeon were associated with the greatest reduction in mortality.
Date: September 10, 2014
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Unintended Consequences of Advance Directive Law
This study sought to identify the unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. Findings show that unintended negative consequences of advance directive legal restrictions may prevent all patients, vulnerable patients in particular, from making and communicating their end-of-life wishes and having them honored. Five overarching legal and content-related barriers were identified: poor readability (i.e., laws in all states were written above a 12th-grade reading level); restrictions on who may serve as a healthcare agent; execution requirements (steps needed to make forms legally valid); inadequate reciprocity (acceptance of advance directives between states); and religious, cultural, and social inadequacies. These restrictions have rendered advance directives less clinically useful. Advance directive statues meant to protect patients’ right of self-determination may instead better protect physicians from punitive action. For example, many states have provisions that enable physicians to presume the validity of an advance directive in the absence of actual knowledge that the directive is invalid. Author recommendations include improving readability (e.g., older persons read at a 5th-grade level), allowing oral advance directives, and eliminating witness or notary requirements. They also suggest that patients be allowed and encouraged to document their values, cultural traditions, and other socially or culturally important information.
Date: January 18, 2011
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More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life
Of the 3,746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required. Of those requiring surrogate decision-making, 67.6% had advance directives. Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it. Individuals with advance directives preferred limited and comfort care more than all care possible. Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.
Date: April 1, 2010
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Patient/Provider Communication in Veterans with Terminal Illness
When providers communicated to Veterans the life-limiting nature of their illness, Veterans were more likely to understand that aspect of their illness and to discuss care preferences with family members. Veterans who believed they had a life-limiting illness more frequently reported that their provider had communicated this to them than those who did not share that belief. More than half of the Veterans reported discussing care preferences with their providers, and 66% reported such discussions with their family. Findings underscore the need to promote effective communication and mutual understanding between Veterans, families, and providers regarding the patient’s illness and prognosis as part of improving patient-centered, late-life care.
Date: March 1, 2010
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Disease-Specific Differences in End-of-Life Treatment of Seriously Ill Veterans of Different Ethnic and Racial Backgrounds
Differences in the level of end-of-life treatments were disease-specific and not based on race and/or ethnicity. In addition, increased end-of-life care for minorities was most pronounced in veterans with dementia, and non-cancer patients received more invasive care than patients with cancer or dementia, independent of their race or ethnicity.
Date: September 1, 2008
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