Rothenberg Lindsay R, Doberman Danielle, Simon Lin E, Gryczynski Jan, Cordts Grace
1 Stony Brook School of Medicine , Stony Brook, New York.
J Palliat Med. 2014 Aug;17(8):899-905. doi: 10.1089/jpm.2013.0512. Epub 2014 Jun 16.
On January 1, 2011, the Centers for Medicare and Medicaid Services (CMS) began requiring U.S. hospices to conduct a "face-to-face" (F2F) assessment of eligibility for continued hospice care with patients entering their third certification period (180 days after initial enrollment). Understanding which patient populations require F2F assessment is important for evaluating the impact of the CMS regulation and gauging the appropriateness of the 6-month prognosis criteria for different patient groups.
Retrospective program records were obtained for patients enrolled in a large hospice 6 months prior to implementation of the CMS regulation (N=375). Patients who remained in hospice and received a F2F (n=140) were compared to patients who were no longer in hospice (n=235) on demographics, terminal condition (categorized as debility/dementia, cancer, or other), presence of serious comorbidity, length of stay, setting of care prior to admission, and hospice outcome using bivariate statistics. Predictors of F2F recertification were examined using a multivariable logistic regression model controlling for demographics, setting of care prior to admission, comorbidity, and primary terminal diagnosis.
At the bivariate level, patients who received an F2F were older (p<0.001), and more likely to have lived in a facility care setting prior to hospice admission (p<0.001) than their non-F2F counterparts. Findings from the logistic regression analysis indicate that initial setting of care (odds ratio [OR] for inpatient versus home=0.20; p=0.01), presence of serious comorbidity (OR=2.84; p<0.001), and primary diagnosis (OR for debility/dementia versus cancer=3.35; p<0.001) were significant predictors of F2F recertification.
Unlike hospice patients with cancer, patients with a primary diagnosis of dementia or debility are more likely to remain in hospice care beyond 6 months and require F2F recertification. Still, these patients need the services provided by hospice care and may be limited by the 6-month recertification criteria.
2011年1月1日，美国医疗保险和医疗补助服务中心（CMS）开始要求美国临终关怀机构对进入第三个认证期（首次登记后180天）的患者进行“面对面”（F2F）评估，以确定其是否有资格继续接受临终关怀服务。了解哪些患者群体需要进行F2F评估，对于评估CMS规定的影响以及衡量不同患者群体6个月预后标准的适用性非常重要。
获取了在CMS规定实施前6个月登记入住一家大型临终关怀机构的患者的回顾性项目记录（N = 375）。使用双变量统计方法，将仍留在临终关怀机构并接受F2F评估的患者（n = 140）与不再接受临终关怀服务的患者（n = 235）在人口统计学特征、终末期状况（分为虚弱/痴呆、癌症或其他）、严重合并症的存在情况、住院时间、入院前的护理环境以及临终关怀结果等方面进行比较。使用多变量逻辑回归模型，在控制人口统计学特征、入院前的护理环境、合并症和主要终末期诊断的情况下，研究F2F重新认证的预测因素。
在双变量层面，接受F2F评估的患者比未接受F2F评估的患者年龄更大（p < 0.001），并且在进入临终关怀机构之前更有可能居住在机构护理环境中（p < 0.001）。逻辑回归分析结果表明，初始护理环境（住院与居家的比值比[OR] = 0.20；p = 0.01）、严重合并症的存在（OR = 2.84；p < 0.001）以及主要诊断（虚弱/痴呆与癌症的OR = 3.35；p < 0.001）是F2F重新认证的重要预测因素。
与患有癌症的临终关怀患者不同，主要诊断为痴呆或虚弱的患者更有可能在6个月后仍接受临终关怀服务，并需要进行F2F重新认证。尽管如此，这些患者需要临终关怀服务所提供的服务，并且可能会受到6个月重新认证标准的限制。
