Department of Health Policy and Management, George Washington University Milken Institute School of Public Health, Washington, DC.
Department of Health Care Evaluation, NORC at the University of Chicago, Bethesda, Maryland.
JAMA Health Forum. 2022 May 6;3(5):e220900. doi: 10.1001/jamahealthforum.2022.0900. eCollection 2022 May.
Hospice is an important end-of-life service for patients with Alzheimer disease and related dementias (ADRD).
To determine whether hospice use among patients with ADRD changed in association with recent policies aimed at reducing hospice misuse and long hospice stays, an outcome that may have disproportionately affected patients with ADRD because of their lengthy end-of-life trajectories.
This observational cross-sectional study used Medicare hospice claims data from Medicare hospice episodes of care beginning between July 2008 and December 2019 among Medicare hospice beneficiaries 65 years or older at time of enrollment. Data analysis was conducted between September 2019 and June 2021.
The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which systematized audits of hospices with a high proportion of long stays, and the 2016 2-tier payment system, which reduced daily reimbursement rates after 60 days.
Monthly percentage of (1) new patient enrollees, (2) patient census, and (3) care days provided to patients with an ADRD code.
The sample included 11 124 992 unique hospice episodes between 2008 and 2019; mean (SD) patient enrollment age ranged from 82.0 (8.2) years to 82.8 (8.7) years; the percentage of male patients ranged from 40.5% to 42.7%, and the percentage of Black, Hispanic, and White patients ranged from 7.7% to 8.2%, 1.5% to 2.0%, and 86.2% to 88.8%, respectively, across years. The percentage of new enrollees with an ADRD code dropped significantly during the months of IMPACT passage (-1.42 percentage points; 95% CI, -2.13 to -0.71) and implementation (-1.98 percentage points; 95% CI, -2.70 to -1.26) but rose again during the following months. While no significant changes were observed at the time of 2-tier payment implementation (0.15 percentage points; 95% CI, -0.21 to 0.51), the average rate of increase during the subsequent period was slower (0.01 percentage points per month; 95% CI, 0-0.02) than in earlier periods (0.05; 95% CI, 0.04-0.06 during the baseline period). Similar patterns were observed for the percentage of patient census and care days provided to patients with an ADRD code.
The results of this cross-sectional study of Medicare hospice claims data suggested that recent Medicare policies were associated with immediate and lasting reductions in the share of patients receiving hospice care with an ADRD code compared with expectations from preimplementation trends. Future research should examine mechanisms through which hospices enacted change and consequences for quality of care.
临终关怀是阿尔茨海默病和相关痴呆症（ADRD）患者的重要临终服务。
确定 ADRD 患者的临终关怀使用是否随着最近旨在减少临终关怀滥用和延长临终关怀时间的政策而发生变化，这种结果可能会对 ADRD 患者产生不成比例的影响，因为他们的临终轨迹很长。
设计、设置和参与者：这项观察性横断面研究使用了 Medicare 临终关怀护理开始于 2008 年 7 月至 2019 年 12 月期间 Medicare 临终关怀受益人的 Medicare 临终关怀案例数据，这些受益人在登记时年龄在 65 岁或以上。数据分析于 2019 年 9 月至 2021 年 6 月进行。
2014 年改善 Medicare 急性后期护理转型（IMPACT）法案，该法案对长期入住率较高的临终关怀进行了系统审计，以及 2016 年的两级支付系统，该系统在 60 天后降低了每日报销率。
每月（1）新患者登记人数、（2）患者普查和（3）为 ADRD 患者提供的护理天数的百分比。
样本包括 2008 年至 2019 年间 11124992 个独特的临终关怀案例；患者入组年龄的平均值（SD）范围为 82.0（8.2）岁至 82.8（8.7）岁；男性患者的比例范围为 40.5%至 42.7%，黑种人、西班牙裔和白人患者的比例分别为 7.7%至 8.2%、1.5%至 2.0%和 86.2%至 88.8%，每年的比例均有所不同。ADRD 代码新登记患者的百分比在 IMPACT 通过期间（-1.42 个百分点；95%CI，-2.13 至-0.71）和实施期间（-1.98 个百分点；95%CI，-2.70 至-1.26）显著下降，但随后几个月又有所上升。虽然在实施两级支付系统时没有观察到显著变化（0.15 个百分点；95%CI，-0.21 至 0.51），但随后期间的平均增长率较慢（每月 0.01 个百分点；95%CI，0-0.02）比早期阶段（基线期间为 0.05；95%CI，0.04-0.06）。患者普查和为 ADRD 患者提供护理天数的百分比也呈现出类似的模式。
这项对 Medicare 临终关怀索赔数据的横断面研究结果表明，最近的 Medicare 政策与实施前趋势相比，立即和持续降低了接受 ADRD 代码临终关怀的患者比例，这超出了预期。未来的研究应该检查临终关怀机构实施变革的机制以及对护理质量的影响。
