Content Analysis of Negative Online Reviews of Hospice Agencies in the United States.

Importance: As online reviews of health care become increasingly integral to patient decision-making, understanding their content can help health care practices identify and address patient concerns. Objective: To identify the most frequently cited complaints in negative (ie, 1-star) online reviews of hospice agencies across the United States. Design, Setting, and Participants: This qualitative study conducted a thematic analysis of online reviews of US hospice agencies posted between August 2011 and July 2019. The sample was selected from a Hospice Analytics database. For each state, 1 for-profit (n = 50) and 1 nonprofit (n = 50) hospice agency were randomly selected from the category of extra-large hospice agencies (ie, serving >200 patients/d) in the database. Data analysis was conducted from January 2019 to April 2019. Main Outcomes and Measures: Reviews were analyzed to identify the most prevalent concerns expressed by reviewers. Results: Of 100 hospice agencies in the study sample, 67 (67.0%) had 1-star reviews; 33 (49.3%) were for-profit facilities and 34 (50.7%) were nonprofit facilities. Of 137 unique reviews, 68 (49.6%) were for for-profit facilities and 69 (50.4%) were for nonprofit facilities. A total of 5 themes emerged during the coding and analytic process, as follows: discordant expectations, suboptimal communication, quality of care, misperceptions about the role of hospice, and the meaning of a good death. The first 3 themes were categorized as actionable criticisms, which are variables hospice organizations could change. The remaining 2 themes were categorized as unactionable criticisms, which are factors that would require larger systematic changes to address. For both for-profit and nonprofit hospice agencies, quality of care was the most frequently commented-on theme (117 of 212 comments [55.2%]). For-profit hospice agencies received more communication-related comments overall (34 of 130 [26.2%] vs 9 of 82 [11.0%]), while nonprofit hospice agencies received more comments about the role of hospice (23 of 33 [69.7%] vs 19 of 31 [61.3%]) and the quality of death (16 [48.5%] vs 12 [38.7%]). Conclusions and Relevance: Regarding actionable criticisms, hospice agencies could examine their current practices, given that reviewers described these issues as negatively affecting the already difficult experience of losing a loved one. The findings indicated that patients and their families, friends, and caregivers require in-depth instruction and guidance on what they can expect from hospice staff, hospice services, and the dying process. Several criticisms identified in this study may be mitigated through operationalized, explicit conversations about these topics during hospice enrollment.

Profit status and delivery of hospice care for infants: the mediating role of pediatric knowledge.

BACKGROUND: Infant mortality is a persistent problem in the United States, and yet, hospice care is rarely provided for infants at the end of life. OBJECTIVE: To examine the influence of profit status on delivery of hospice care for infants, and to explore the mediating role of pediatric knowledge (pediatric program and pediatric knowledge) on the relationship between profit status and the delivery of infant care. METHODS: Our study was a cross-sectional secondary analysis, using data from the 2008 California State Utilization Data File of Home Health Agencies and Hospice Facilities survey. RESULTS: Of the hospices in the sample, 13% delivered care for infants. Nonprofit hospices were more likely to delivery care for infants (B=0.67, p<0.05), have a specialized pediatric program (B=0.85, p<0.05) and have more experience caring for pediatric patients (B=1.49, p<0.05). Regarding the mediator variables, hospices with a pediatric program were no more likely to deliver care to infants than hospices without a pediatric program (B=0.82, p>0.05). Experience with greater numbers of any pediatric patients facilitated the delivery of hospice infant care in nonprofits (B=0.86, p<0.05). CONCLUSION: Hospices may need to explore ways to direct resources toward assisting hospice staff members in gaining pediatric experience.

Differences between non-profit and for-profit hospices: patient selection and quality.

This research compares the behavior of non-profit organizations and private for-profit firms in the hospice industry, where there are financial incentives created by the Medicare benefit. Medicare reimburses hospices on a fixed per diem basis, regardless of patient diagnosis. Because under this system patients with lower expected costs are more profitable, hospices can selectively enroll patients with longer lengths of stay. While it is illegal for hospices to reject potential patients explicitly, they can influence their patient mix through referral networks. A fixed per diem rate also creates an incentive shirk on quality and to substitute lower skilled for higher skilled labor, which has implications for quality of care. By using within-market variation in hospice characteristics, the empirical evidence suggests that for-profit hospices differentially take advantage of these incentives. The results show that for-profit hospices engage in patient selection through significantly different referral networks than non-profits. They receive more patients from long-term care facilities and fewer patients through more traditional paths, such as physician referrals. This mechanism of patient selection is supported by the result that for-profits have fewer cancer patients and more patients with longer lengths of stay. While non-profit and for-profit hospices report similar numbers of staff visits per patient, for-profit firms make significantly less use of skilled nursing providers. We also find some weak evidence of lower levels of quality in for-profit hospices.

Comparison of home health and hospice care agencies by organizational characteristics and services provided: United States, 2007.

OBJECTIVE: This report presents national estimates of the organizational characteristics of home health and hospice care agencies in 2007. Comparisons of organizational characteristics and provision of selected services are made by agency type. A comparison of selected characteristics between 1996 and 2007 is also provided to highlight changes that have occurred leading to the current composition of the home health and hospice care sector. METHODS: Estimates are based on data collected on agencies from the 1996, 2000, and 2007 National Home and Hospice Care Survey, conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Estimates are derived from data collected during interviews with administrators and staff designated by the administrators. RESULTS: In 2007, there were 14,500 home health and hospice care agencies in the United States, an increase from 11,400 in 2000. Three-quarters of these agencies provided home health care only, 15% provided hospice care only, and 10% provided both home health and hospice care (mixed). The percentage of proprietary home health care only and hospice care only agencies increased during 1996-2007, whereas the percentage of proprietary mixed agencies remained relatively stable. The average number of home health care patients that home health care only and mixed agencies served decreased, while the average number of hospice care patients that hospice care only agencies served increased across years. Among mixed agencies, no significant changes were observed in the average number of hospice care patients being served. The percentage of home health care only agencies offering certain therapeutic and nonmedical services declined over the years. There was an increase in the proportion of hospice care only agencies' providing many core and noncore hospice care services during 1996-2007. Also during this time, the proportion of mixed agencies providing selected nonmedical services decreased.

Differences in services provided by hospices based on home health agency certification status.

BACKGROUND: Similar patient populations and favorable regulations have led many home health agencies to become Medicare and/or Medicaid certified as hospice agencies (mixed), but home health and hospice programs differ in focus and scope. Little research has been performed examining the differences between mixed hospices and those agencies only certified as hospices (nonmixed). OBJECTIVES: To describe the differences in agency characteristics between mixed and nonmixed agencies; and to compare frequencies of service provision by mixed and nonmixed agencies. RESEARCH DESIGN: Cross-sectional study using data from the 2000 National Home and Hospice Care Survey. SUBJECTS: A total of 760 Medicare and/or Medicaid certified hospice agencies providing services during the survey, including 393 mixed agencies (52% of sample) and 367 nonmixed hospices. MEASURES: Survey responses by administrators about services provided by agency. RESULTS: Nonmixed agencies were significantly more likely than mixed agencies to provide many types of services, including: volunteers [96.1% vs. 77.4%, respectively; odds ratio (OR): 7.27; 95% confidence interval (CI): 5.26-10.05], social services (96.1% vs. 93.5%; OR: 1.70; 95% CI: 1.20-2.40), spiritual care (95.1% vs. 77.8%; OR: 5.53; 95% CI: 4.13-7.41), bereavement care (93.5% vs. 79.8%; OR: 3.63; 95% CI: 2.80-4.72), counseling (89.5% vs. 70.2%; OR: 3.62; 95% CI: 2.92-4.48), and physician services (87.2% vs. 52.0%; OR: 6.30; 95% CI: 5.18-7.66). In logistic regression models, these differences remained significant after adjustment for census region, operation by a hospital, number of patients and number of hospice patients, and Medicare and Medicaid hospice certification status. CONCLUSIONS: Mixed agencies provide a narrower range of services to hospice patients than nonmixed agencies, including fewer services considered cornerstones of hospice treatment.

Length of survival of patients with cancer in hospice: a retrospective analysis of patients treated at a major cancer center versus other practice settings.

This is a retrospective study of the length of survival (LOS) in hospice of patients with cancer treated at a major cancer center compared to other treatment sites. Of 670 patients, the 185 (28%) treated at a major cancer center had unique characteristics, including higher median Palliative Performance Score (PPS) at the time of hospice enrollment (45 versus 40, p = 0.009), and longer median LOS in hospice (35 versus 21 days, p = 0.02: log rank test). Additional variables that predicted longer LOS were higher PPS, Medicare or Medicaid, self-referral, unmarried status, and non-executed advance directives. After adjusting survival for PPS with a Cox proportional hazard model, the hazard ratio for PPS remained statistically significant (95% confidence interval [CI]: 0.95-0.97] while that for the treatment site was not (95% CI: 0.73-1.04]. The performance status, and not the treatment site, was the dominant predictor of the LOS of patients with cancer in hospice.

The academic hospice.

The academic hospice is a recent development in health care. Hospice programs and hospitals evolved from the same historical roots in Greek and Roman medicine. The academic hospital emerged as a place where patient care, education, and research are pursued as inextricable parts of the mission. The unique role of the academic medical center in health care is supported by the government, the medical profession, and the public. This article provides a perspective on the emergence of the academic hospice. Dr. Cicely Saunders, who died on 14 July 2005, founded the first such hospice in London, England, in 1967. The authors show that the philosophy of hospice care has the same historical roots as standard health care and describe those elements that distinguish academic hospice programs from other kinds of hospice programs. Finally, the authors note that demographic and economic challenges in the United States and elsewhere only increase the need for academic hospice programs.

Can we be connected while remaining separate? Forging partnerships between all-volunteer & Medicare-certified hospices.

When the Medicare hospice benefit was enacted 20 years ago, many hospices greeted the news with great relief. This benefit helped many fledgling hospices start up and survive. However, a group of hospices realized that some of the people for whom they previously cared were not eligible for services under the Medicare hospice benefit. Thus, volunteer hospices filled that need, supporting and advocating for people who did not fit the hospice benefit criteria, but who wanted hospice support. Since volunteer hospices and Medicare-certified hospices play two very different roles in the hospice care delivery system, there are many opportunities for the two types of hospices to partner to meet patient care needs.

An overview of home health and hospice care patients: 1996 National Home and Hospice Care Survey.

OBJECTIVE: This report presents numbers and percents of home health and hospice care agencies, their current patients, and their discharges. Agency characteristics include type of ownership, region, certification, location, and affiliation. Patient and discharge characteristics include age, sex, race, marital status admission diagnoses, and procedures. METHODS: The data used for this report are from the National Center for Health Statistics' 1996 National Home and Hospice Care Survey. This is a sample survey through which data are collected on the use of home health and hospice care agencies in the United States. RESULTS: During 1996, there were an estimated 2.5 million current patients and 8.2 million discharges from 13,500 home health and hospice care agencies in the United States. The agencies tended to be proprietary, certified by Medicare and Medicaid as a home health agency, and located in a metropolitan statistical area. Almost half were part of a chain or group of agencies. The home health and hospice care patients and discharges tended to be 65 years of age and over, female, white, and married or widowed. The most common diagnoses for home health care patients were diseases of the circulatory system, and the most common diagnoses for hospice care patients were malignant neoplasms. About a third of the home health care patients and about a fifth of the hospice care patients had a surgical or diagnostic procedure related to their admission for care. The most common procedures for home health care patients were operations on the musculoskeletal system, and for hospice care patients they were miscellaneous diagnostic and therapeutic procedures.

A comparison of hospice programs based on Medicare certification status.

This article presents results from a study of 119 hospice programs in the United States. Personal interviews and questionnaires were utilized to collect data about hospice programs, their directors, nurses, social workers, and chaplains. Specifically, this article describes reasons programs sought Medicare certification, and the perceived advantages and disadvantages to being a Medicare certified program. Characteristics of both certified and non-certified programs are presented, and examined for differences. Potential access barriers such as restrictive admission criteria are examined in this article. Finally, perceptions of staff about hospice services in certified and non-certified programs are compared. Results from this study indicate that Medicare certified programs have longer lengths of stays, were more likely to include a nurse on the first visit, and billed patients more frequently than noncertified programs. Volunteer use was lower in the Medicare certified programs. Staff in Medicare certified programs were much more likely to view patients' medical needs as the primary focus of their programs. Results from this study suggest that Medicare certified programs may reflect a more medical model of palliative care.

Volunteer hospice offers unique & special services.

Two types of hospices exist: medical and volunteer. Medical hospices are constrained by Medicare regulations. Volunteer hospices fill in the gaps that those regulations leave, providing flexible, supportive care. The community that is served by both medical and volunteer hospice programs offers truly comprehensive care to the dying and their families.

The effects of hospice coverage on Medicare expenditures.

This article reports on the findings of a study of the effects of the hospice program on Medicare Part A expenditures during the first three years of the program. The analysis compared treatment costs between hospice beneficiaries and nonbenefit patients with diagnosis of malignant cancer during their last seven months of life. It was estimated that during the first three years of the hospice program, Medicare saved $1.26 for every dollar spent on Part A expenditures. While the methodology included use of data from Medicare claims to adjust for confounding factors, including self-selection bias, our estimated savings might still have been overstated due to persistent selection effects. The extent of savings also varied according to the hospice's organization. Freestanding hospices, in contrast to those affiliated with either a hospital, nursing home, or home health agency, achieved the greatest savings by utilizing home care more extensively. However, we note that payment rates are increasing and the limits on the benefit period are being lifted, making it possible that the savings related to the hospice program found in this study will not continue. Of greater importance may be the long-term access and quality effects engendered by the benefit's preference for home care.

An alternative in terminal care: results of the National Hospice Study.

Hospice is a program of supportive services for terminally ill patients and their families, provided either at home or in designated inpatient settings, which is purported to improve patient and family quality of life at lower cost than conventional terminal care. The National Hospice Study was a multi-site, quasi-experimental study to compare the experiences of terminal cancer patients and their families in hospices with those of similar patients and families receiving conventional terminal care. The results indicate that, although care is different in hospices, e.g. lesser utilization of aggressive interventional therapy and diagnostic testing, patients' quality of life is similar in the hospice and conventional care systems with the exception of pain and symptom control, which may be better in the inpatient hospice setting. Hospice patients are more likely to die at home and their families are satisfied with that outcome. Otherwise, no consistent superiority of family outcome was associated with the hospice approach. The cost of hospice care is less than that of conventional terminal care for patients in hospices without inpatient facilities, but the cost of hospice appears to be equivalent to conventional care for patients in hospices having beds.