Improving the use of hospice services in nursing homes: a randomized controlled trial.
BACKGROUND
Hospice care may improve the quality of end-of-life care for nursing home residents, but hospice is underutilized by this population, at least in part because physicians are not aware of their patients' preferences.


OBJECTIVE
To determine whether it is possible to increase hospice utilization and improve the quality of end-of-life care by identifying residents whose goals and preferences are consistent with hospice care.


METHODS
Randomized controlled trial (December 2003-December 2004) of nursing home residents and their surrogate decision makers (N=205) in 3 US nursing homes.


METHODS
A structured interview identified residents whose goals for care, treatment preferences, and palliative care needs made them appropriate for hospice care. These residents' physicians were notified and asked to authorize a hospice informational visit.


METHODS
The primary outcome measures were (1) hospice enrollment within 30 days of the intervention and (2) families' ratings of the quality of care for residents who died during the 6-month follow-up period.


RESULTS
Of the 205 residents in the study sample, 107 were randomly assigned to receive the intervention, and 98 received usual care. Intervention residents were more likely than usual care residents to enroll in hospice within 30 days (21/107 [20%] vs 1/98 [1%]; P<.001 [Fisher exact test]) and to enroll in hospice during the follow-up period (27/207 [25%] vs 6/98 [6%]; P<.001). Intervention residents had fewer acute care admissions (mean: 0.28 vs 0.49; P = .04 [Wilcoxon rank sum test]) and spent fewer days in an acute care setting (mean: 1.2 vs 3.0; P = .03 [Wilcoxon rank sum test]). Families of intervention residents rated the resident's care more highly than did families of usual care residents (mean on a scale of 1-5: 4.1 vs 2.5; P = .04 [Wilcoxon rank sum test]).


CONCLUSIONS
A simple communication intervention can increase rates of hospice referrals and families' ratings of end-of-life care and may also decrease utilization of acute care resources.
Casarett
David
D
Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA. casarett@mail.med.upenn.edu
Karlawish
Jason
J
Morales
Knashawn
K
Crowley
Roxane
R
Mirsch
Terre
T
Asch
David A
DA
D005190:Family / Q000523:psychology; D017051:Hospice Care / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D009730:Nursing Assessment; D009735:Nursing Homes / Q000458:organization & administration / Q000592:standards*; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D010817:Physician-Patient Relations; D011785:Quality Assurance, Health Care / Q000379:methods*; D012017:Referral and Consultation; D014481:United States