Improving the quality of end of life care in nursing homes:

1
Improving the quality of end of life care in
nursing homes results of a randomized
controlled trial
David Casarett, MD MA(1), Jason Karlawish MD(2),
Knashawn Morales ScD(3), Roxane Crowley BA(4),
Terre Mirsch RN BSN CHPN(5) and David A. Asch MD
MBA(6) From the Center for Health Equity Research
and Promotion at the Philadelphia Veterans
Affairs Medical Center (1,6), the Division of
Geriatric Medicine (1,2), Center for Bioethics
(1,2,6), Leonard Davis Institute of Health
Economics (1,2,6) and the Center for Clinical
Epidemiology and Biostatistics (3) at the
University of Pennsylvania (1-3,6), Temple
University Law School (4) and Holy Redeemer Home
Health and Hospice Care (5).
Table Outcomes in intervention and usual care

• Intervention vs. usual care groups
• Assignment determined by blocked randomization,
  stratified by site of care.
• Intervention
• For hospice appropriate residents, physicians
  were notified and asked to authorize a hospice
  informational visit.
• Usual care
• All residents and families were given a brief
  description of hospice and hospice services and
  told that they could learn more about hospice by
  speaking with the residents health care
  provider.
• Follow-up data
• Residents were followed for 6 months or until
  death
• Medical records were reviewed biweekly to
  identify deaths, hospitalizations, new orders to
  limit life-sustaining treatment, and hospice
  enrollment
• When residents died during the follow-up period,
  the surrogate was asked to complete a brief
  interview approximately 2 months after the
  residents death. (See table)
• Sample size
• Sample size was planned to provide at least 80
  power to detect a 15 absolute difference in
  30-day hospice referral rates (0 vs. 15) and a
  0.5-point difference in overall ratings of
  end-of-life care (1-5 scale standard
  deviation0.5 assuming a 15 mortality at 6
  months)(?0.05 for each comparison).

All residents Usual care
Intervention P-value (n205)
(n98) (n107) -Referral to hospice
within 30 days 22 (11) 1 (1)
21 (20) Plt.0001 Resident only (n32) 6
(19) 0 (0) 6
(32) 0.059 Surrogate (n128)
10 (8) 1 (2) 9
(13) 0.020 Resident and surrogate (n45) 6
(13) 0 (0) 6
(32) 0.003 -Acute care admissions mean
(range) 0.38 (0-4) 0.49 (0-4)
0.28 (0-4) 0.041 -Days in hospital
mean (range) 2.0 (0-29) 3.0 (0-29)
1.2 (0-18) 0.030 -6-month mortality N
() 23 (11) 8 (8)
15 (14) 0.185 -Enrolled in hospice at death
N () 9 (39) 3 (38) 5
(36) 0.933 -Surrogate interviews -Overall
assessment of quality 3.53 (1-5) 2.2
(1-5) 4.3 (2-5) 0.013 of care in
last month of life (Possible range
1-5) Fishers exact test

• A simple, efficient intervention can increase
  access tho hospice in nursing home populations
• Increased use of hospice is associated with
• Improved family satisfaction
• Reduced resource utilization
• This intervention could feasibly be implemented
  in most long term care settings.

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