Hospice Patients and Hospital Mortality Rates: Understanding the Exclusion Criteria


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In recent years, the evaluation of hospital mortality rates has become a critical factor in assessing healthcare quality. A key area of focus within this evaluation is how patients who transition to hospice care are accounted for in these metrics. Hospice care, which is designed to provide comfort and support for patients with terminal illnesses, presents unique challenges when it comes to measuring hospital performance.

To address these challenges, specific guidelines have been established to exclude certain hospice patients from hospital mortality measures. Patients enrolled in Medicare hospice programs during the 12 months prior to or on the first day of the index admission are typically excluded from these measures. This exclusion is intended to prevent hospitals from being unfairly penalized for deaths that are anticipated due to the terminal nature of the patients' conditions, rather than reflective of the quality of hospital care provided.

These guidelines have been updated to also exclude patients enrolled in hospice programs before admission to Veterans Affairs facilities. The rationale for this approach is based on the understanding that transitions to hospice care often result in outcomes that are not indicative of hospital performance but rather a reflection of the patients' end-of-life trajectory. Moreover, palliative care, which focuses on symptom relief rather than extending life, is recognized as a crucial aspect of care for terminally ill patients. Therefore, including these patients in mortality measures could distort the true quality of care provided by hospitals, which aim to support the goals and needs of patients during their final stages of life.

Are Hospice Patients Included in the Measure Cohort?

The below table categorizes various measure outcomes (mortality, readmission, complication) and specifies whether hospice patients are included in the cohorts for each condition or procedure.

Measure Outcome Procedure/Condition Yes/No
Mortality AMI
Mortality HF
Mortality Stroke
Mortality COPD
Mortality Pneumonia
Mortality CABG
Readmission AMI
Readmission COPD
Readmission CABG
Readmission THA/TKA
Readmission Hospital-Wide
Readmission HF
Readmission Pneumonia
Complication THA/TKA
EDAC AMI
EDAC HF
EDAC Pneumonia

All readmission, EDAC, complication, TKA/THA payment, and CABG mortality measures include Medicare hospice patients (and those who used VA hospice services) in the measure cohorts.

Example Scenarios for Inclusion / Exclusion for Hospice

Scenario 1: Patient A

Timeline: Enrolled in Medicare Hospice 12 months before the index admission.
Outcome: Patient dies within 30 days of the index admission.
Cohort Inclusion: Excluded.
Reason: Patient A is enrolled in Medicare Hospice during the risk-adjustment look-back period (12 months prior to the index admission). This pre-existing hospice enrollment leads to the exclusion of this patient from the cohort because the patient's death is anticipated due to the terminal nature of their condition.

Scenario 2: Patient B

Timeline: Enrolled in Medicare Hospice on the first day of the index admission (day 0).
Outcome: Patient dies within 30 days of the index admission.
Cohort Inclusion: Excluded.
Reason: Patient B is enrolled in Medicare Hospice on the same day as the index admission. Since the enrollment happens on day 0, the patient is excluded from the cohort. This exclusion is because the hospice enrollment coincides with the beginning of the index admission, indicating the patient was already in a terminal stage at the start of the hospital stay.

Scenario 3: Patient C

Timeline: Enrolled in Medicare Hospice after the first day of the index admission (after day 0).
Outcome: Patient dies within 30 days of the index admission.
Cohort Inclusion: Included.
Reason: Patient C enrolls in Medicare Hospice after the index admission day. This timing means the patient was not in hospice care at the start of the hospital stay but transitioned to hospice care during the hospital stay. Therefore, this patient is included in the cohort as their condition at the start of the admission is relevant to the hospital's care outcomes.

Scenario 4: Patient D

Timeline: Enrolled in non-Medicare Hospice at any time.
Outcome: Patient dies within 30 days of the index admission.
Cohort Inclusion: Included.
Reason: Patient D is enrolled in a non-Medicare Hospice program. Unlike Medicare Hospice, enrollment in a non-Medicare Hospice does not lead to automatic exclusion. This inclusion recognizes the diversity in hospice care programs and ensures that patients not covered by Medicare Hospice are still considered in the cohort.

Key Points:

How Dexur Can Help

Dexur has access to the full patient journey from the underlying CMS data. In a prior analysis, Dexur had shown that 20-40% of CMS 30 Day Mortality have had a Hospice interaction. Hospitals can leverage detailed mortality metrics to better understand how Hospice related mortalities impact final CMS Mortality metrics.