Hospice Admission Practices: Where Does Hospice Fit in the Continuum of Care?
Karl A. Lorenz, MD, MSHS, Steven M. Asch, MD, MPH, Kenneth E. Rosenfeld, MD, Hui Liu, MS, and Susan L. Ettner, PhD

Objectives: To evaluate selected hospice admission practices that could represent barriers to hospice use and the association between these admission practices and organizational characteristics.

Design: From December 1999 to March 2000, hospices were surveyed about selected admission practices, and their responses were linked to the 1999 California Office of Statewide Health Planning and Development’s Home and Hospice Care Survey that describes organizational characteristics of California hospices.

Setting: California statewide.

Participants: One hundred of 149 (67%) operational licensed hospices.

Measurements: Whether hospices admit patients who lack a caregiver; would not forgo hospital admissions; or are receiving total parenteral nutrition (TPN), tube feedings, radiotherapy, chemotherapy, or transfusions.

Results: Sixty-three percent of hospices restricted admission on at least one criterion. A significant minority of hospices would not admit patients lacking a caregiver (26%). Patients unwilling to forgo hospitalization could not be admitted to 29% of hospices. Receipt of complex medical care, including TPN (38%), tube feedings (3%), transfusions (25%), radiotherapy (36%), and chemotherapy (48%), precluded admission. Larger program size was significantly associated with a lower likelihood of all admission practices except restricting the admission of patients receiving TPN or tube feedings. Hospice programs that were part of a hospice chain were less likely to restrict the admission of patients using TPN, radiotherapy, or chemotherapy than were freestanding programs.

Conclusion: Patients who are receiving complex palliative treatments could face barriers to hospice enrollment. Policy makers should consider the clinical capacity of hospice providers in efforts to improve access to palliative care and more closely incorporate palliation with other healthcare services. J Am Geriatr Soc 2004;52(5):725-730.

Physical Therapy and Mobility 2 and 6 Months After Hip Fracture
Joan D. Penrod, PhD, Kenneth S. Boockvar, MD, MS, Ann Litke, MA, Jay Magaziner, PhD, Edward L. HannanPhD, Ethan A. Halm, MD, MPH, Stacey B. Silberzweig, MS, RD, R. Sean Morrison, MD, Gretchen M. Orosz, MD, Kenneth J. Koval, MD, and Albert L. Siu, MD, MSPH

Objectives: To examine the relationship between early physical therapy (PT), later therapy, and mobility 2 and 6 months after hip fracture.

Design: Prospective, multisite observational study.

Setting: Four hospitals in the New York City area.

Participants: Four hundred forty-three hospitalized older patients discharged after surgery for hip fracture in 199798.

Measurements: Patient demographics, fracture type, comorbidities, dementia, number of new impairments at discharge, amount of PT between day of surgery and postoperative day (POD) 3, amount of therapy between POD4 and 8 weeks later, and prefracture, 2-, and 6-month mobility measured using the Functional Independence Measure.

Results: More PT immediately after hip fracture surgery was associated with significantly better locomotion 2 months later. Each additional session from the day of surgery through POD3 was associated with an increase of 0.4 points (P= .032) on the 14-point locomotion scale, but the positive relationship between early PT and mobility was attenuated by 6 months postfracture. There was no association between later therapy and 2- or 6-month mobility.

Conclusion: PT immediately after hip fracture surgery is beneficial. The effects of later therapy on mobility were difficult to assess because of limitations of the data. Well-designed randomized, controlled trials of the effect of varying schedules and amounts of therapy on functional status after hip fracture would be informative. J Am Geriatr Soc 2004;52(7):1114-1120.

A Clinical Trial of the Effectiveness of Regularly Scheduled Versus As-Needed Administration of Acetaminophen in the Management of Discomfort in Older Adults with Dementia
Martha D. Buffum, DNSc, APRN, BC, CS, Laura Sands, PhD, Christine Miaskowski, RN, PhD, FAAN, Meryl Brod, PhD, and Allyson Washburn, PhD

Objectives: To determine in a sample of nursing home patients with dementia and a painful condition whether the regularly scheduled administration of acetaminophen (650 mg four times a day (qid)) was more or less effective than as-needed (prn) administration of acetaminophen in reducing discomfort.

Design: Double-blind, double-dummy, placebo-controlled, crossover study. One arm consisted of 650 mg of acetaminophen administered qid with placebo prn; the other arm consisted of placebo administered qid with acetaminophen prn.

Setting: Two community and one Veterans Affairs nursing homes in the San Francisco Bay area.

Participants: Thirty-nine nursing home patients with a mean±standard deviation Mini-Mental State Examination score of 4.3±5, a mean Global Deterioration Scale score of 5.7±0.4, and a mean Discomfort Scale score of 10.7±6.8. Approximately 84% had degenerative joint disease.

Results: Mean Discomfort Scale scores of 7.4±3.7 during the prn arm and 7.2±2.1 during the qid arm (t=0.249, nonsignificant) were within the range previously shown to indicate substantial discomfort. No significant differences in discomfort scores were found between the trial arms after controlling for baseline discomfort and prn use of acetaminophen.

Conclusion: Although this trial was negative in terms of the analgesic effects of acetaminophen, the findings have important implications for clinical practice. Prn administration of acetaminophen is sometimes the standard of care for pain management in nursing homes or is offered as an intervention to assess effectiveness. Findings from this study suggest that a 2,600-mg/d dose of acetaminophen is inadequate for elderly nursing home patients with degenerative joint disease, fractures, or back pain who have significant discomfort. J Am Geriatr Soc 2004;52(7): 1093-1097.

BRIEF REPORTS
The Quality of Medical Care Provided to Vulnerable Older Patients with Chronic Pain
Joshua Chodosh, MD, MSHS, David H. Solomon, MD, Carol P. Roth, RN, MPH, John T. Change, MD, MPH, Catherine H. MacLean, MD, PhD, Bruce A. Ferrell, MD, Paul G. Shekelle, MD, PhD, and Neil S. Wenger, MD, MPH

Objectives: To assess the quality of chronic pain care provided to vulnerable older persons.

Design: Observational study evaluating 11 process-of-care quality indicators using medical records and interviews with patients or proxies covering care received from July 1998 through July 1999.

Setting: Two senior managed care plans.

Participants: A total of 372 older patients at increased risk of functional decline or death identified by interview of a random sample of community dwellers aged 65 and older enrolled in these managed-care plans.

Measurements: Percentage of quality indicators satisfied for patients with chronic pain.

Results: Fewer than 40% of vulnerable patients reported having been screened for pain over a 2-year period. One hundred twenty-three patients (33%) had medical record documentation of a new episode of chronic pain during a 13-month period, including 18 presentations for headache, 66 for back pain, and 68 for joint pain. Two or more history elements relevant to the presenting pain complaint were documented for 39% of patients, and at least one relevant physical examination element was documented for 68% of patients. Treatment was offered to 86% of patients, but follow-up occurred in only 66%. Eleven of 18 patients prescribed opioids reported being offered a bowel regimen, and 10% of patients prescribed noncyclooxygenase-selective nonsteroidal antiinflammatory medications received appropriate attention to potential gastrointestinal toxicity.

Conclusion: Chronic pain management in older vulnerable patients is inadequate. Improvement is needed in screening, clinical evaluation, follow-up, and attention to potential toxicities of therapy. J Am Geriatr Soc 2004;52(5):756-761.