Bereaved Respondent Perceptions of Quality of Care by Site of Death and Palliative Care in the Last Month of Life

Outcomes 1. Participants will be able to demonstrate understanding of the importance of temporality in measuring quality of care, emphasizing the need to assess quality of care over the last month of life as a care episode.2. Participants will be able to identify the need for early palliative care referral and how this may be incorporated into improving the quality of care of palliative care services offered through alternative payment models. Key Message Examining bereaved respondent perceptions of quality of care (QOC) from the NHATS Last Month of Life survey, stratified by site of death and palliative care utilization, dying at home with hospice was associated with higher QOC and improved symptom management, communication, and shared decision-making, revealing the importance of analyzing QOC over the last month of life as a care episode. Introduction/Context Policymakers have developed alternative payment models to control rising patient costs and have recently begun testing these alternative payment models with palliative care services. Quality of care has been proposed as an accountability measure but has not been measured over a care episode such as the last month. Objectives We examined bereaved respondent perceptions of quality of care in the last month of life stratified by site of death and palliative care utilization. Methods Over 2011-2020 (Waves 3-11), we conducted a retrospective cohort study using the National Health Aging Trends Study of U.S. decedents age 65 and older with family member or close friend survey response, using palliative care utilization as the exposure of interest. Primary outcomes included the overall quality of care ratings, symptom management, being treated with respect, spiritual support, communication, and receipt of unwanted care. Results Among 2,796 interviews (weighted N= 12.6 million), 25.8% died at home with hospice, 10.9% home without hospice, 10.0% ICU, 6.4% hospital palliative care unit (PCU), 6.4% hospital hospice IPU, 9.1% hospital without palliative care, 13.1% nursing home without hospice, 9.8% nursing home with hospice, 4.1% hospice residence, and 4.4% other locations without hospice. Dying at home with hospice received the highest rating of the quality of care (60.2% stated excellent care) while other sites of death with palliative care were rated lower: hospice residence 25.6% lower (95% CI (-13.7%, -37.5%)) and a freestanding IPU was 16.9% points lower (95% CI (- 4.9%, -29.0%)). Conclusion While palliative care is associated with higher quality of care, these ratings depend on when decedents receive palliative care referral prior to death. Quality of care ratings were higher for home with hospice compared to other palliative care services, demonstrating the importance of measuring quality over the last month of life as a care episode. Keywords Quality Improvement / Scientific Research