Center to Advance Palliative Care

These are good questions. Let me address your last two statements first. An acute patient who is 'discharged' to inpatient hospice and immediately enrolled in the Medicare Hospice Benefit -- that is he/she remains in the same hospital (even in the same bed) but is now treated under Hospice -- is technically a live discharge from the hospital's acute care perspective. This does not necessarily mean that third parties such as CMS, Joint Commission, and various award programs such as HealthGrades, USNews's "Best Hospitals" and Thomson/Solucient's "Top Hospitals" will interpret this the same way. For example CMS and JC use 30-day mortality from admission for heart failure, heart attack and pneumonia as quality measures; and the metric is based on the expected versus observed volume of deaths, not the gross or raw number of deaths. JC and CMS will exclude cases which had a Medicare Hospice Benefit claim in 12 months PRIOR to the index admission... but they don't exclude cases which enroll in Hospice during/immediately after the index admission, nor do they exclude index admissions which had the V66.7 "palliative care encounter" diagnosis code among diagnoses. Regarding your last sentence, your thinking is not correct. The presence of the V66.7 code does not make the index admission "expected". The risk-adjustment methodologies differ from one metrix to another, but generally they are taking into account the patient's entire set of diagnoses (and demographics and hospital characteristics, too) to determine expectedness of deaths. CMS has a readable description of its own methodology at its Hospital Compare website, http://www.hospitalcompare.hhs.gov/

Regarding the question posed earlier, about the potential need for two different EOL codes, you'all are right in pointing out that the current code catches all aspects of PC, EOL and Hospice involvement which may include any physician ordering "comfort care" order sets for a patient without distinct involvement of an actual PC team. Whether this is a good thing or not is certainly one of the questions CAPC is attending to, as it works with other groups such as HPNA, NHPCO and AAHPM to examine the issue of mortality statistics. That effort is active and on-going. I recommend the Holloway & Quill article, "Mortality as a measure of quality" JAMA Aug 15 2007, vol 298 # 7, pp. 802-804. Let me know what you think. Brian Cassel, VCU PCLC, jbcassel@vcu.edu, 804-628-1926.