David Casarett

University of Pennsylvania, Filadelfia, Pennsylvania, United States

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Publications (180)1191 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: In the United States, hospices sometimes provide high-intensity "continuous care" in patients' homes. However, little is known about the way that continuous care is used, or what impact continuous care has on patient outcomes. To describe patients who receive continuous care, and to determine whether continuous care reduces the likelihood that patients will die in an inpatient unit or hospital. Data from 147,137 patients admitted to 11 U.S. hospices between 2008 and 2012 were extracted from the electronic medical records. The hospices are part of a research-focused collaboration. The study used a propensity score-matched cohort design. A total of 99,687 (67.8%) patients were in a private home or nursing home on the day before death, and of these, 10,140 (10.2%) received continuous care on the day before death. A propensity score-matched sample (N=24,658) included 8524 patients who received continuous care and 16,134 patients who received routine care on the day before death. Using the two matched groups, patients who received continuous care on the day before death were significantly less likely to die in an inpatient hospice setting (350/8524 vs. 2030/16,134; 4.1% vs. 12.6%) (odds ratio [OR] 0.29; 95% confidence interval [CI] 0.27-0.34; P<0.001). When patients were cared for by a spouse, the use of continuous care was associated with a larger decrease in inpatient deaths (OR 0.12; 95% CI 0.09-0.16; P<0.001) compared to those patients cared for by other family members (OR 0.37; 95% CI 0.32-0.42; P<0.001). It is possible that unmeasured covariates were not included in the propensity score match. Use of continuous care on the day before death is associated with a significant reduction in the use of inpatient care on the last day of life, particularly when patients are cared for by a spouse. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
    Journal of pain and symptom management 04/2015; DOI:10.1016/j.jpainsymman.2015.04.007 · 2.74 Impact Factor
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    ABSTRACT: Measuring quality of hospice and palliative care is critical for evaluating and improving care, but no standard U.S. quality indicator set exists. The Measuring What Matters (MWM) project aimed to recommend a concise portfolio of valid, clinically relevant, cross-cutting indicators for internal measurement of hospice and palliative care. MWM was a sequential consensus project of the American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA). We identified candidate indicators mapped to National Consensus Project (NCP) Palliative Care Guidelines domains. We narrowed the list through a modified Delphi rating process by a Technical Advisory Panel and Clinical User Panel and ratings from AAHPM and HPNA membership and key organizations. We narrowed the initial 75 indicators to a final list of 10. These include one in the NCP domain Structure and Process (Comprehensive Assessment), three in Physical Aspects (Screening for Physical Symptoms, Pain Treatment, Dyspnea Screening and Management), one in Psychological and Psychiatric Aspects (Discussion of Emotional or Psychological Needs), one in Spiritual and Existential Aspects (Discussion of Spiritual/Religious Concerns), and three in Ethical and Legal Aspects (Documentation of Surrogate, Treatment Preferences, and Care Consistency with Documented Care Preferences). The list also recommends a global indicator of patient/family perceptions of care, but does not endorse a specific survey instrument. This consensus set of hospice and palliative care quality indicators is a foundation for standard, valid internal quality measurement for U.S. settings. Further development will assemble implementation tools for quality measurement and benchmarking. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
    Journal of Pain and Symptom Management 02/2015; 49(4). DOI:10.1016/j.jpainsymman.2015.01.012 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):419. DOI:10.1016/j.jpainsymman.2014.11.204 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):338-339. DOI:10.1016/j.jpainsymman.2014.11.046 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):334. DOI:10.1016/j.jpainsymman.2014.11.037 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):382-383. DOI:10.1016/j.jpainsymman.2014.11.134 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):345-346. DOI:10.1016/j.jpainsymman.2014.11.061 · 2.74 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):339-340. DOI:10.1016/j.jpainsymman.2014.11.048 · 2.74 Impact Factor
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    ABSTRACT: The Centers for Medicare & Medicaid Services have elected to include a bereaved family member survey in public reporting of hospice quality data as mandated in the Affordable Care Act. However, it is not known what timepoint after death offers the most reliable responses. To examine the stability of bereaved family members' survey responses when administered three, six and nine months after hospice patient death. Bereaved family members from six geographically diverse hospices were interviewed three, six, and nine months after patient death. All respondents completed a core survey. Those whose family member died at home, in a free-standing inpatient unit, or in a nursing home also completed a site-specific module. Stability was based on top-box scoring of each item with kappa statistics, and multivariable regression models were used to assess directionality and predictors of change. To analyze the effects of grief, we assessed response stability among respondents at least one standard deviation from the mean change in grief between three and six months. We had 1532 surveys (536 three-month surveys, 529 six-month surveys, and 467 nine-month surveys) returned by 643 respondents (average age 61.7 years, 17.4% Black, 50.5% a child respondent) about hospice decedents (55.3% female, average age 78.6 years, 57.0% non-cancer, 40.0% at home.) The average kappa for core items between three and nine months was 0.54 (range: 0.42-0.74), 0.58 (0.41-0.69) for home-specific items, and 0.54 (0.39-0.63) for nursing home. Even among individuals demonstrating large grief changes, core items demonstrated moderate to high stability over time. Bereaved family member responses are stable between three and nine months after the death of the patient. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
    Journal of Pain and Symptom Management 01/2015; 49(2). DOI:10.1016/j.jpainsymman.2015.01.006 · 2.74 Impact Factor
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    ABSTRACT: Context Nursing homes (NHs) are increasingly the site of hospice care. High quality of care is dependent on successful NH-hospice collaboration. Objectives To examine bereaved family members’ perceptions of NH-hospice collaborations in terms of what they believe went well or could have been improved. Methods Focus groups were conducted with bereaved family members from five diverse geographic regions, and included participants from inner-city and rural settings, with over-sampling of blacks. Results Twenty-eight participants (14.8% African American, mean age 61.4 years) identified three major aspects of collaboration as important to care delivery. First, the majority (67.9%) voiced concerns with knowing who (NH or hospice) is responsible for which aspects of patient care. Second, nearly half (42.9%) stated concern about information coordination between the NH and hospice. Finally, 67.9% of participants mentioned the need for hospice to advocate for high-quality care rather than their having to directly do so on behalf of their family members. Conclusion The important concerns raised by bereaved family members about NH-hospice collaboration have been incorporated into the revised Family Evaluation of Hospice Care (FEHC), a post-death survey used to evaluate quality of hospice care.
    Journal of pain and symptom management 12/2014; DOI:10.1016/j.jpainsymman.2014.04.003 · 2.74 Impact Factor
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    ABSTRACT: Abstract Background: Most pediatric hospice patients receive services from agencies typically oriented to adults. Information regarding how pediatric hospice patients differ from adult hospice patients is lacking. Objective: We aim to assess differences between pediatric and adult hospice patients regarding patient characteristics and outcomes. Methods: We compiled a retrospective inception cohort of patients enrolled at nine hospices in the CHOICE network (Coalition of Hospices Organized to Investigate Comparative Effectiveness) between August 1, 2008 and June 30, 2012. Measurements included patient characteristics and outcomes, including discharge from hospice and site of death. Results: Among 126,620 hospice patients, 986 (0.8%) were 18 years of age or younger. Pediatric patients were less likely to have an admitting diagnosis of cancer (odds ratio [OR] 0.62; 95% confidence interval [CI]: 0.54-0.72). Although children were less likely to use oxygen at enrollment (OR 0.31; 95% CI: 0.26-0.37), they were more likely to have an enteral feeding tube (OR 4.04; 95% CI: 3.49-4.67). Pediatric patients were half as likely as adults to have a do-not-resuscitate order (DNR) order upon hospice enrollment (OR 0.52; 95% CI: 0.46-0.59). The average hospice length of stay for pediatric patients was longer than that of adults (103 days versus 66 days, p<0.001). Children were more likely to leave hospice care (OR 2.59; 95% CI: 2.00-3.34), but among patients who died while enrolled in hospice, pediatric patients were more likely to die at home (OR 3.25; 95% CI: 2.27-3.88). Conclusions: Pediatric hospice patients differ from adult patients in their broader range of underlying diagnoses and their use of hospice services.
    Journal of Palliative Medicine 11/2014; 18(2). DOI:10.1089/jpm.2014.0195 · 2.06 Impact Factor
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    ABSTRACT: Growth in hospice utilisation has been accompanied by an increase in the proportion of hospice patients who die in an inpatient hospice setting rather than at home.
    Supportive and Palliative Care 11/2014; 47(2). DOI:10.1136/bmjspcare-2013-000599
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    ABSTRACT: Purpose To define patient characteristics associated with hospice enrollment in the last 3 days of life, and to describe adjusted proportions of patients with late referrals among patient subgroups that could be considered patient-mix adjustment variables for this quality measure. Methods Electronic health record-based retrospective cohort study of patients with cancer admitted to 12 hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network. Results Of 64,264 patients admitted to hospice with cancer, 10,460 (16.3%) had a length of stay <= 3 days. There was significant variation among hospices (range, 11.4% to 24.5%). In multivariable analysis, among patients referred to hospice, patients who were admitted in the last 3 days of life were more likely to have a hematologic malignancy, were more likely to be male and married, and were younger (age < 65 years). Patients with Medicaid or self-insurance were less likely to be admitted to hospice within 3 days of death. Conclusion Quality measures of hospice lengths of stay should include patient-mix adjustments for type of cancer and site of care. Patients with hematologic malignancies are at especially increased risk for late admission to hospice. (C) 2014 by American Society of Clinical Oncology
    Journal of Clinical Oncology 08/2014; 32(28). DOI:10.1200/JCO.2014.55.8817 · 17.88 Impact Factor
  • Thomas W. LeBlanc, Amy P. Abernethy, David J. Casarett
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    ABSTRACT: Context. Although much is known about solid tumor patients who utilize hospice, the hematologic malignancies hospice population is inadequately described. Objectives To compare the characteristics and outcomes of hospice patients with hematologic malignancies to those with solid tumors. Methods We extracted electronic patient data (2008-2012) from a large hospice network (CHOICE), and used bivariate analyses to describe between-group differences. Results In total, 48,147 patients with cancer were admitted during the study period; 3518 (7.3%) had a hematologic malignancy. These patients had significantly worse Palliative Performance Scale scores (32% vs. 24% were below 40; P<0.001) and shorter lengths of stay (median 11 days vs. 19; P<0.001). They were more likely to die within 24 hours of hospice enrollment (10.9% vs. 6.8%; odds ratio [OR] 1.66, 95% confidence interval [CI] 1.49, 1.86, P<0.001) or within seven days (36% vs. 25.1%; OR 1.68, 95% CI 1.56, 1.81, P<0.001), and were more likely to receive hospice services in an inpatient or nursing home setting (OR 1.34, 95% CI 1.16, 1.56, and OR 1.54, 95% CI 1.39, 1.72, both P<0.001). Among hematologic malignancy patients, those with leukemia had the shortest survival (hazard ratio 1.23, 95% CI 1.13, 1.34, P<0.001), and 40.3% used hospice for less than seven days (OR 1.31, 95% CI 1.11, 1.56, P=0.002). Conclusion Hospice patients with hematologic malignancies are more seriously ill at time of admission, with worse functional status and shorter length of stay than other cancer patients. Differences in outcomes suggest the need for targeted interventions to optimize hospice services for the hematologic malignancies population, especially those with leukemia.
    Journal of Pain and Symptom Management 08/2014; 49(3). DOI:10.1016/j.jpainsymman.2014.07.003 · 2.74 Impact Factor
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    ABSTRACT: Palliative medicine must prioritize the routine assessment of the quality of clinical care we provide. This includes regular assessment, analysis, and reporting of data on quality. Assessment of quality informs opportunities for improvement and demonstrates to our peers and ourselves the value of our efforts. In fact, continuous messaging of the value of palliative care services is needed to sustain our discipline; this requires regularly evaluating the quality of our care. As the reimbursement mechanisms for health care in the United States shift from fee-for-service to fee-for-value models, palliative care will be expected to report robust data on quality of care. We must move beyond demonstrating to our constituents (including patients and referrers), “here is what we do,” and increase the focus on “this is how well we do it” and “let’s see how we can do it better.” It is incumbent on palliative care professionals to lead these efforts. This involves developing standardized methods to collect data without adding additional burden, comparing and sharing our experiences to promote discipline-wide quality assessment and improvement initiatives, and demonstrating our intentions for quality improvement on the clinical frontline.
    Journal of Pain and Symptom Management 07/2014; 49(2). DOI:10.1016/j.jpainsymman.2014.06.008 · 2.74 Impact Factor
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    ABSTRACT: Patients diagnosed with an advanced cancer frequently have a very limited life expectancy and need to understand their prognosis in order to make good choices about care. Advance care planning (ACP) is an important aspect of this care but can be especially difficult to address. Most patients and families prefer direct and honest communication, but they may interpret the information they are given in very different ways. In addition, oncologists strive to communicate honestly and sensitively, but often struggle with the best approach. Finally, standardization of ACP is challenging because patients have highly individualized values, traditions and social and family dynamics that guide their preferences. Palliative Care is a rapidly growing field that specializes in communication and patient-centered approaches to care. Treatment of patients with advanced or metastatic cancer should prioritize early discussions of ACP to ensure high quality end-of-life care. When available, this care should be delivered through careful integration with palliative care specialists.
    07/2014; 3(3):144-149. DOI:10.3978/j.issn.2224-5820.2014.07.04
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    ABSTRACT: Abstract Objective: To determine whether it is possible to predict, at the time of hospice enrollment, which patients will die within 6 months. Design: Electronic health record-based retrospective cohort study. Setting: Patients admitted to 10 hospices in the CHOICE network (Coalition of Hospices Organized to Investigate Comparative Effectiveness). Participants: Hospice patients. Main outcome measures: Mortality at 6 months following hospice admission. Results: Among 126,620 patients admitted to 10 hospices, 118,532 (93.6%) died within 6 months. In a multivariable logistic regression model, five characteristics were independent predictors of 6-month mortality. For instance, patients younger than 65 years were less likely to die within 6 months (odds ratio [OR] 0.64; 95% confidence interval [CI] 0.45-0.91; p=0.014). Conversely, male patients were more likely to die within 6 months (OR 1.47; 95% CI 1.05-2.02; p=;0.036). After adjusting for other variables in this model, there were several subgroups with a low probability of 6-month probability (e.g., stroke and Palliative Performance Scale [PPS] score=50; adjusted probability of 6-month mortality=39.4%; 95% CI: 13.9%-72.5%). However, 95% confidence intervals of these 6-month mortality predictions extended above 50%. Conclusions: Hospices might use several variables to identify patients with a relatively low risk for 6-month mortality and who therefore may become ineligible to continue hospice services if they fail to show significant disease progression.
    Journal of Palliative Medicine 06/2014; 17(8). DOI:10.1089/jpm.2013.0631 · 2.06 Impact Factor
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    ABSTRACT: Objectives To describe individuals with advance directives at the time of hospice enrollment and to determine whether they have patterns of care and outcomes that are different from those of individuals without advance directives. Design Electronic health record-based retrospective cohort study with propensity score-adjusted analysis. Setting Three hospice programs in the United States. Participants Individuals admitted to hospice between January 1, 2008, and May 15, 2012 (N=49,370). Measurements Timing of hospice enrollment before death, rates of voluntary withdrawal from hospice, and site of death. Results Most participants (35,968, 73%) had advance directives at the time of hospice enrollment. These participants were enrolled in hospice longer (median 29 vs 15days) and had longer survival times before death (adjusted hazard ratio=0.62; 95% confidence interval (CI) 0.58-0.66; P<.001). They were less likely to die within the first week after hospice enrollment (24.3% vs 33.2%; adjusted odds ratio (aOR)=0.83, 95% CI=0.78-0.88; P<.001). Participants with advance directives were less likely to leave hospice voluntarily (2.2% vs 3.4%; aOR=0.82, 95% CI=0.74-0.90; P=.003) and more likely to die at home or in a nursing home than in an inpatient unit (15.3% vs 25.8%; aOR=0.82, 95% CI=0.77-0.87; P<.001). Conclusion Participants with advance directives were enrolled in hospice for a longer period of time before death than those without and were more likely to die in the setting of their choice.
    Journal of the American Geriatrics Society 05/2014; 62(6). DOI:10.1111/jgs.12851 · 4.22 Impact Factor
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    ABSTRACT: Most patients will lose decision-making capacity at the end of life. Little is known about the quality of care received by patients who have family involved in their care. To evaluate differences in the receipt of quality end-of-life care for patients who died with and without family involvement. We retrospectively reviewed the charts of 34,290 decedents from 146 acute and long-term care VA facilities between 2010-2011. Outcomes included: 1) palliative care consult; 2) chaplain visit; and 3) death in an inpatient hospice/palliative care unit. We also assessed DNR orders. Family involvement was defined as documented discussions with the health care team in the last month of life. We used logistic regression adjusted for demographics, comorbidity, and clustered by facility. For chaplain visit, hospice/palliative care unit death, and DNR, we additionally adjusted for palliative care consults. Mean (SD) age was 74(± 12) years, 98% were men, and 19% were non-White. Most decedents (94.2%) had involved family. Veterans with involved family were more likely to have had a palliative consult, AOR 4.31 (95% CI 3.90-4.76), a chaplain visit, AOR 1.18 (95% CI 1.07-1.31), and a DNR order, AOR 4.59 (95% CI 4.08-5.16), but not more likely to die in a hospice/palliative care unit. Family involvement at the end of life is associated with receipt of palliative care consultation and a chaplain visit, and a higher likelihood of a DNR order. Clinicians should support early advance care planning for vulnerable patients who may lack family or friends.
    Journal of pain and symptom management 05/2014; DOI:10.1016/j.jpainsymman.2014.04.001 · 2.74 Impact Factor
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    ABSTRACT: Abstract Background: All hospices were required by the Centers for Medicare and Medicaid Services (CMS) to collect the "Comfortable Dying" measure in 2012 (National Quality Forum measure #0209). However, it is not known how scores on this measure are affected by patient characteristics. It is important to identify these characteristics so that a hospice's case mix can be taken into account when interpreting its scores. Objective: Our aim was to describe the implementation of the NQF #0209 measure in 10 hospices and to identify patient characteristics associated with scores. Methods: We conducted an electronic health record (EHR)-based retrospective cohort study of patients in 10 hospices in the United States. The main outcome measure was the proportion of patients with pain that made them uncomfortable whose pain was controlled within 48 hours. Results: A total of 4157 patients were eligible for an initial pain assessment. Of those who reported pain (n=1992), 1152 (58%) reported having their pain controlled on the follow-up assessment. In a multivariable regression model, clustered by hospice, six variables were independently associated with pain control. These included age (adjusted odds ratio [OR] 1.02; 95% confidence interval [CI] 1.02-1.03, p=0.003), a cancer diagnosis (OR 1.37; 95% CI 1.20-1.53, p=0.008), initial care in an inpatient unit (OR 1.28; 95% CI 1.08-1.47, p=0.031), presence of a Foley catheter (OR 1.40; 95% CI 1.15-1.59, p=0.038), use of opioid medication (OR 1.34; 95% CI 1.03-1.74, p=0.027), and higher Palliative Performance Scale (PPS) score (OR 1.02; 95% CI 1.01-1.03, p<0.001). Presence of a Stage 2 pressure ulcer was independently associated with worse pain control (OR 0.63; 95% CI 0.31-0.96, p=0.012). Conclusions: Several patient characteristics are associated with #0209 pain scores. As hospices are increasingly required to report quality measures, it will be essential to understand how their scores are affected by case mix.
    Journal of palliative medicine 04/2014; 17(6). DOI:10.1089/jpm.2013.0571 · 2.06 Impact Factor

Publication Stats

3k Citations
1,191.00 Total Impact Points


  • 2001–2015
    • University of Pennsylvania
      • • Perelman School of Medicine
      • • Department of Medicine
      • • Center for Health Equity Research
      • • Institute on Aging
      • • Graduate School of Education
      Filadelfia, Pennsylvania, United States
    • The Philadelphia Center
      • Philadelphia Veterans Administration Medical Center
      Philadelphia, Pennsylvania, United States
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
  • 2003–2014
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 2000–2010
    • Philadelphia University
      Filadelfia, Pennsylvania, United States
  • 2008
    • The Children's Hospital of Philadelphia
      Filadelfia, Pennsylvania, United States
  • 2007
    • Rhode Island Hospital
      Providence, Rhode Island, United States
  • 1997–2007
    • University of Chicago
      Chicago, Illinois, United States
  • 2005
    • Brown University
      Providence, Rhode Island, United States
    • Temple University
      Filadelfia, Pennsylvania, United States
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States
  • 1999
    • University of Iowa
      • Department of Internal Medicine
      Iowa City, Iowa, United States