David Casarett

University of Pennsylvania, Filadelfia, Pennsylvania, United States

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Publications (183)1276.18 Total impact

  • Nina R O'Connor · Mary E Moyer · Maryam Behta · David J Casarett
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    ABSTRACT: Inpatient palliative care consultations have been shown to reduce acute care utilization by reducing length of stay, but less is known about their impact on subsequent costs including hospital readmissions. The study's objective was to examine the impact of inpatient palliative care consultations on 30-day hospital readmissions to a large urban academic medical center. The hospital's electronic medical record system was used to identify all live discharges between August 2013 and November 2014. After adjusting for a propensity score, readmission rates were compared between palliative care and usual care groups. Of the 34,541 hospitalizations included in the study, 1430 (4.1%) involved a palliative care consult. After adjusting for the propensity score, patients seen by palliative care had a lower 30-day readmission rate-adjusted odds ratio (AOR) 0.66, 0.55-0.78; p<0.001. Adjusted rates were 10.3% (95% confidence interval [CI] 8.9%-12.0%) for palliative care and 15.0% (95% CI 14.4%-15.4%) for usual care. Among all palliative care patients, consultations that involved goals of care discussions were associated with a lower readmission rate (AOR 0.36, 0.27-0.48; p<0.001), but consultations involving symptom management were not (AOR 1.05, 0.82-1.35; p=0.684). Palliative care palliative care consultations facilitate goals discussions, which in turn are associated with reduced rates of 30-day readmissions.
    Journal of palliative medicine 08/2015; DOI:10.1089/jpm.2015.0138 · 1.91 Impact Factor
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    ABSTRACT: To compare residents of assisted living facilities receiving hospice with people receiving hospice care at home. Electronic health record-based retrospective cohort study. Nonprofit hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network. Individuals admitted to hospice between January 1, 2008, and May 15, 2012 (N = 85,581; 7,451 (8.7%) assisted living facility, 78,130 (91.3%) home). Hospice length of stay, use of opioids for pain, and site of death. The assisted living population was more likely than the home hospice population to have a diagnosis of dementia (23.5% vs 4.7%; odds ratio (OR) = 13.3, 95% confidence interval (CI) = 12.3-14.4; P < .001) and enroll in hospice closer to death (median length of stay 24 vs 29 days). Assisted living residents were less likely to receive opioids for pain (18.1% vs 39.7%; OR = 0.33, 95% CI = 0.29-0.39, P < .001) and less likely to die in an inpatient hospice unit (9.3% vs 16.1%; OR = 0.53, 95% CI = 0.49-0.58, P < .001) or a hospital (1.3% vs 7.6%; OR = 0.16, 95% CI = 0.13-0.19, P < .001). Three are several differences between residents of assisted living receiving hospice care and individuals living at home receiving hospice care. A better understanding of these differences could allow hospices to develop guidelines for better coordination of end-of-life care for the assisted living population. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.
    Journal of the American Geriatrics Society 06/2015; 63(6):1153-1157. DOI:10.1111/jgs.13429 · 4.57 Impact Factor
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    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; 50(3). DOI:10.1016/j.jpainsymman.2015.04.007 · 2.80 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 · 2.80 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):419. DOI:10.1016/j.jpainsymman.2014.11.204 · 2.80 Impact Factor
  • Nina O'Connor · Rong Hu · Pamela Harris · Kevin Ache · David Casarett
    Journal of Pain and Symptom Management 02/2015; 49(2):338-339. DOI:10.1016/j.jpainsymman.2014.11.046 · 2.80 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):334. DOI:10.1016/j.jpainsymman.2014.11.037 · 2.80 Impact Factor
  • Tovah Tripp · Joan Teno · David Casarett · Carol Spence · Melissa Clark
    Journal of Pain and Symptom Management 02/2015; 49(2):382-383. DOI:10.1016/j.jpainsymman.2014.11.134 · 2.80 Impact Factor
  • Journal of Pain and Symptom Management 02/2015; 49(2):345-346. DOI:10.1016/j.jpainsymman.2014.11.061 · 2.80 Impact Factor
  • David Casarett · Laura Bender · Susan Farrington · Joan Teno
    Journal of Pain and Symptom Management 02/2015; 49(2):339-340. DOI:10.1016/j.jpainsymman.2014.11.048 · 2.80 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 · 2.80 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; 48(6). DOI:10.1016/j.jpainsymman.2014.04.003 · 2.80 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 · 1.91 Impact Factor
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    ABSTRACT: Background: 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. Objective: To determine whether this increase in inpatient utilisation is consistent with patient preferences. Design: Retrospective cohort study. Setting: Seven hospices in the Coalition of Hospices Organised to Investigate Comparative Effectiveness (CHOICE) network. Patients: 70 488 patients admitted between 1 July 2008 and 31 May 2012. Measurements: We measured changes in patients' stated preferences at the time of admission regarding site of death, including weights to adjust for non-response bias. We also assessed patients' actual site of death and concordance with patients' preferences. Results: More patients died receiving inpatient care in 2012 as compared to 2008 (1920 (32.7%), 2537 (18.5%); OR 1.21; 95% CI 1.19 to 1.22; p<0.001). However, patients also expressed an increasing preference for dying in inpatient settings (weighted preferences 27.5% in 2012 vs 7.9% in 2008; p<0.001). The overall proportion of patients who died in the setting of their choice (weighted preferences) increased from 74% in 2008 to 78% in 2012 (p<0.001). Limitations: This study included only seven hospices, and results may not be representative of the larger hospice population. Conclusions: Although more patients are dying while receiving inpatient care, these changes in site of death seem to reflect changing patient preferences. The net effect is that patients in this sample were more likely to die in the setting of their choice in 2012 than they were in 2008.
    Supportive and Palliative Care 11/2014; 47(2). DOI:10.1136/bmjspcare-2013-000599
  • Nina R O'Connor · Rong Hu · Pamela S Harris · Kevin Ache · David J Casarett
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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.
    Journal of Clinical Oncology 08/2014; 32(28). DOI:10.1200/JCO.2014.55.8817 · 18.43 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 · 2.80 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 · 2.80 Impact Factor
  • Anjana Ranganathan · Orvar Gunnarsson · David Casarett
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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 · 1.91 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 · 4.57 Impact Factor

Publication Stats

3k Citations
1,276.18 Total Impact Points


  • 2000–2015
    • University of Pennsylvania
      • • Perelman School of Medicine
      • • Department of Medicine
      • • Division of Hematology/Oncology
      • • Center for Health Equity Research
      • • Center for Bioethics
      • • Institute on Aging
      Filadelfia, Pennsylvania, 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
    • Brown University
      • Alpert Medical School
      Providence, Rhode Island, United States
  • 2005
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States
  • 2004
    • United States Department of Veterans Affairs
      Бедфорд, Massachusetts, United States
  • 2001
    • American college of Physicians
      Filadelfia, Pennsylvania, United States
  • 1998
    • University of Iowa Children's Hospital
      Iowa City, Iowa, United States
  • 1997–1998
    • University of Chicago
      Chicago, Illinois, United States