Anthi Katsouli, MD, MPH

Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.

Study design: Cross-sectional observational study.

Setting: Using the United States Renal Data System registry.

Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.

Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.

The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.

Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.

Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.

Study design: Cross-sectional observational study.

Setting: Using the United States Renal Data System registry.

Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.

Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.

The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.

Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.

Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.

Study design: Cross-sectional observational study.

Setting: Using the United States Renal Data System registry.

Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.

Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.

The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.

Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.

Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

Study design: Randomized, double-blind, placebo-controlled study.

Setting: Tertiary referral teaching hospital.

Synopsis: A randomized, double-blind trial including a total of 1,805 patients aged 18-75 years who were scheduled for eligible surgery was conducted at a single-center, tertiary referral teaching hospital. The treatment group received 1,200 mg of gabapentin preoperatively followed by 600 mg 3 times a day postoperatively. Meanwhile, the placebo group received lorazepam 0.5 mg preoperatively followed by inactive placebo postoperatively for 72 hours. With use of intention to treat analysis, this study showed that perioperative gabapentin did not affect time to postoperative pain resolution. However, a modest increase in the rate of opioid cessation was uncovered. Specifically, there was a 24% increase in the rate (hazard ratio, 1.24; 95% confidence interval, 1.00-1.54; P = .05) of opioid cessation after hospital discharge, with a median time of 25 days in the gabapentin group versus 32 days in the placebo group.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

Study design: Randomized, double-blind, placebo-controlled study.

Setting: Tertiary referral teaching hospital.

Synopsis: A randomized, double-blind trial including a total of 1,805 patients aged 18-75 years who were scheduled for eligible surgery was conducted at a single-center, tertiary referral teaching hospital. The treatment group received 1,200 mg of gabapentin preoperatively followed by 600 mg 3 times a day postoperatively. Meanwhile, the placebo group received lorazepam 0.5 mg preoperatively followed by inactive placebo postoperatively for 72 hours. With use of intention to treat analysis, this study showed that perioperative gabapentin did not affect time to postoperative pain resolution. However, a modest increase in the rate of opioid cessation was uncovered. Specifically, there was a 24% increase in the rate (hazard ratio, 1.24; 95% confidence interval, 1.00-1.54; P = .05) of opioid cessation after hospital discharge, with a median time of 25 days in the gabapentin group versus 32 days in the placebo group.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

Study design: Randomized, double-blind, placebo-controlled study.

Setting: Tertiary referral teaching hospital.

Synopsis: A randomized, double-blind trial including a total of 1,805 patients aged 18-75 years who were scheduled for eligible surgery was conducted at a single-center, tertiary referral teaching hospital. The treatment group received 1,200 mg of gabapentin preoperatively followed by 600 mg 3 times a day postoperatively. Meanwhile, the placebo group received lorazepam 0.5 mg preoperatively followed by inactive placebo postoperatively for 72 hours. With use of intention to treat analysis, this study showed that perioperative gabapentin did not affect time to postoperative pain resolution. However, a modest increase in the rate of opioid cessation was uncovered. Specifically, there was a 24% increase in the rate (hazard ratio, 1.24; 95% confidence interval, 1.00-1.54; P = .05) of opioid cessation after hospital discharge, with a median time of 25 days in the gabapentin group versus 32 days in the placebo group.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.