Talk:Hospice care in the United States/GA1

GA Review
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Initial thoughts
This article looks good and will probably go through review OK. Please be patient - it may take me a few days to fully review. hamiltonstone (talk) 01:39, 15 March 2009 (UTC)
 * Thank you for undertaking review. :) --Moonriddengirl (talk) 02:26, 15 March 2009 (UTC)

Review points
This is a very promising article of which you (plural) should be proud.

Not all of the following is necessary to pass GA. The points beginning "%" are desirable but would not prevent it reaching GA. I would suggest they would be necessary to reach Featured Article status (nothing wrong with a bit of ambition!).
 * Para 2 of lead: I am not sure about the words "Largely defined by the Medicare system and other health insurance providers,..." I think my main issue is the use of the word "defined". Do you mean it is largely funded by the insurers? Or provided (which seems unlikely)? If it means something more complex, such as that the nature of hospice care is shaped by the funding, policies, and/or other features of the insuring bodies, the sentence may need to become two sentences to make that more explicit. My minor concern is that Medicare is a term that means something a bit different in Australia. I accept that this can be addressed by a reader by clicking on the link. Rather than using the proper name, maybe one could describe it, such as "the public health insurance system for older Americans" (though I realise that is actually not entirely accurate). Have a think, and maybe on balance the only realistic way is to retain it as is.
 * Oh. You could use the phrase from the body text: "a social insurance program in the United States" :-)


 * Para 2 of lead: Perhaps because I am not American, I do not know what "length of service" means. Is this a reference to amount of time a person has had health insurance?
 * A major fact that should be in the lead and the body is how many people are in hospice care at a given time. It is strange to have stats like number of hospices, rate of growth of sector and average length of stay, but not how many patients are actually involved. Is a figure available?
 * % Can you take or get a photograph of one or more types of hospice / hospice facility? The article would benefit from some images.
 * History para 1: where are St Joseph's Hospice and St Christopher's Hospice? USA? England? Just a brief indication of location would be good.
 * % Is 1995 the most recent date for which the value and percentage non-profit figures are available? It seems a fair while ago.
 * Philosophy para 1 states "Hospices typically do not perform treatments that are meant to diagnose or cure an illness.[10] In keeping with this philosophy, many hospice patients, though not all,[11] have made decisions not to receive CPR should their heart or breathing stop. Hospice does not seek to hasten death or extend life" This is a tricky area. I have three concerns with these sentences.
 * Although hospices do not perform curative treatments, I have difficulty with the notion that a patient's choice not to receive CPR is in any way connected with this. Is it the case that there are hopsices that would not provide CPR if a patient wished to receive it in the event of heart failure? While I imagine some may not be equiped for this, that does not seem to be related to their philosophy or function. "In keeping with this..." seems the wrong way to approach this subject.
 * Second, I would not suggest that the fact that hopsices to do not do diagnosis etc is a matter of "philosophy". It seems the wrong word. It may be a matter of policy, or a feature of the functional divisions in the health care system.
 * Third, "Hospice does not seek to hasten death or extend life" is probably the general philosophy of some in the sector, but I would suggest not all. There may be a point-of-view (POV) issue here. I would suggest that some hospices would regard "extending life" (possibly expressed as "extending the quality of life", but probably including extending life in practical terms) as part of their objective. You might want to look carefully at the objectives or operational parameters of any hospices administered within the Catholic Church's care arm, for example (I am assuming there are such entities in the US as there are here). I am not an expert, though, and am happy to hear further discussion of this. I would certainly suggest that the sentence "Hospice does not seek to hasten death or extend life" needs its own citation.
 * % Sorry - it does have its own citation. OK. I note this comes from a care manual. I think you may wish to go to an academic text that analyses and reflects upon hospice care and see if they are saying the same thing. But the current citation is good enough for GA.


 * % Philosophy: "...and Medicare regulations reflect this philosophy." Can you give a concrete example of how the regs demonstrate patient-centred philosophy and provide a ref that states that the regs reflect this change in philosophy?
 * Hospice demographic para 2: "Many physicians are slow to refer to hospice care, waiting until they are absolutely certain of a terminal prognosis, because they believe that the patient must have a six month prognosis or less or because they are overly optimistic in their assessment of prognosis, presuming treatment will be more effective than it is". I got lost a little here. Try splitting the sentence in two.
 * I am surprised by the expression "on hospice" rather than "in hospice", but I take it that that is common practice. Actually, it makes sense, because only some hopsice care patients are actually in a hospice facility. Forget it :-)
 * Re-certification: This section makes reference to "Commercial, managed care and Medicaid often have their own individual regulations..." This was confusing on two levels. First, it was the first reference to "commercial", "managed care", or "Medicaid", and I don't know what they mean. Looking further on, i thought I might find the answer in the section "Providers". But this is almost entirely about the care team. As a reader, I somehow need to find out what these types of care provider are. One option would be to expand the sentence in the re-cert section, but my preferred option (probably the one major improvement I think the article needs) is a new section regarding service providers (by which I mean organisations, not care team members).
 * Expense. This section needs to begin with some sort of more general sentence, before diving into the detail of how costs are met for different people. It would go something like "The cost of hospice care may be met by health insurance providers, including Medicare for eligible Americans, blah blah..."
 * Expense. Major missing fact: how much do patients actually pay for hospice care? I don't mean how much is spent on the system - I mean what are the typical costs faced by an individual patient?
 * Levels of care: "All hospices in the United States certified by Medicare are required to offer each of these levels of care." Are there non-certified hopsices that only offer three or less of the levels? Are they a significant element of the overall hopsice care system?
 * Routine home care: "In spite of its title, routine home care does not indicate a location of care, but a level (or intensity) of care provided." Because this is indeed counter-intuitive, the sentence should have its own citation.
 * % "...continuous care is usually only provided for a maximum of about three to five days." Can you provide a citation for this?
 * Providers: As mentioned above, the significant omission from this article is a description of the industry structure. Who are the main financiers of care? Who are the main service providers? (to illustrate what I am thinking, if I were writing this in Australia, it would say something like "X percent / about one third / whatever of hopsice care is provided by the two church-administered national service providers Anglicare and Catholic Health Australia. Other religious-affiliated organisations, such as Baptist Care Queensland, provide significant facilities in some regional areas. State governments administer X percent of facilities, with a particular focus on high-needs patients. The Commonwealth government, while providing X funding through the Y policy, is not a service provider itself." That's the kind of thing I have in mind. One to two paras. I would assume there would be a (govt?) report summarising such features of the industry (or an industry peak body document?)
 * baby's awake - gotta go! This is a great article. See how you go with the above. I'll keep tabs on things and provide a bit more input during the weekend. hamiltonstone (talk) 01:41, 21 March 2009 (UTC)


 * Thank you. It's fairly late in my part of the world, so I'll try to respond with what I can tomorrow. :) --Moonriddengirl (talk) 02:47, 21 March 2009 (UTC)

Lead

 * Para 2 of lead: "Largely defined" & explaining Medicaire: sentence now reads "With practices largely defined by the Medicare system, a social insurance program in the United States, and other health insurance providers...." --Moonriddengirl (talk) 14:40, 21 March 2009 (UTC)
 * Length of service: clarified (I hope. :)) --Moonriddengirl (talk) 16:25, 21 March 2009 (UTC)
 * # of people: have found a reliable news source with # and % of Americans as of 2007 & 2008. Added to lead and with other stats in history. (I've also located more recent values, which I have added to the history section. I've renamed that accordingly.) --Moonriddengirl (talk) 14:53, 21 March 2009 (UTC)

Body

 * St. Joseph's & St. Christopher's in London. So noted. --Moonriddengirl (talk) 15:19, 21 March 2009 (UTC)
 * Confusing sentence, "Many physicians are slow..." divided. Helpful, or more clarity needed? --Moonriddengirl (talk) 15:19, 21 March 2009 (UTC)
 * Expense. General intro expanded. Adding some info on expenses, but so far the only out-of-pocket payments I've found relate to in-home care. Still looking. --Moonriddengirl (talk) 15:46, 21 March 2009 (UTC)
 * I've added a bit on co-pay for private insurance, but there may not be specific out-of-pocket information on that or on in-patient care. I've scanned several years worth of google news without finding anything. --Moonriddengirl (talk) 16:23, 21 March 2009 (UTC)
 * (%)I haven't been able to source the continuous care of three to five days, so I've changed it to a less precise statement that I can source, pending location of a specific one. --Moonriddengirl (talk) 16:40, 21 March 2009 (UTC)
 * "In spite of its title, routine home care does not indicate a location of care, but a level (or intensity) of care provided" This may be one where clarification of language is needed, more than additional sources. The next sentence (which is sourced) notes that routine home care can also be provided in an institutional setting, like a nursing home. That's what's meant by not indicating location. Intensity is by contrast to "continuous care"; that is, this care is routine and does not require the same amount of intervention as continuous care, though it may also be located at home. Would it make more sense to cut out the confusing statement or to try to reword that? :) --Moonriddengirl (talk) 17:03, 21 March 2009 (UTC)
 * Non-certified. Yes, there are. I've added some detail on these in the "Provider section." --Moonriddengirl (talk) 17:24, 21 March 2009 (UTC)
 * I separated out the Interdisciplinary team material from Providers, since that's gone more into agencies now. --Moonriddengirl (talk) 18:38, 21 March 2009 (UTC)
 * I haven't found specifically the kind of information you mentioned; while there are large for-profit agencies, such as Odyssey Healthcare and VITAS (the self-proclaimed biggest) we don't seem to have much by way of national services...at least none that I've found so far. Do you believe that the agency information I've drawn from the NHPCO is sufficient? Most of the news reports I've found discussing individual agencies have been press releases. --Moonriddengirl (talk) 18:57, 21 March 2009 (UTC)
 * "Commercial, managed care and Medicaid" are all types of insurance agencies (well, managed care is a little more than that; somewhat complex) and not specifically related to hospice, although obviously important in that context. :) Though I did expand the section on service providers, I've gone more into detail on financiers of care--including noting the percentage covered by Medicare--under Expense. Please let me know if you don't think sufficient attention has been paid to insurance providers. Would a More note under Expense linking to Health insurance in the United States be of use here? I haven't done a lot of work on GA, and I don't really know if that's standard. --Moonriddengirl (talk) 19:02, 21 March 2009 (UTC)
 * I'm having trouble finding sources to answer your question about hospices that do not offer all levels of care, but, yes, there are. Non-certified hospices composed entirely of volunteers do not have inpatient facilities, for example. These are not statistically a major portion of hospices in the US, obviously, as less than 7% of hospices are not certified. (My source did not indicate how many were content to remain not-certified, but it seems small.) Do you have a suggestion for how to approach this without OR? :) --Moonriddengirl (talk) 19:18, 21 March 2009 (UTC)
 * Regarding hospices who don't provide all levels of care, you wont be able to prove it because in order to be licensed they have to offer all levels of care. However, you would have to be an "insider" to know that not all hospice's provides all levels of care; notably continuous and general inpatient. Also, your right there is nothing about 3-5 days being the average for continuous care, I was letting my own bias in there. It should be changed to "continuous care is offered for short periods of time for the purpose of controlling symptoms"Tbolden (talk) 19:45, 21 March 2009 (UTC)

Still working on

 * Philosophy para 1, "Hospices typically do not..." with related subpoints. --Moonriddengirl (talk) 15:19, 21 March 2009 (UTC)

Images

 * I have so far been unable to find a usable photo of a hospice in the US at commons or elsewhere and have asked User:Tbolden if he can help. --Moonriddengirl (talk) 15:14, 21 March 2009 (UTC)

Final (hopefully!) thoughts
This article is going really well and is very close to GA. I think there are three things left to do: These last two sources are vital, as they substantiate some controversial arguments (I have no issue with them myself, but they will sooner or later attract attention). See what you can do on these, and I hope I will be ticking this off soon. Excellent work!
 * The work on the philosophy section, which you've already indicated you are still considering;
 * A citation is needed to support the claims made under "Barriers to access - reimbursement - physicians". This may be one of the most contentious points in the article, so it is critical that it be sourced.
 * Ditto for "Stigma - physicians".

I thought I had a source for the issues of reimbursement and stigma as related to physicians. In a day or two I should get it together---as well as the images.Tbolden (talk) 12:42, 22 March 2009 (UTC)
 * I've sourced the stigma. I'm currently looking for sources for the reimbursement issues. --Moonriddengirl (talk) 12:54, 22 March 2009 (UTC)
 * And located. --Moonriddengirl (talk) 15:52, 22 March 2009 (UTC)
 * Okay, please let me know if you think more sourcing is needed for reimbursement & stigma. Meanwhile, Tbolden and I are discussing the philosophy section at his talk page and may be able to address that very soon. :) --Moonriddengirl (talk) 18:10, 22 March 2009 (UTC)
 * And we have now come up with a passage on philosophy (retitled "Philosophy and practices") with more information about extension of life, CRP and other issues (like "Do not resuscitate" orders). Does this fix your concerns, or is there more needed? --Moonriddengirl (talk) 19:40, 22 March 2009 (UTC)

Conclusion of GA process
Moonriddengirl and Tbolden have done an excellent job in improving this article. I believe it meets GA standards and am promoting it accordingly. Please continue to improve it if you have the opportunity. Additional up-to-date stats in some areas, and images, would both be valuable improvements. Check out the Manual of Style and ensure everything is consistent (I have done some such checks, but not all), seek a peer review and then, if you wish, you should then be ready to take this thing to Feature Article - something, I have to say, I've never been game to do with an article! hamiltonstone (talk) 22:37, 22 March 2009 (UTC)