Researchers reported a decrease in the proportion of Medicare beneficiaries who died in an acute care hospital. However, there was an increase in ICU use within the last 30 days of life and in the rate of health care transitions at the time of death, indicating a change in end-of-life medical care.
“Site of death has been proposed as a quality measure for end-of-life care because, despite general population surveys indicating the majority of respondents and those with serious illness want to die at home, in actuality, most die in an institutional setting,” the researchers wrote.
Joan M. Teno, MD, MS, of Brown University, and colleagues performed a retrospective cohort study of a random 20% sample of more than 800,000 Medicare beneficiaries aged at least 66 years who died in 2000, 2005 or 2009. The researchers used billing data to classify the beneficiaries as having a diagnosis of cancer, chronic obstructive pulmonary disease or dementia in the last 180 days of life. They also accounted for site of death, place of care, rates of health care transitions and “potentially burdensome transitions” — referring to health care transitions in the last 3 days of life.
The percentage of deaths occurring in acute care hospitals decreased from 32.6% (95% CI, 32.4-32.8) in 2000 to 24.6% in 2009 (95% CI, 24.5-24.8). More decedents had an ICU stay in the last month of life in 2009 (29.2%; 95% CI, 29-29.3) vs. 2000 (24.3%; 95% CI, 24.1-24.5).
Hospice care use at the time of death also increased, from 21.6% (95% CI, 21.4-21.7) in 2000 to 42.2% (95% CI, 42-42.4) in 2009. The percentage of short hospice stays (3 days or less) increased from 22.2% (95% CI, 21.8-22.5) in 2000 to 28.4% (95% CI, 27.9-28.5) in 2009. According to the researchers, 40.3% (95% CI, 27.9-28.5) of these late hospice referrals were preceded by hospitalization with an ICU stay. In 2009, almost half (48.3%; 95% CI, 48-48.7) of Medicare beneficiaries with a dementia diagnosis and 59.5% (95% CI, 59.1-59.9) with cancer were enrolled in hospice at the time of death.
Additionally, the average rate of health care transitions increased from 2.1 per decedent in 2000 to 3.1 per decedent in 2009 (P≤.001). The percentage of potentially burdensome transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1-10.4) to 14.2% (95% CI, 14-14.3) in 2009 (incidence rate ratio=1.36; 95% CI, 1.33-1.40). Almost one-half of these late transitions were from an acute care hospital (45.5%; 95% CI, 45-46).
The results are not consistent with Centers for Disease Control and Prevention reports indicating public trends toward less aggressive care at the end of life.
“Our findings of an increase in the number of short hospice stays following a hospitalization, often involving an ICU stay, suggest that increasing hospice use may not lead to a reduction in resource utilization,” the researchers wrote. “Short hospice lengths of stay raise concerns that hospice is an ‘add-on’ to a growing pattern of more utilization of intensive services at the end of life.”
Disclosure: See the study for a full list of financial disclosures.