PerspectiveIn the Journals

Hospice care reduced end-of-life costs, hospitalizations for Medicare beneficiaries

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November 11, 2014

Medicare beneficiaries with poor-prognosis cancers who received hospice care had lower health care costs at the end of life, according to study results.

Those individuals also experienced lower rates of hospitalization, ICU admissions and invasive procedures, results showed.

Ziad Obermeyer, MD, MPhil, of the department of emergency medicine at Brigham and Women’s Hospital, evaluated data from 86,851 Medicare beneficiaries who died in 2011 from poor-prognoses cancers, such as brain cancer or pancreatic cancer. The median time from cancer diagnosis to death was 13 months (interquartile range, 3-34).

Sixty percent (n=51,924) of these patients received hospice care. The analysis included 18,165 of these patients, and researchers matched them for age, sex, region, time from diagnosis to death, and baseline care utilization to a cohort of 18,165 patients who did not receive hospice care.

The median hospice duration was 11 days.

A higher percentage of patients who did not receive hospice were hospitalized (65.1% vs. 42.3%; OR=1.5; 95% CI, 1.5-1.6) or admitted to the ICU (35.8% vs. 14.8%; OR=2.4; 95% CI, 2.3-2.5) during the last year of the lives. Patients who did not receive hospice also were more likely to undergo an invasive procedure in the last year of their lives (51% vs. 26.7%; OR=1.9; 95% CI, 1.9-2).

A majority of patients who did not receive hospice died in a hospital or nursing facility (74.1%), whereas only 14% of patients who received hospice died in one of those settings (OR=5.3; 95% CI, 5.1-5.5).

Average daily costs in the final week of life were $556 among patients who received hospice and $1,760 for those who did not receive hospice (difference, $1,203; 95% CI, 1,161-1,245). Also, hospice care was associated with lower total costs during the entire last year of life ($62,819 vs. $71,517; difference, $8,697; 95% CI, 7,560-9,835).

Many of the patients who did not receive hospice were admitted to the hospital or ICU due to acute conditions unrelated to their cancer, researchers wrote.

“Our findings highlight the potential importance of frank discussions between physicians and patients about the realities of care at the end of life, an issue of particular importance as the Medicare administration weighs decisions around reimbursing physicians for advance care planning,” Obermeyer and colleagues wrote.

Despite the advantages associated with hospice care demonstrated in these data, further evaluation of the quality of end-of-life care is necessary, Joan M. Teno, MD, MS, and Pedro L. Gozalo, PhD, both of the Brown University School of Public Health, wrote in an invited commentary.

“As financial incentives change in the US health care system, valid measures of care quality are increasingly important for ensuring transparency and accountability,” Teno and Gozalo wrote. “Obermeyer and colleagues assessed hospitalization rates, intensive care admissions and invasive procedures, but additional measures must have evidence of their ability to discriminate the quality of care and must be responsive to change, easy to understand and actionable. This will involve investing public dollars in the ‘quality’ of quality measures and their dissemination. If quality of care is not front and center, the momentum to improve end-of-life care in the United States could face a serious setback.”

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Disclosure: The study was supported by grants from the NIH, NCI, and Agency for Healthcare Research and Quality. The researchers report no relevant financial disclosures.

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T. Declan Walsh

T. Declan Walsh

This paper is the latest in a series of contributions to the literature about the benefits of various aspects of palliative care. More than 18,000 matched pairs of Medicare fee-for-service beneficiaries with poor prognosis cancers (mostly solid tumors) were compared by various parameters of service utilization and care costs. The non-hospice and hospice groups studied were well balanced with regard to demographic and clinical characteristics both before and after hospice referral.
The conclusions are dramatic, with significant implications for public health, cancer care and the rapidly expanding field of palliative medicine.
The authors found lower hospitalization rates, ICU admissions and invasive procedures in those admitted to hospice. In addition, their health care expenditures in the last year of life were significantly less.
There was a mean reduction of nearly $9,000 per beneficiary in the cost of care in the last year of life. Lower rates of hospitalization (42% vs. 65%), ICU admissions (8% vs. 27%) and invasive procedures (27% vs. 51%) in the hospice group paint a dramatic picture of the benefits of hospice admission and care. Only 14% of the hospice group died in the hospital compared with 74% of the non-hospice group. The operational and financial impact on cancer care and health service utilization is the United States would be significant if these results were extrapolated to the more than 500,000 people who die of cancer in the country each year.
Much hospice costs are front loaded. The authors noted that hospice enrollment of 5 to 8 weeks produced the greatest savings. Yet, the median hospice duration in the study hospice cohort was 11 days. Presumably, even larger savings and greater operational efficiencies would have been found with earlier referrals and with longer hospice length of stay.
There are some caveats. Performance status or details of cancer primary sites are not provided. It is noteworthy that the mean age of the matched cohorts was 80 years (older than the typical patient with cancer). The hospice group also lived in wealthier areas. Important clinical outcomes like symptom control are not included. The paper did not address the effect of short hospice length of stay on the financial viability of hospice providers. These issues should be the subject of further research.
Hospice services for cancer care in the United States are widely abused by last minute referrals, “dumping” of critically ill patients and poor integration of hospice into care pathways. These data are the latest to challenge the cancer community to focus more on treating the patient rather than the tumor, and to make more appropriate and earlier use of hospice care. In addition, Medicare should consider a structural change in the hospice benefit to one that is additive. The current regulations force patients to elect out of other interventions as a pre-condition of hospice admission, a harsh and unpalatable “choice.” The results of this study also support the automatic inclusion of structured palliative medicine services in all cancer programs.

T. Declan Walsh, MD, MSc, FACP, FRCP
HemOnc Today Editorial Board member
Trinity College Dublin and University College Dublin

Disclosure: Walsh reports no relevant financial disclosures.