In the JournalsPerspective

Hospice Care May Come too Late for Patients With Chronic Liver Disease

Patients with chronic liver disease, such as nonalcoholic fatty liver disease, alcoholic liver disease and chronic hepatitis C, had significantly longer hospital length of stay, annual health care charges and shorter hospice length of stay compared with other patients, according to recently published data.

“Although many experts have advocated for the expansion of hospice care to persons dying of all chronic illnesses including those patients without cancer, patterns of health care use at the end of life remain uneven among diseases,” Natsu Fukui, MD, from the Inova Fairfax Hospital, Virginia, and colleagues wrote. “Unfortunately, studies have shown that only a small proportion of patients with CLD receive palliative care.”

To determine the characteristics of Medicare beneficiaries with CLD, the researchers evaluated 2,179 patients aged 65 years old or older with CLD who were discharged to hospice between 2010 and 2014. These patients were compared with 34,986 controls without CLD.

Compared with controls, patients with CLD were younger (mean age, 70 vs. 83 years; P < .001) and more likely to be eligible for Medicare due to disability rather than age (23.5% vs. 3.1%; P < .001) when discharged to hospice care.

Annually, patients with CLD had more hospital visits (2.73 vs. 1.97; P < .0001), longer hospital length of stay (19.35 vs. 13.02 days; P < .0001), higher total hospital charges ($175,281 vs. $108,999; P < .0001) and Medicare payments ($36,683 vs. $23,839; P < .0001), more 30-day readmissions (51.6% vs. 34.2%; P < .0001), and more hospital transfers (6.2% vs 2.5%; P < .0001) compared with controls before discharge.

In contrast, those with CLD had shorter hospice length of stay annually (13.68 vs. 17.65 days; P < .0001) compared with controls and were more likely to die in-hospice (88.8% vs. 84.7%; P < .0001) and within 1 year of discharge (96.6% vs. 94%; P < .0001).

Among all patients discharged to hospice, HCV and congestive heart failure were the strongest contributors to increased total annual hospital costs (34.6% and 31.4%, respectively; P < .001) and hospital length of stay (25.9% and 42.7%, respectively; P < .001). Similarly, HCV was a greater factor for total annual 30-day readmission (OR = 2.18; 95% CI, 1.8-2.6), as was congestive heart failure (OR = 2.19; 95% CI, 2.09-2.3), compared with other etiologies.

“Our findings support previous research showing that patients with chronic illnesses are generally referred to hospice late in their disease course, which may lead to inadequate time to benefit fully from hospice care. Our study further highlights the fact that this trend is substantially more prominent among patients with CLD. These results should raise awareness for timely hospice referral and incite conscious efforts to improve access to hospice services, which will be essential for enhancing the quality of end-of-life care of our patient with CLD.” – by Talitha Bennett

Disclosure: Fukui reports no relevant financial disclosures. Please see the full study for the other authors’ relevant financial disclosures.

Patients with chronic liver disease, such as nonalcoholic fatty liver disease, alcoholic liver disease and chronic hepatitis C, had significantly longer hospital length of stay, annual health care charges and shorter hospice length of stay compared with other patients, according to recently published data.

“Although many experts have advocated for the expansion of hospice care to persons dying of all chronic illnesses including those patients without cancer, patterns of health care use at the end of life remain uneven among diseases,” Natsu Fukui, MD, from the Inova Fairfax Hospital, Virginia, and colleagues wrote. “Unfortunately, studies have shown that only a small proportion of patients with CLD receive palliative care.”

To determine the characteristics of Medicare beneficiaries with CLD, the researchers evaluated 2,179 patients aged 65 years old or older with CLD who were discharged to hospice between 2010 and 2014. These patients were compared with 34,986 controls without CLD.

Compared with controls, patients with CLD were younger (mean age, 70 vs. 83 years; P < .001) and more likely to be eligible for Medicare due to disability rather than age (23.5% vs. 3.1%; P < .001) when discharged to hospice care.

Annually, patients with CLD had more hospital visits (2.73 vs. 1.97; P < .0001), longer hospital length of stay (19.35 vs. 13.02 days; P < .0001), higher total hospital charges ($175,281 vs. $108,999; P < .0001) and Medicare payments ($36,683 vs. $23,839; P < .0001), more 30-day readmissions (51.6% vs. 34.2%; P < .0001), and more hospital transfers (6.2% vs 2.5%; P < .0001) compared with controls before discharge.

In contrast, those with CLD had shorter hospice length of stay annually (13.68 vs. 17.65 days; P < .0001) compared with controls and were more likely to die in-hospice (88.8% vs. 84.7%; P < .0001) and within 1 year of discharge (96.6% vs. 94%; P < .0001).

Among all patients discharged to hospice, HCV and congestive heart failure were the strongest contributors to increased total annual hospital costs (34.6% and 31.4%, respectively; P < .001) and hospital length of stay (25.9% and 42.7%, respectively; P < .001). Similarly, HCV was a greater factor for total annual 30-day readmission (OR = 2.18; 95% CI, 1.8-2.6), as was congestive heart failure (OR = 2.19; 95% CI, 2.09-2.3), compared with other etiologies.

“Our findings support previous research showing that patients with chronic illnesses are generally referred to hospice late in their disease course, which may lead to inadequate time to benefit fully from hospice care. Our study further highlights the fact that this trend is substantially more prominent among patients with CLD. These results should raise awareness for timely hospice referral and incite conscious efforts to improve access to hospice services, which will be essential for enhancing the quality of end-of-life care of our patient with CLD.” – by Talitha Bennett

Disclosure: Fukui reports no relevant financial disclosures. Please see the full study for the other authors’ relevant financial disclosures.

    Perspective
    Mayur Brahmania, MD, FRCPC, MPH

    Mayur Brahmania

    The current study adds to the growing literature that patients with end-stage liver disease (ESLD) are receiving palliative care (PC) too late in their disease course.

    As the incidence of cirrhosis continues to rise but the number of liver transplants remain stable, there is a growing number of patients that are vulnerable to the debilitating symptoms of ESLD. Barriers to PC referral include misconceptions about the role of PC, misidentifying disease prognosis along with socio-cultural beliefs.

    There is already an abundance of studies in non-ESLD populations linking early PC referral to lower hospital costs and health care use along with improving symptom control and overall patient satisfaction. However, ongoing research is still needed looking at which factors lead to PC referral and patient outcomes after PC referral along with ongoing education to care providers about the importance of PC referral in ESLD patients.

    • Mayur Brahmania, MD, FRCPC, MPH
    • Assistant Professor of Medicine
      Division of Gastroenterology and Multi-Organ Transplant Unit
      University of Western
      London, ON. Canada

    Disclosures: Brahmania reports no relevant financial disclosures.