Not enough patients on dialysis are using or getting early referral to hospice care, according to a recently published study in Health Affairs.
“Medicare’s lack of flexibility in providing hospice to these patients really stands out here,” Ann M. O’Hare, MD, the lead author of the study, a professor of medicine at the University of Washington School of Medicine and a physician-scientist at the Kidney Research Institute, a collaboration of Northwest Kidney Centers and University of Washington Medicine, said in a press release. “Whether there was a gradual or sudden increase in health care costs, it made little difference to their access to hospice.”
Ann M. O'Hare
O’Hare and colleagues used data from the U.S. Renal Data System to identify nearly 1.3 million dialysis patients who died between 2000 and 2014. Patients younger than 18 years; those who did not have Medicare Parts A and B; had a transplant in the last year of life; and whose last treatment modality before death was not hemodialysis, were excluded from the review. The final analytic cohort included 639,466 patients. Researchers used trajectory modeling to estimate mortality.
In reviewing patterns of care within the Medicare patients in the cohort, researchers identified four spending trajectories during the last year of life “that represented markedly different intensities of care,” they wrote.
“Within the cohort, 9% had escalating spending and 13% had persistently high spending throughout the last year of life, while 41% had relatively low spending with late escalation, and 37% had moderate spending with late escalation,” they wrote.
After reviewing the use of hospice at the time of death, researchers found low marks in all four groups, “ranging from 19% of those with persistently high costs to 21% of those with moderate costs. The median number of days spent in hospice during the last year of life was almost the same (either 5 or 6 days) among the four groups,” the researchers wrote.
“What was striking is that, despite the marked heterogeneity across the groups – in spending, use of acute and subacute care, and patient characteristics – it made little difference to whether patients were enrolled in hospice and how long they received hospice services,” O’Hare said in the release.
For all groups, fewer than one in four patients enrolled in hospice. That compares with the almost 50% hospice-enrollment rate of Medicare’s overall population, according to the release.
There are prospects for change. The Center for Medicare and Medicaid Innovation is testing several care models that might be adapted to more flexibly provide hospice and palliative care for patients on dialysis, O’Hare said in the release.
The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (U01DK102150) and by a private donation from Jeff Lehman and Katrina Russell. The authors had no financial disclosures.