Mixed results for hospice care in site-of-death study

In a study that included data on more than 800,000 Medicare beneficiaries who died between 2000 and 2009, a lower proportion died in an acute care hospital in recent years, although both ICU use and the rate of healthcare transitions increased during the last month of life.

“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,” researchers wrote in background information for the study, which appears in the Feb. 6 issue of the Journal of the American Medical Association.

“One [previous] study found poorer quality of care in the institutional setting compared with care at home, especially with hospice services. The place of care and site of death have implications for the grief and posttraumatic stress disorders experienced by family members.”

Joan M. Teno, MD, MS, of the Warren Alpert Medical School at Brown University in Providence, R.I., and colleagues assessed end-of-life care by analyzing Medicare claims data to document places of care and healthcare transitions for Medicare decedents in the last months of life. The study consisted of a random 20% sample of fee-for-service Medicare beneficiaries, ages 66 and older, who died in 2000, 2005 or 2009.

Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease or dementia in the last 180 days of life. The main outcome measures for the study were site of death, place of care, rates of healthcare transitions, and potentially burdensome transitions (for example, healthcare transitions in the last three days of life).

Among the findings, the percentage of deaths that occurred in acute care hospitals decreased from 32.6% in 2000 to 24.6% in 2009. More decedents in 2009 than in 2000 had an ICU stay in the last month of life (from 24.3% to 29.2%). Hospice use at the time of death increased from 21.6% in 2000 to 42.2% in 2009.

Short hospice stays increased from 22.2% in 2000 to 28.4% of hospice decedents using hospice for three days or less in 2009. Of these late hospice referrals in ’09, 40.3% were preceded by hospitalizations with an ICU stay.

Transitions in the last three days of life increased from 10.3% to 14.2% in 2009. The average rate of healthcare transitions in the last 90 days of life increased from 2.1 per decedent in 2000 to 3.1 per decedent in 2009, with an increase in two types of potentially burdensome transitions: transitions in the last three days of life and multiple hospitalizations in the last 90 days 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 authors wrote. “Short hospice length of stays raise concern that hospice is an ‘add-onÂ’ to a growing pattern of more utilization of intensive services at the end of life.”

In an accompanying editorial, Grace Jenq, MD, and Mary E. Tinetti, MD, of the Yale School of Medicine in New Haven, Conn., noted that “site of death has been proposed as a measure of the quality of end-of-life care, perhaps based on studies showing that the majority of people, including those with serious illness, want to die at home.

“The study by Teno et al suggests that site of death is an insufficient metric given the many transitions endured, and intensive care services received, prior to the actual event of death. A more appropriate metric might be whether patientsÂ’ goals were elicited and care predicated on meeting those goals was instituted soon enough to make a difference in end-of-life care.”

The study is available at http://jama.jamanetwork.com/article.aspx?articleid=1568250.

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