Dying Medicare Beneficiaries Increasingly Moved to Hospice

Diedtra Henderson

February 05, 2013

Some 42.2% of Medicare beneficiaries died in hospice care in 2009 compared with 21.6% in 2000, according to a retrospective cohort study. However, that finding is clouded by the fact that just over a quarter of those using hospice (28.4%) in 2009 did so for fewer than 3 days and 40.3% of them moved to hospice after intensive care unit (ICU) stays.

Joan M. Teno, MD, from the Warren Alpert Medical School of Brown University, Providence, Rhode Island, and colleagues report their findings in the February 6 issue of JAMA.

Dr. Teno and colleagues randomly selected 20% of fee-for-service Medicare beneficiaries who were at least 66 years old and who died in 2000, 2005, or 2009. The researchers analyzed the beneficiaries' claims data to determine the location of their care and to characterize the healthcare transitions in the patients' last months of life. The mean age of the 848,303 beneficiaries enrolled in the study was 82.3 years; 57.9% were women and 88.1% were white.

The researchers found that 24.6% of Medicare beneficiaries died in acute care hospitals in 2009, which was a decrease from 32.6% in 2000. However, more beneficiaries had an ICU stay in their last month of life in 2009 than in 2000 (going from 24.3% [95% confidence interval, 24.1% - 24.5%] to 29.2% [95% confidence interval, 29.0% - 29.3%]; test for trend, P < .001). In the last 3 days of life, 14.2% of beneficiaries experienced a change in the location of their care in 2009 compared with 10.3% in 2000.

In addition, among 40,576 beneficiaries whose location of care shifted in their last 3 days of life, 70.3% were moved into hospice care, 20.8% were moved to an acute care hospital, 17.8% were moved to a nursing home with hospice services, and 9.3% were moved to a nursing home without hospice services.

"Hospice use increased, but 28.4% of those decedents used a hospice for 3 days or less in 2009. About one-third of these short hospice stays were preceded by an ICU stay in the last month of life," Dr. Teno and colleagues write. "Although a hospice stay of 1 day may be viewed as beneficial by a dying patient and family, an important yet unanswered research question is whether this pattern of care is consistent with patient preferences and improved quality of life."

Grace Jenq, MD, and Mary E. Tinetti, MD, from the Yale School of Medicine, New Haven, Connecticut, note in an accompanying editorial that "[t]he increased availability of palliative and hospice care services does not appear to have changed the focus on aggressive, curative care. Hospice services appeared to be tagged on to the last days of life."

Dr. Jenq and Dr. Tinetti suggest that likely benefit for patients and their life expectancy be considered before admitting a patient to ICU. "Some might worry that these recommendations will lead to rationing ICU care. It is worth considering, however, whether providing unwanted intensive medical care that has little chance of success in lieu of timely access to symptomatic, emotional, spiritual, and other supports that help patients and caregivers through the last phase of life already constitutes rationing."

Study limitations include its reliance on Medicare claims data, which does not characterize disease severity or patients' preference for care. Because the data were specific to fee-for-service beneficiaries, the study results may not be generalizable for other types of Medicare plans.

"Although the [Centers for Disease Control and Prevention] reports that decedents aged 65 years and older are more likely to die at home, our results are not consistent with the notion that there is a trend toward less aggressive care. Between 2000 and 2009, the ICU utilization rate, overall transition rate, and number of late transitions in the last 3 days of life increased," Dr. Teno and coauthors conclude.

Support for this study was provided by the National Institute on Aging and the Robert Wood Johnson Foundation. The study authors disclosed having received grants or travel support from the National Institutes of Health and the Robert Wood Johnson Foundation. Various coauthors reported receiving speaking fees from a number of academic organizations and advocacy groups, and one coauthor acknowledged owning stock in PointRight. The commentators have disclosed no relevant financial relationships.

JAMA. Published online February 6, 2013.

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