Caroline Helwick

May 23, 2014

ORLANDO, Florida — Only 29% of hospices in the United States employ massage, art, or music therapists, according to the first national survey to examine such services.

"We were surprised, given the focus of interdisciplinary care and symptom management in hospice, that these services are not being used more," said study investigator Sarah Dain, a medical student at the Icahn School of Medicine at Mount Sinai, New York.

"Interest in complementary and alternative medicine [CAM] is growing, and patients are requesting these services," she told Medscape Medical News. "They are beneficial to patients and would be wonderful to include in hospice care."

She presented the survey results here at the American Geriatrics Society 2014 Annual Scientific Meeting.

Intervention Without Adverse Effects

Hospice care is generally holistic, involving both physical and psychosocial interventions, such as bereavement counseling, social worker visits, and pastoral care, Dain explained.

Small studies have shown that music therapy helps relieve pain, agitation, and depression, and that massage therapy reduces pain intensity, morphine requirements, and even hospital admissions in cancer patients.

These are interventions without significant side effects and they can help patients.

"These are interventions without significant side effects and they can help patients," she said.

Hospice care increased by 70% from 2000 and 2009; there are now more than 5300 hospices in the United States, serving more than 1.65 million patients. The cost of hospice care is about $153 per day, and the annual cost to Medicare is almost $10 billion.

Because of the speed at which the hospice industry is growing, the researchers conducted a survey to determine whether the focus is still on interdisciplinary care, or whether it has shifted more toward medical care, explained Melissa Aldridge, PhD, associate professor of geriatrics and palliative medicine at the Icahn School of Medicine, who was also involved in the study.

A total of 591 Medicare-certified hospices responded to the national cross-sectional survey (84% response rate).

Survey Results

Overall, 29% of hospices reported having at least 1 full-time equivalent music, art, or massage therapist (mean, 1.55 full-time equivalent). Hospital size had a significant effect on the number of hours a CAM therapist was employed, Dain reported.

Of the hospices with CAM employees, 74% reported having massage therapists, 53% reported having music therapists, and 22% reported having art therapists.

There was some regional variation. CAM services were more common in the Mountain/Pacific (44%), North Central (39%), and New England/Middle Atlantic (38%) regions of the United States than in the South Atlantic (24%) and South Central (17%) regions. In addition, hospices in the South Central and South Atlantic regions were more than 50% less likely than those in the New England/Middle Atlantic regions to have full-time equivalent CAM employees (P < .05).

There was also a significant association between CAM services and the size and ownership of the hospice.

Table. Odds of a Hospice Having a Full-Time Equivalent CAM Employee

Hospice Characteristic CAM Employee, % Adjusted Odds Ratio P Value
Patients per day      
   <20 19 1.00
   20–49 27 1.91 <.05
   50–99 28 2.50 <.01
   100+ 55 6.56 <.01
   Nonprofit 40 1.00
   For profit 24 0.48 <.01
Concern about loss of market share      
   None 47 1.00
   Slightly 43 0.91 NS
   Somewhat 30 0.48 NS
   Very 27 0.36 <.05


Hospices concerned about losing market share were the least likely to offer CAM services. "We were surprised to find this inverse relation," Dain explained. "We believe this means that hospices concerned about competition may be more financially strapped, and may not be able to offer these services."

"This points to what we have seen in a number of studies," said Dr. Aldridge. "Under the reimbursement system for hospice, especially the per diem setup, it is very difficult to provide the range of services that hospices intend to provide. We particularly see this for smaller hospitals. It's what you are able to do with the reimbursement you have. Unfortunately for patients and their families, there is quite a variation in the range of services."

Balancing Resource Use

The correlation between the use of CAM, hospice characteristics, and region is interesting, said Louise Aronson, MD, MFA, associate professor in geriatrics and director of the medical humanities program and the Northern California Geriatrics Education Center at the University of California, San Francisco.

"It's very clear that the larger hospices and the nonprofit hospices are more able to fulfill the stated mission of hospice, which is to care for the whole person," she told Medscape Medical News. "Part of this probably has to do with having more capacity in terms of access to resources and funding. If you are less interested in profits, your primary concern will be patient care."

She said she thinks the regional differences could be cultural, but they might also reflect the proportion of for-profit, compared with nonprofit, hospices in those areas.

Dr. Aronson pointed out that only a few small studies have shown that CAM has benefit in the hospice setting. "Given the health finance crisis, it would be helpful to know if these [therapies] are beneficial. If so, we need to invest in them; if not, other things need our money."

Ms. Dain, Dr. Aldridge, and Dr. Aronson have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2014 Annual Scientific Meeting. Abstract P42. Presented May 17, 2014.


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