Hospice Care Lowers Cost and ICU Use in Cancer Patients

Roxanne Nelson

November 11, 2014

Hospice care at the end of life can significantly lower rates of hospitalization, intensive care unit (ICU) admission, and invasive procedures for cancer patients, according to a new study. Not surprisingly, it can also significantly lower healthcare costs.

The study, which was published in the November 12 issue of JAMA, adds further evidence to research that has shown that hospice care can reduce aggressive medical interventions and healthcare costs.

The researchers, led by Ziad Obermeyer, MD, MPhil, from Brigham and Women's Hospital and Harvard Medical School in Boston, looked at poor-prognosis cancers (lung, brain, pancreatic, any metastatic or ill-defined malignancy, and hematologic malignancies designated as relapsed or not in remission). They compared the use and costs of healthcare in Medicare patients who received hospice care and in those who did not.

From a national sample of Medicare fee-for-service beneficiaries who died in 2011, the team identified 86,851 patients with poor-prognosis cancers, 60% of whom entered hospice before death.

In the final cohort of 36,330 patients, 18,165 received hospice care and 18,165 did not. The median duration of hospice care was 11 days. Less than 6% of hospice stays went beyond 6 months.

In the last year of life, the overall cost was $62,819 for hospice patients and $71,517 for nonhospice patients.

Table. Outcomes in the Two Groups

Outcome Nonhospice Patients, % Hospice Patients, % Risk Ratio 95% Confidence Interval
Hospitalization 65.1 42.3 1.5 1.5–1.6
Invasive procedures 51.0 26.7 1.9 1.9–2.0
Death in hospital or nursing facility 74.1 14.0 5.3 5.1–5.5
ICU admission 35.8 14.8 2.4 2.3–2.5

 

End-of-Life Discussions Needed

Dr Obermeyer noted that the length of hospice care in this study was very short. The average patient had known metastatic or other poor-prognosis cancer for 7 months, but only received hospice care for about 2 weeks.

"There are a number of factors driving this, and reluctance to discuss the end of life is one of them," he told Medscape Medical News. "A related factor is overly optimistic predictions about patients' prospects for survival and cancer treatment."

Patients sometimes avoid end-of-life planning because they want to get "healthy enough to start chemotherapy again," he explained. "Our study shows what usually happens instead is frequent hospitalizations, ICU care, and invasive procedures — mostly for infections and organ failure, not for treating cancer. This isn't the kind of care that most people say they want."

These findings highlight the potential importance of frank discussions between physicians and patients about the realities of care at the end of life, which is an issue "of particular importance as the Medicare administration weighs decisions around reimbursing physicians for advance care planning," write Dr Obermeyer and his colleagues.

In a previous study of patients with advanced cancer, when end-of-life discussions were started earlier rather than later, hospice care increased and care during the final days of life was less aggressive (J Clin Oncol. 2012;30:4387-4395). Although aggressive treatment at the end of life is not necessarily the wrong thing, the decision of which option to pursue is best made early on.

Cost Should Not Be the Driver

In an accompanying editorial, Joan M. Teno, MD, MS, and Pedro L. Gozalo, PhD, from the Brown University School of Public Health in Providence, Rhode Island, note that despite some limitations, this study raises several important policy issues.

"A key policy concern is if hospice saves money, should healthcare policy promote increased hospice access?" they write. "Perhaps an even larger policy issue involves the role of costs and not quality in driving US health policy in care of the seriously ill and those at the close of life."

The editorialists point out that the general expectation is that patients who choose hospice care should not reach the end of their life in an acute care hospital; similarly, their hospital costs should be less.

But a pressing policy issue is that the cost of prolonged hospice stays for patients with chronic illnesses, aside from cancer, exceed the potential savings from hospitalizations, they point out.

However, even in that policy debate, focusing solely on expenditures is not warranted, Drs Teno and Gozalo caution. "That hospice or hospital-based palliative care teams save money is only ethically defensible if there is improvement in the quality of care and medical decisions are consistent with the informed patient's wishes and goals of care."

Dr Obermeyer pointed out that a number of insurance companies — Medicare included — are experimenting with "open access" hospice programs that don't require patients to give up curative care. "There has been some hesitation about this because of concerns that it might drive up costs," he said. "But having more choices would give patients more freedom to choose the care they want, and could get patients and doctors to talk about end-of-life issues earlier than a few days before death."

"Our study also shows that getting patients with poor-prognosis cancers into hospice earlier is unlikely to increase costs; in fact, it's far more likely that giving patients what they want will reduce costs," he added. "More choice and more patient-centered care that also happens to cost less — that seems like an easy decision."

This study was supported by grants from the National Institutes of Health, the National Cancer Institute, and the Agency for Healthcare Research and Quality. Dr Obermeyer, Dr Teno, and Dr Gozalo have disclosed no relevant financial relationships.

JAMA. 2014;312:1868-1869, 1889-1896. Editorial, Abstract

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