Obese Patients Receive Suboptimal End-of-Life Care

Becky McCall

February 06, 2017

Obesity is associated with diminished use of hospice services, leaving patients vulnerable to suboptimal end-of-life care, shows the first such study to explore the association.

In an article published online February 7 in Annals of Internal Medicine, John Harris, MD, from the University of Pittsburgh School of Medicine, Pennsylvania, and colleagues conclude that "the disparities in hospice use and Medicare expenditures by patient BMI [body mass index] provide an excellent opportunity for improvement."

"All people — regardless of body size — and their families should have equal opportunities to experience the benefits of high-quality end-of-life healthcare," they stress.

Results from their retrospective cohort study showed that increased BMI was independently associated with decreased enrollment in hospice care — in the United States, this is an insurance benefit that allows increased nursing and home health visits at the end of life. It requires a doctor's referral and when used is associated with higher satisfaction for patients and family members. Patients with a BMI of at least 40 kg/m2 had a predicted probability of hospice enrollment of 23.1% vs 38.3% in those with a BMI of 20 kg/m2.

Higher BMI was also associated with decreased duration of hospice services, less in-home death, and increased Medicare expenditures in the last 6 months of life.

Health and Retirement Study Data Linked to Medicare Claims

A large sample of data was drawn from the US Health and Retirement Study (HRS) and linked to Medicare claims data to examine hospice enrollment, number of days spent in hospice, deceased patients' place of death, and Medicare expenditures in relation to patients' BMI values. Results were adjusted for demographic, medical, functional, and geographic factors.

Medicare spending during the last 180 days of life included inpatient, outpatient, physician or supplier, durable medical, hospice, home health, and skilled nursing costs. Each measure was analyzed at five BMI levels (20, 25, 30, 35, and 40 kg/m2).

The researchers hypothesized that higher BMI would be associated with decreased hospice use and fewer in-home deaths due to patient, provider, and system factors affecting referral to and enrollment in hospice services.

Furthermore, they assumed that higher BMI would be associated with increased healthcare expenditures due to increased use of hospital and healthcare services.

Downward Trend for Hospice Care Benefit in the Obese

In total, data from 5677 deceased patients were analyzed. Of these, 44% were normal weight (BMI of 18.5 to 24.9 kg/m2), 31% overweight (BMI of 25 to 29.9 kg/m2), 15% obese (BMI of 30 to 39.9 kg/ m 2), and 2% morbidly obese (BMI ≥40 kg/m2). The remainder had a BMI of <18.5 kg/m2.

In addition to findings relating to enrollment for hospice care (overall enrollment was 34.7%), the predicted total hospice days decreased as BMI increased.

Participants with a BMI of at least 40 kg/m2 spent 4.3 fewer days in hospice care than those with a BMI of 20 kg/m2 and had significantly fewer in-home deaths.

Key Outcomes for Different BMIs

BMI (kg/m2) Predicted probability of enrollment in hospice benefit (%) Hospice duration (d) Probability of in-home death (%) Total Medicare expenditures ($)
20 38.3% 42.8 61.3 42,803
30 31.7 39.0 58.1 46,274
35 27.5 38.3 56.5 46,508
≥40 (morbid obesity) 23.1 38.5 55.0 45,698

Possible Reasons for Less Hospice Care Benefit for Obese Patients

Suggesting possible reasons for the observed differences in hospice care among patients with different BMIs, the authors point out that cachexia, often experienced at end of life, might have a role to play.

Physicians and family members often relate cachexia to the dying process, and patients who do not experience this (eg, obese patients) are less likely to be referred for hospice care.

Second, the authors note that enrollment policies vary among hospice services, with some restricting access to those with higher-cost medical needs, such as obese patients in home hospice care. These patients might require increased nursing assistance or mechanical lifting devices, which will boost costs, for example.

Discussing costs in the last 6 months of life, Dr Harris and colleagues write: "For obese participants in this community-dwelling cohort, we found that inpatient, outpatient, and physician Medicare expenditures were 13% higher (a difference of $4343), but hospice, home health, and durable medical equipment expenditures were 20% lower (a difference of $1173)."

Medicare expenditures were 60% less for patients of BMI of 40 kg/m2 or greater, due to differences in both hospice benefit enrollment and length of stay.

Predicted mean hospice Medicare expenditures for participants with a BMI of 40 kg/m2 were $1321, compared with $3357 in patients with BMI of 20 kg/m2.

"This is, to our knowledge, the first study to identify obesity as an independent risk factor for disparity in the use of hospice services," say the investigators, adding that "obesity was a risk factor for lower-quality end-of-life care."

Dr Harris reports no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

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Ann Intern Med . Published online February 6, 2017. Abstract

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