Medicare patients with poorprognosis cancers who received hospice care had significantly lower rates of hospitalization, intensive care unit (ICU) admissions and invasive procedures at the end of life, along with significantly lower health care expenditures during the last year of life, according to a study in a recent issue of JAMA.1
Multiple studies have documented the high intensity of medical care at the end of life, and there is increasing consensus that such care can produce poor outcomes and conflict with patient preferences. The Institute of Medicine report Dying in America has drawn attention to the difficulties of promoting palliative care, including Medicare’s hospice program, the largest palliative care intervention in the United States.
More patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health-care utilization and costs have hampered efforts to promote it, according to background information in the article.
Using data from Medicare beneficiaries with poor-prognosis cancers (eg, brain, pancreatic, metastatic malignancies), Ziad Obermeyer, MD, MPhil, of Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues matched those enrolled in hospice before death to those who died without hospice care and compared utilization and costs at the end of life. The study included a nationally representative 20% sample of Medicare fee-for-service beneficiaries who died in 2011.
Among 86,851 patients with poor-prognosis cancers, 51,924 (60%) entered hospice before death. Matching patients based on various criteria produced a hospice and nonhospice group, each with 18,165 patients. Median hospice duration was 11 days.
The researchers found that nonhospice beneficiaries had significantly greater health-care utilization, largely for acute conditions not directly related to cancer and higher overall costs. Rates of hospitalizations (65% vs 42%), ICU admissions (36% vs 15%), invasive procedures (51% vs 27%), and death in a hospital or nursing facility (74% vs 14%) were higher for nonhospice beneficiaries compared to hospice patients. Overall, costs during the last year of life were $62,819 for hospice beneficiaries and $71,517 for nonhospice beneficiaries.
“Our findings highlight the potential importance of frank discussions between physicians and patients about the realities of care at the end of life, an issue of particular importance as the Medicare administration weighs decisions around reimbursing physicians for advance care planning,” the authors wrote. ■
Disclosure: This work was supported by grants from the National Institutes of Health, National Cancer Institute, and Agency for Healthcare Research and Quality. For full disclosures of the study authors, visit jama.jamanetwork.com.
1. Obermeyer Z, et al: JAMA 312:1888-1896, 2014.