Hospice care use rising, but timing still needs improvement

The use of hospice has increased in recent years, but a significant proportion of patients are still entering the program too early or too late, according to a collection of studies published last week.

Two studies looked at health care resources used by heart failure patients in the last six months of their lives. A retrospective cohort study of U.S. patients, which included more than 200,000 Medicare beneficiaries who died in 2000-2007, found that use of hospice increased from 19% to nearly 40% over the course of the study. Yet the average number of days the patients spent in intensive care increased from 3.5 to 4.6 and adjusted Medicare costs increased by 11%. About 80% of patients were hospitalized during their last six months.

A similar study of Canadian heart failure patients also found increasing costs over the time period, although the Canadian costs were substantially lower (an average cost of $27,983 in Canadian dollars in 2006 [equivalent to $24,674 in U.S.] vs. a mean cost of $36,216 in 2007 in the U.S. study.) The percentage of Canadian patients dying in the hospital decreased from 60% to 54% and hospitalization rates during the last six months decreased from 84% to 76% during the study.

Study authors noted that further reductions in hospitalization rates and deaths may be limited by the relative unavailability of hospice care in Canada compared to the U.S. Both studies noted that increasing costs appeared do not appear to be driven by use of costly invasive cardiac procedures, rates of which remained low throughout the study period in both countries.

The U.S. study also assessed the length of patients' stays in hospice and found that the percentage of patients who entered hospice only shortly before their deaths remained steady: about 19% stayed three days or less and about 37% were in hospice for less than a week. Another study, also published online by the Archives of Internal Medicine, assessed hospice use among men dying of prostate cancer between 1992 and 2005. Of the patients who used hospice (53% of the total), 22% were in it for less than a week. Such short stays don't allow patients to receive the full benefits of enrollment in hospice, the study authors noted.

The study of prostate cancer patients did find an increase in the use of hospice over time. By 2003, 62% of the patients were in hospice. Hospice patients were less likely to receive high-intensity care, including imaging, hospitalization, ICU stays, and emergency department visits, the study found. Increasing the appropriate use of hospice care for patients at the end of life could both improve the quality of death and reduce ineffective health care expenditures, the study authors concluded.