More at-home deaths in Medicare patients, but also more end-of-life ICU stays

More Medicare patients died at home in 2009 than in 2000, but there was also an increase in intensive care use during the last 30 days of life, a new study found.

The retrospective cohort study included a random 20% sample of Medicare fee-for-service beneficiaries (more than 800,000 patients) who died in 2000, 2005 or 2009. Researchers compared these patients' sites of death, places of care in the last 30 days, hospice use and health care transitions at the end of life. Results appeared in the Feb. 6 Journal of the American Medical Association.

Between 2000 and 2009, the percentage of patients dying in acute care hospitals dropped from 32.6% to 24.6%. The percentage of patients in hospice at the time of death also changed significantly, from 21.6% to 42.2%. However, the study also found an increase in the use of the intensive care unit (ICU) in the final 30 days, from 24.3% of deaths in 2000 to 29.2% in 2009. The researchers noted an increase in health care transitions at the end of life too, especially in the last three days (10.3% of patients in 2000 versus 14.2% in 2009). Specifically focusing on the patients who used hospice in 2009, they found that 28.4% of them had been in for three days or less and, of those, 40.3% had come from the ICU.

Previous reports have also shown that more elderly patients are dying at home, but this study shows that these patients are not necessarily receiving less aggressive care, the authors concluded. The finding that hospice admissions were short and followed ICU stays suggests that the increasing use of hospice may not reduce resource utilization. Although the study was not able to collect data on patient preferences, the authors speculated that the observed patterns of care were not the result of patient choice and could be improved.

An accompanying editorial also called for greater attention to patient preferences and goals, as well as provision of active treatments such as intravenous fluids or antibiotics outside the hospital whenever possible. Set criteria for ICU admissions, based on likely benefit and life expectancy, could also be helpful in reducing inappropriate and costly care, the editorialist said.