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, which covers all comfortoriented care related to terminal illnesses from medications to home care to hospitalizations. 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 (e.g., brain, pancreatic, metastatic malignancies), Ziad Obermeyer, M.D., M.Phil., 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 percent sample of Medicare fee-for-service beneficiaries who died in 2011.
Among 86,851 patients with poor-prognosis cancers, 51,924 (60 percent) 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 percent vs 42 percent), ICU admissions (36 percent vs 15 percent), invasive procedures (51 percent vs 27 percent), and death in a hospital or nursing facility (74 percent vs 14 percent) 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 write.
Joan M. Teno, M.D., M.S., and Pedro L. Gozalo, Ph.D., of the Brown University School of Public Health, Providence, R.I., comment on end-of-life care in an accompanying editorial.2
“As financial incentives change in the U.S. health care system, valid measures of care quality are increasingly important for ensuring transparency and accountability. Obermeyer and colleagues assessed hospitalization rates, intensive care admissions, and invasive procedures, but additional measures must have evidence of their ability to discriminate the quality of care and must be responsive to change, easy to understand, and actionable. This will involve investing public dollars in the ‘quality’ of quality measures and their dissemination. If quality of care is not front and center, the momentum to improve end-of-life care in the United States could face a serious setback.”