Hospice usage up but not delivered soon enough, study finds



LEBANON, N.H. – Medicare patients with advanced cancer are more likely to receive hospice care than in previous years, although it is still too late in their treatment to deliver the full benefits of palliative care, according to a report issued by the Dartmouth Institute for Health Policy and Clinical Practice.

The report also states that geography and the treatment styles favored by individual health systems, rather than patient preferences, drive the level of intensive, end-of-life treatments used.

The findings are part of the Dartmouth Atlas Project, which uses Medicare data to examine how health care resources are allocated nationally. The report is the institute’s first longitudinal analysis of trends in end-of-life care for advanced cancer patients across regions, academic medical centers, and National Cancer Institute–designated cancer centers.

Dr. David C. Goodman

Controlling for patient age, sex, race, tumor type, and non–cancer-related comorbidities, the investigators found that, when compared with similar data collected from 2003 to 2007 and published by the institute in 2010, the number of advanced cancer patients on Medicare dying in the hospital decreased by an average of 28.8% during 2003-2007 to 24.7% in 2010. An increase from 54.6% to 61.3% in the number of patients who were enrolled in hospice in the last month of life was also found. The number of patients for whom hospice was initiated during the last 3 days of life increased from 8.3% during 2003-2007 to 10.9% in 2010.

When asked in an interview about the importance of starting hospice sooner in terminal care, Dr. Lorenzo Norris, director of psycho-oncology services at George Washington University Medical Center in Washington, said, "The biggest misconception is that hospice is strictly for end of life. Palliative care is just good medicine. If you limit the hospice care to the last 3 days, you’ve already limited the options a patient has. If you offer palliative care 5 or 6 months out, you can start reducing symptom burdens and increase a patient’s quality of life, which is very important because during that last year to 6 months is when patients are finishing unresolved financial and relationship issues. Palliative care allows them to more fully engage in their life."

When viewed according to the medical center delivering the care, between 13% and 50% of Medicare patients with advanced cancer died in a hospital in 2010, rather than in a hospice setting – typically the patient’s home. These figures include data from NCI-designated cancer centers. Hospice treatment in the last month of life for patients treated in mid- and northwestern states such as Oregon and Iowa trended as much as nearly 50% higher than in places such as Alaska and New York City.

Addressing the reasons for regional variations in care, Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., wrote in an accompanying editorial that, "Previous research has also shown that regional supply of health care resources, such as hospital and intensive care beds and imaging equipment, is one driver of the intensity of care, irrespective of the patient’s particular condition or illness level."

The analysts found the overall rate of ICU admissions for treatments such as intubation, a feeding tube, or cardiopulmonary resuscitation during the last month of life increased from 23.7% in the period between 2003 and 2007 to 28.8% in 2010. The number of days patients spent in the ICU in the last month of life varied more than fivefold across all centers, the analysts wrote.

"Our research continues to find that patients with advanced cancer are often receiving aggressive care until their final days, when we know that most patients would prefer care directed toward a better quality of life through hospice and palliative services. The increase in patients admitted to hospice care only days before death suggests that hospice services are often provided too late to provide much benefit," Dr. David C. Goodman, coprincipal investigator for the Dartmouth Atlas Project, said in a statement.

When asked why some oncologists are not referring their patients to hospice sooner, Dr. Clifford Hudis, president of the American Society of Clinical Oncology said, "There are many circumstances, based on culture, family dynamics, and patient’s wishes, where it is hard to communicate the value of hospice services. Some patients remain fearful of the very word and, in some situations, there is an unwillingness to acknowledge the severity of illnesses. These barriers can often be overcome through an increase in communication between doctors and patients about care goals and wishes."

When asked about the potential economic implications of the data, Dr. Goodman said, "The goal of better end-of-life care is to improve patient well-being. Often, it is less expensive to provide good care that patients want, [rather] than the usual care that patients receive."


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