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Medicare beneficiaries in hospice care get better care, have fewer costs

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Despite limitations, study highlights several key issues

Although the study by Obermeyer et al. adds to the evidence regarding hospice care for patients with poor-prognosis cancer, several caveats should be considered. An important threat to the validity of this study was that the unobserved difference in preferences for aggressive care may explain the observed cost savings. Rightfully, the authors acknowledge this and other limitations, such as restriction of the study population to patients with cancer, exclusion of Medicare beneficiaries with managed care and non-Medicare patients, and reliance only on claims-based information for risk adjustments, Dr. Joan M. Teno and Pedro L. Gozalo, Ph.D., both of the Brown University School of Public Health, Providence, R.I., wrote in an editorial accompanying the study.

The findings from this study raise several important policy issues, they said. If hospice saves money, should health care policy promote increased hospice access? Perhaps an even larger policy issue involves the role of costs and not quality in driving U.S. health policy in care of the seriously ill and those at the close of life (JAMA 2014;312:1868-69).

The pressing policy issue in the United States involves not only patients dying of poor-prognosis cancers, but patients with noncancer chronic illness for whom the costs of prolonged hospice stays exceed the potential savings from hospitalizations. Even in that policy debate, focusing solely on expenditures is not warranted. That hospice or hospital-based palliative care teams save money is ethically defensible only if there is improvement in the quality of care and medical decisions are consistent with the informed patient’s wishes and goals of care.

Dr. Teno is a professor at the Brown University School of Public Health. Dr. Gozalo is an associate professor at the university.


 

FROM JAMA

References

Medicare fee-for-service beneficiaries suffering from poor-prognosis cancer who received hospice care were found to have lower rates of hospitalizations, admissions to intensive care units, and invasive procedures than those who did not receive hospice care, according to a study published in JAMA.

“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,” said Dr. Ziad Obermeyer of the emergency medicine department at Brigham and Women’s Hospital in Boston, and his associates.

Dr. Ziad Obermeyer

Dr. Ziad Obermeyer

In a matched cohort study, Dr. Obermeyer and his colleagues examined the records of 86,851 patients with poor-prognosis cancer – such as brain, pancreatic, and metastatic malignancies – using a nationally representative, 20% sample of Medicare fee-for-service beneficiaries who died in 2011. Of that group, 51,924 individuals (60%) entered hospice care prior to death, with the median time from first diagnosis to death being 13 months (JAMA 2014;312:1888-96).

The researchers then matched patients in hospice vs. nonhospice care, using factors such as age, sex, region, time from first diagnosis to death, and baseline care utilization. Each sample group consisted of 18,165 individuals, with the non–hospice-care group acting as the control. The median hospice duration for the hospice group was 11 days.

Dr. Obermeyer and his associates discovered that hospice beneficiaries had significantly lower rates of hospitalization (42%), intensive care unit admission (15%), invasive procedures (27%), and deaths in hospitals or nursing facilities (14%), compared with their nonhospice counterparts, who had a 65% rate of hospitalization, a 36% rate of intensive care unit admission, a 51% rate of invasive procedures, and a 74% rate of deaths in hospitals or nursing facilities.

Furthermore, the authors found that nonhospice beneficiaries had a higher rate of health care utilization, largely for acute conditions that were not directly related to their cancer, and higher overall costs. On average, costs for hospice beneficiaries were $62,819, while costs for nonhospice beneficiaries were $71,517.

“Hospice enrollment of 5 to 8 weeks produced the greatest savings; shorter stays produced fewer savings, likely because of both hospice initiation costs, and need for intensive symptom palliation in the days before death,” Dr. Obermeyer and his coauthors wrote. “Cost trajectories began to diverge in the week after hospice enrollment, implying that baseline differences between hospice and nonhospice beneficiaries were not responsible for cost differences,” they added.

The study was supported by grants from the National Institutes of Health, the National Cancer Institute, and the Agency for Healthcare Research and Quality. The authors reported no relevant conflicts of interest.

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