When confronted with the reality of death, the majority of people asked about their preferences say they'd like to die at home, surrounded by friends and family, and with minimal pain and discomfort. Yet the sad fact remains that many people are unable to achieve that goal, Rick and I discuss on PodMed this week, in spite of abundantly available hospice services.What are the barriers to more widespread utilization of hospice and can a cost analysis help provide evidence that such services are not only humane but cost-effective? That's the substance of a study published this week in JAMA.
Researchers crunched numbers from a 20% sample of Medicare fee-for-service beneficiaries who died in 2011, all with a cancer diagnosis. Patients with brain, pancreatic, metastatic malignancies or other poor-prognosis cancers enrolled in hospice before death were matched to similar patients who died without hospice care, resulting in almost 87,000 enrollee records for the analysis, about 60% of whom were enrolled in hospice care at the end of life. The final cohort consisted of 18,165 patients with poor prognosis cancers who were enrolled in hospice and the same number who were not, matched on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization.
Here's what the analysis showed: "After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. After exposure, nonhospice beneficiaries had significantly more hospitalizations (65% [95% CI, 64%-66%], vs hospice with 42% [95% CI, 42%-43%]; risk ratio, 1.5 [95% CI, 1.5-1.6]), intensive care (36% [95% CI, 35%-37%], vs hospice with 15% [95% CI, 14%-15%]; risk ratio, 2.4 [95% CI, 2.3-2.5]), and invasive procedures (51% [95% CI, 50%-52%], vs hospice with 27% [95% CI, 26%-27%]; risk ratio, 1.9 [95% CI, 1.9-2.0]), largely for acute conditions not directly related to cancer; and 74% (95% CI, 74%-75%) of nonhospice beneficiaries died in hospitals and nursing facilities compared with 14% (95% CI, 14%-15%) of hospice beneficiaries. Costs for hospice and nonhospice beneficiaries were not significantly different at baseline, but diverged after hospice start. Total costs over the last year of life were $71 517 (95% CI, $70 543-72 490) for nonhospice and $62 819 (95% CI, $62 082-63 557) for hospice, a statistically significant difference of $8697 (95% CI, $7560-$9835)." Wow. That's a lot of resources saved at the end of life, and as I query Rick in the podcast, wonder what would have happened if hospice had been utilized sooner than the median of 11 days found in this study?
It's revealing to look at what the authors consider to be major barriers to more hospice utilization. They cite the penalty exacted by the Medicare administration against hospices with extended hospice stays, current lack of reimbursement for end-of-life discussions to physicians by the same agency, and finally, the requirement that patients forego any treatment with a curative intent in order to enroll as all having a chilling effect on enthusiasm for earlier adoption of hospice services. Yet at least one myth, that of potential increased costs relative to hospice care, is clearly dispelled by this study. Our hope is that the evidence provided here will help inform discussion around overcoming barriers and toward adoption of a more compassionate model of medical care at the end of life.
Other topics this week include Ebola treatment of two patients here in the US in NEJM, Tdap vaccination during pregnancy in JAMA, and four popular weight loss diets compared in Circulation. Until next week, y'all live well.