Patients who do not enroll in hospice are more likely to receive aggressive cancer care
More patients with cancer use hospice today than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Researchers at Brigham and Women's Hospital (BWH) examined how hospice affects health care utilization and costs and found that in a sample of elderly Medicare patients with advanced cancer, hospice care was associated with significantly lower rates of both health care utilization and total costs during the last year of life. Ultimately, those who chose hospice were five times less likely to die in hospitals and nursing homes.
Findings of the study, led by Ziad Obermeyer, MD, MPhil, associate physician in BWH's Department of Emergency Medicine and assistant professor of emergency medicine and health care policy at Harvard Medical School, are published in the Journal of the American Medical Association on November 12, 2014.
"Our study shows very clearly that hospice matters. Hospice and non-hospice patients had very similar patterns of health care utilization, right up until the week of hospice enrollment—then the care started to look very different," said Obermeyer. "Patients who didn't enroll in hospice ended up with far more aggressive care in their last year of life—most of it related to acute complications like infections and organ failure, and not directly related to their cancer diagnosis."
The research team measured health care utilization and costs in a nationally-representative sample of 18,165 patients with poor-prognosis cancers (e.g., brain, pancreatic and metastatic malignancies) who enrolled in hospice before death, and compared them to 18,165 similar patients who died without hospice care. Overall, non-hospice patients had significantly more health care utilization—hospitalizations, intensive care, and invasive procedures—largely for acute conditions not directly related to cancer, and 74 percent of non-hospice patients died in hospitals and nursing facilities. Only 14 percent of patients who enrolled in hospice care died in a hospital or nursing facility. The costs of care for hospice and non-hospice patients were not significantly different before hospice care began, but diverged sharply thereafter, contributing to a statistically-significant difference in total costs of $8,697 over the last year of life ($71,517 for non-hospice and $62,819 for hospice).
"These findings highlight the importance of honest discussions between doctors and patients about our patients' goals of their care at the end of life, relating to treatment decisions and quality of life," said Obermeyer, who is also a researcher at Ariadne Labs, a joint center for health systems innovation at BWH and Harvard School of Public Health. "This is of particular importance now, in light of the ongoing policy discussions around reimbursing providers for advance care planning."