Variation in hospice visits for Medicare patients in last two days of life

Medicare patients in hospice care were less likely to be visited by professional staff in the last two days of life if they were black, dying on a Sunday or receiving care in a nursing home, according to an article published online by JAMA Internal Medicine.

Hospice programs do not have any mandated minimum number of required visits for the most common level of hospice care referred to as routine home care (RHC). However, a hospice program must deliver the highest possible quality of care for the dying person and support family members in their role as caregivers with the payments they receive from Medicare.

Joan M. Teno, M.D., M.S., of the University of Washington, Seattle, and coauthors examined Medicare administrative claims data for the federal fiscal year 2014 to look at patterns in visits by hospice professional staff to the dying patient and their family in the final two days of life.

The study included 661,557 Medicare patients and of them, 81,478 or 12.3 percent, received no professional staff visits in the last two days of life, according to the results. Variations existed by state with Alaska having the highest proportion of patients not receiving visits from professional staff in the last two days of life (97 of 492 patients or 19.7 percent). In Wisconsin, the proportion was 3.8 percent (590 of 15,399 patients), according to the results.

Analysis of 3,448 of the hospices in the study group found that 281 hospice programs (8.1 percent) provided no visits during the last two days of life, while 21 hospice programs (0.6 percent) provided visits to 100 percent of their patients receiving RHC services during the last two days of life.

The authors report variation by patient characteristics. Black patients were less likely to have any visits from professional staff in the last two days of life (white patients 12 percent vs. black patients 15.2 percent); hospice patients in nursing homes also had a higher proportion of not having any visits from professional staff in the last two days of life (patients in nursing homes 16.5 percent vs. patients not in nursing home 10.6 percent); and about 1 in 5 patients who died on a Sunday (20.3 percent) did not have a visit from professional staff in the last two days of life, the results indicate.

There also was variation by hospice program characteristics with smaller hospice programs (90 deaths or less) and hospice programs based in nursing homes less likely to provide visits in the last two days of life. Visits did not differ by for-profit or nonprofit status, the authors report.

The study has limitations that include not having knowledge of the severity of the symptoms of the dying patients or the family preference for a visit. It is also possible that professional staff had previously determined that a visit during the last two days of life was not needed.

"Our findings that professional staff from 281 hospice programs, which had at least 30 discharges, did not visit any of their patients who received RHC services during the last two days of life raises concerns that deserve further research to understand whether a lack of visits by professional staff affects the quality of care for that dying patient and their family. In addition, black patients and frail, older patients residing in nursing homes often did not receive visits from hospice staff in the last two days of life, providing evidence of disparities of care found in other area of health care," the study concludes.

"In this issue of JAMA Internal Medicine, Teno and colleagues present more evidence that hospice agencies differ in how they support patients at the very end of life. ... The Centers for Medicare & Medicaid Services is particularly concerned about this variability. Owing to worries about whether beneficiaries and their families are receiving needed hospice care and support at the very end of life, the Centers for Medicare & Medicaid Services is planning to reform payments to hospice agencies," write Eric Widera, M.D., of the University of California, San Francisco, and Shaida Talebreza, M.D, of the University of Utah School of Medicine, Salt Lake City, in a related commentary.