A study of elderly patients with cancer during their last year of life, especially those with poor-prognosis cancers, found that patients who received hospice care were five times less likely to die in a hospital or nursing home than those who did not have the benefits of hospice.1 This, despite the fact that patients with cancer utilize hospice care more than any other group of patients.1
Ziad Obermeyer, MD, led the study. He is associate physician in the department of emergency medicine at Brigham and Women’s Hospital and assistant professor of emergency medicine and health care policy at Harvard Medical School, both in Boston, Massachusetts. His group undertook the study to compare the costs and utilization of health care between two groups of patients with cancer: those undergoing treatment without hospice care and those enrolled in hospice.
HOSPICE STAYS ARE GETTING SHORTER
The Medicare hospice program is the largest palliative care plan in the United States, the study authors report. It covers all aspects of a terminally ill patient’s end-of-life care, including medicine, whether the patient is in the home or in hospital. However, an interesting dichotomy exists concerning the utilization of Medicare’s hospice program by people with cancer. The hospice program began in 1982, and although the number of days that patients with cancer spend in hospice has decreased since that time, the number of patients enrolled in the plan has increased.1
The Boston group cites three possible reasons for this, all of which are related to Medicare.
- Medicare administrators audit—and actually take money back—if they think the hospice stay is inappropriately long. This creates a disincentive for physicians to refer patients to hospice early, since early referral could lead to long enrollments.
- Medicare does not reimburse physicians for discussions with patients on end-of-life care preferences.
- A requirement of Medicare is for patients to relinquish therapeutic interventions when they enroll in hospice. For patients with cancer, especially, this is a difficult demand because they often want to continue treatment as long as possible. Those treatments increasingly are new targeted therapies, which are less toxic and more expensive than more established therapies.1
COMPARING THE GROUPS
In this study, Obermeyer and his team evaluated 18,165 patients with poor-prognosis cancers, such as pancreatic, brain, and metastatic malignancies, who enrolled in hospice before they died, comparing them with a group of 18,165 similar patients who were not enrolled in hospice care. Both groups of patients had approximately the same amounts of fluid and electrolyte disturbances, anemia, dementia, hemiplegia, and weight loss. Most of the patients in both groups had solid tumors: 91% in the hospice group and 88% in the nonhospice group. More of the patients in hospice were white and lived in wealthier neighborhoods, as evidenced by their zip codes.
The patients who were not in hospice often needed treatment for conditions such as infections or organ failure that were not related to their cancer but required invasive procedures and/or intensive care, so they experienced more hospitalizations than the hospice group. Significantly, of this nonhospice group, 74% died in nursing facilities and hospitals whereas only 14% of the hospice group died in nursing homes or hospitals.
HOSPICE = FEWER PROBLEMS, LOWER COSTS
The patients who were in hospice stayed an average of 11 days, although the authors found that 5 to 8 weeks in hospice led to the greatest cost savings. Fewer than 6% of patients stayed in hospice for more than 6 months. In their last week of life, the cost per day for patients with cancer in hospice was $1,203 lower than for similar nonhospice patients. Overall costs during these patients’ last year of life were $62,819 for patients in hospice and $71,517 for those who were not enrolled in hospice. The patients who were enrolled in hospice required less intervention overall, which was reflected in the costs for their care.
The authors concluded, “Our findings highlight the potential importance of frank discussions between physicians and patients about the realities of care at the end of life.”1
Bette Weinstein Kaplan is a medical writer based in Tenafly, New Jersey.
1. Obermeyer Z, Makar M, Abujaber S, et al. Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA. 2014;312(18):1888-1896.