One-quarter of nursing home residents who enrolled in a hospice program for end-of-life care required hospitalization in the 30 days prior to their deaths, compared with 43% of residents who did not enroll in a hospice program, results from a large analysis have shown.
The finding provides further evidence that offering hospice as an end-of-life option for nursing home residents is beneficial, lead study author Pedro L. Gozalo, Ph.D., said in an interview.
“Prognosis is the big problem: when to figure out whether a person is close to death or not,” said Dr. Gozalo, of the Center for Gerontology and Health Care Research in the department of community health at Brown University, Providence, R.I. “Some medical directors feel more aggressive about trying to cure people at the end of life than others. In the end, it's always a matter of personal belief from the medical director's perspective as to whether the person is still at a stage where life can be prolonged substantially. But once it's clear that the person is entering the last stages in life, then hospice appears to be a valid alternative that can save unnecessary hospitalizations.”
He and his associate, Susan C. Miller, Ph.D., used Minimum Data Set and Centers for Medicare and Medicaid Services files to review the records of 183,742 nursing home residents in Kansas, Maine, New York, Ohio, and South Dakota who died between 1995 and 1997 (Health Services Research 2006;doi:10.1111/j.1475-6773.2006.00623.x). These states were chosen because they represent the kind of wide variation in hospice enrollment seen from state to state. “For example, Maine has a totally different utilization pattern than New York, even though they are relatively close geographically,” Dr. Gozalo said. “The same goes for Kansas and Ohio. We felt that [these states] represented a good sample of the overall states.”
Of the 183,742 nursing home residents in the study, the majority (169,127) did not enroll into hospice during their last 30 days of life, while 14,615 did. As expected, the rates of hospice enrollment varied widely and were as follows: 12.5% in Ohio, 11.6% in Kansas, 6.6% in New York, 5.4% in South Dakota, and 2.4% in Maine. Almost twice as many hospice residents had do-not-hospitalize and do-not-resuscitate orders and had diagnoses of cancer, compared with nonhospice residents (47% vs. 22%, respectively).
Compared with nonhospice nursing home residents, those who enrolled into hospice were more likely to live in a nursing home that was for-profit and part of a chain, had a higher private-pay/Medicare-pay ratio, had a lower percentage of nonwhite residents, and had a special care unit; in addition, it was more likely that their nearest hospice provider was for-profit and/or based in a hospital.
The researchers also found that in the 30 days before death, 26% of the hospice patients (3,730) and 43% of the nonhospice patients (73,410) were hospitalized.
When they adjusted for characteristics that might influence a patient to select hospice care, Dr. Gozalo and Dr. Miller found that about one-quarter of the hospice patients chose it because they preferred less-aggressive care. “That means the brunt of the observed effect is real,” not solely influenced by one's preference for hospice care, Dr. Gozalo said.
“It would benefit medical directors to enter into cooperative agreements with hospice providers, to refer people to hospice early enough so that they can take advantage of these benefits,” he concluded.
The researchers acknowledged certain limitations of the study, including the fact that it did not distinguish hospice treatment by its length of exposure and that the data came from only five states.
The study was funded by the Agency for Healthcare Research and Quality.