Use of hospice for Medicare patients with congestive heart failure has been on a dramatic upswing, one important example of how the U.S. healthcare system is changing the way it treats terminal patients in their last six months.
Not only did the percentage of patients who used hospice go up, from 19% in the year 2000 to 40% in 2007, total number of days in hospice care increased from 36.5 days to 44 days and the percentage discharged to a hospice from an inpatient setting went from 5.2% to 33.7%.
Those are some findings from an analysis of care provided to 229,543 Medicare beneficiaries with CHF who died between Jan. 1, 2000 and Dec. 31, 2007 by researchers at Duke University and the Universities of Alberta and Calgary in Canada. Their paper is published in this week's print edition of the Archives of Internal Medicine.
"We found that most patients frequently accessed the healthcare system and spent some time in the hospital," they wrote. "The use of health services at the end of life in this population has increased over time, with higher rates of intensive care and higher costs. However, the use of hospice services has also increased markedly, representing a substantial shift in patterns of care at the end of life."
But "there continues to be a high level of use of inpatient care in the last six months of life," the researchers said, "with approximately 80% of patients spending some time in the hospital."
Total costs to Medicare, not including costs patients paid out of pocket, went from $28,766 to $36,216. Risk-adjusted costs in this eight-year period increased 11%
Also, the researchers noted, that even though hospice services appear to be used much more, the use of other expensive services at the end of life remained high, "suggesting that the potential for hospice to prevent costly hospitalizations has yet to be fully realized. It remains unclear whether hospice services [are being used] as a complement to or a substitution for usual acute care."
The percentage of patients hospitalized in intensive care units went from 3.5 days to 4.6 days, which the authors described as significant.
The report shows that these patients continued to receive echocardiograms, stress tests, cardiac catheterizations, coronary artery bypass grafts, cardioverter-defibrillator implantations, pacemakers, and dialysis, although the percentages did not significantly increase except for echocardiograms, and fewer patients received bypass procedures.
In these eight years, the mean number of physician visits went from 7 per patient to 8.3, the number of days home health was used went from 53.2 to 58.6 and the cost for home health care went from $3,484 to $4,232.
In an editorial accompanying the Duke researchers' article, Rosemary Gibson, formerly the leader of the Robert Wood Johnson Foundation's strategy to improve end-of-life care, wrote that the number of palliative care programs in the U.S. in hospitals with 50 more beds increased from 658 in 2000 to 1,487 in 2008.