profession
Marked decline in Medicare patients who spend final days in hospital
■ Research shows that more people are seeking hospice, but physicians say patients often enter such programs too late to experience the palliative and social benefits.
Trends in end-of-life care may mean that Medicare patients get to spend their last days the way they desire: Out of the hospital and in community or home-based settings, said a Dartmouth Atlas Project report issued in June.
Researchers examined 1 million Medicare claims’ records of patients who died in 2010. They found an 11% decline in hospital deaths among these Medicare patients and a 13.3% increase in those who were enrolled in hospice care, according to the report (link).
“We’ve known for a long time that elderly patients with serious illness strongly prefer to receive care in community settings,” said David L. Goodman, MD, co-principal investigator for Dartmouth Atlas Projects and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H. “The growing use of hospice care and the decrease in hospital use at the end of life are promising trends that may reflect attempts to provide care that aligns more closely with patients’ preferences.”
Some hospitals still treat patients at the end-of-life more aggressively while others use palliative care, he said.
“Improvements in care are not even across regions and hospitals,” Dr. Goodman said. “And many are changing at a much slower pace — or not at all.”
While the Hospital at the University of Pennsylvania in Philadelphia had a dramatic 55% increase in hospice care, the hike may be misleading, because some patients don’t go into hospice care until their last day.
“Our average hospice length of stay is seven days, with many patients coming into hospice in the last 24 hours of life,” said David Casarett, MD, an associate professor of medicine at the Perelman School of Medicine at the University of Pennsylvania.
Too late for hospice
When patients arrive later in hospice, that leaves little time for meeting dying patient needs, he added.
“They die before we have time to get a chaplain or a social worker,” Dr. Casarett said. “When a patient dies in the ambulance on the way to hospice, that is not good care.”
A study in the Feb. 6 issue of The Journal of the American Medical Association also shows an increase of hospice services among the elderly (link). The percentage of Medicare patients who died in the hospital declined from 33% to 25% between 2000 and 2009, the study said. Those who were in hospice when they died increased from 22% to 43% during the same period.
“Many of the hospice referrals are in the last three days of life,” said Joan M. Teno, MD, co-author of the JAMA study and professor of health services, policy and practice at the Warren Alpert Medical School of Brown University in Rhode Island. “It is not enough time for a hospice intervention beyond symptom management. … Our data suggest that many persons are referred to hospice too late.”
Palliative care is not supposed to begin so late, physicians said.
“Virtually all of us working in palliative care would like more quality time with our patients,” Dr. Casarett said. “Patients coming to hospice very late is a serious public health problem.”
