Lower Percentage of Medicare Patients Dying in
Hospitals; Increase in Use of ICUs, Hospice
The use of hospice care has doubled but it tends to
be for a very short period before death - see video
Feb. 5, 2013 In a study that included data on
more than 800,000 Medicare patients who died between 2000 - 2009, a
lower proportion died in an acute care hospital in recent years,
although both intensive care unit (ICU) use and the rate of health care
transitions increased during the last month of life, according to a
study appearing in the February 6 issue of JAMA.
Site of death has been proposed as a quality
measure for end-of-life care because, despite general population surveys
indicating the majority of respondents and those with serious illness
want to die at home, in actuality, most die in an institutional
setting, according to background information in the article.
"One study found poorer quality of care in the
institutional setting compared with care at home, especially with
hospice services. The place of care and site of death have implications
for the grief and posttraumatic stress disorders experienced by family
The researchers, led by Joan M. Teno, M.D., M.S.,
of the Warren Alpert Medical School of Brown University and colleagues, analyzed
Medicare claims data to document places of care and health care
transitions for Medicare decedents in the last months of life to assess
The study consisted of a random 20 percent sample
of fee-for-service Medicare beneficiaries, 66 years of age and older,
who died in 2000 (270,202), 2005 (291,819), or 2009 (286,282).
Based on billing data, patients were classified as
having a medical diagnosis of cancer, chronic obstructive pulmonary
disease, or dementia in the last 180 days of life. The main outcome
measures for the study were site of death, place of care, rates of
health care transitions, and potentially burdensome transitions (e.g.,
health care transitions in the last 3 days of life).
Among the findings of the researchers, the
percentage of deaths that occurred in acute care hospitals decreased
from 32.6 percent in 2000 to 24.6 percent in 2009. More decedents in
2009 than in 2000 had an ICU stay in the last month of life (from 24.3
percent to 29.2 percent).
Hospice use at the time of death increased
from 21.6 percent in 2000 to 42.2 percent in 2009.
Short hospice stays increased from 22.2 percent in
2000 to 28.4 percent of hospice decedents using hospice for 3 days or
less. Of these late hospice referrals in 2009, 40.3 percent were
preceded by hospitalizations with an ICU stay, the authors write.
Transitions in the last 3 days of life increased
from 10.3 percent to 14.2 percent in 2009. The average rate of health
care transitions in the last 90 days of life increased from 2.1 per
decedent in 2000 to 3.1 per decedent in 2009, with an increase in 2
types of potentially burdensome transitions: transitions in the last 3
days of life and multiple hospitalizations in the last 90 days of life.
Our findings of an increase in the number of short
hospice stays following a hospitalization, often involving an ICU stay,
suggest that increasing hospice use may not lead to a reduction in
resource utilization. Short hospice lengths of stay raise concerns that
hospice is an add-on to a growing pattern of more utilization of
intensive services at the end of life, the researchers write.
This research was funded by a National Institute on
Aging grant and in part by the Robert Wood Johnson Foundation.
Editorial: Changes in End-of-Life Care Over the
Past Decade More Not Better
In an accompanying editorial, Grace Jenq, M.D., and
Mary E. Tinetti, M.D., of the Yale School of Medicine, New Haven, Conn.,
write that site of death has been proposed as a measure of the quality
of end-of-life care, perhaps based on studies showing that the majority
of people, including those with serious illness, want to die at home.
The study by Teno et al suggests that site of
death is an insufficient metric given the many transitions endured, and
intensive care services received, prior to the actual event of death. A
more appropriate metric might be whether patients goals were elicited
and care predicated on meeting those goals was instituted soon enough to
make a difference in end-of-life care.
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