Hospice associated with reduced healthcare utilization in cancer patients

1. Individuals with poor-prognosis cancer who received hospice care had fewer hospital admissions, intensive care unit stays, invasive procedures, and were less likely to die in the hospital or a nursing facility when compared to those who did not receive hospice care.

2. Individuals with poor-prognosis cancer who received hospice care had lower health care costs in the last year of life when compared to those who did not receive hospice care.

Evidence Rating Level: 1 (Excellent)

Study Rundown: End of life care is an increasingly important issue in the United States and studies have shown that end of life health care utilization and cost of care is high. While hospice has been suggested as a potential strategy to help patients remain comfortable, there are conflicting viewpoints regarding its impact on health care utilization and cost. This study analyzed health care utilization and cost in 18,165 pairs of individuals with poor-prognosis cancer, with pairs comprised of one individual receiving hospice care and one who was not. Overall, individuals enrolled in hospice were less likely to be admitted to the hospital, cared for in the intensive care unit (ICU), undergo procedures, and were less likely to die in a hospital or nursing facility. In contrast, most non-hospice beneficiaries were likely to be admitted to the hospital or be in the ICU at the end of life. The total health care-related costs at the end of life were significantly lower in the hospice group than in the non-hospice group, with costs diverging approximately one week after entering hospice and the cost difference increasing as more time passed.

Strengths of this study include the large sample size, careful matching, and detailed analysis of costs for various complications and procedures. The fact that all diagnoses were based on ICD-9 codes represents a limitation to the study because ICD-9 coding is not always accurate. Its inclusion of only poor-prognosis cancer patients may limit generalizability, as there are many reasons why individuals go into hospice care. Overall, this study highlights the economic advantages of hospice care in this population. Further research is required to examine its impact on health care quality and its impact on and compliance with patient preference.

Click to read the study, published today in JAMA

Click to read an accompanying editorial, published today in JAMA

Relevant Reading: Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay.

In-Depth [retrospective observational study]: This study compared care utilization and cost at the end of life in 18,165 pairs of individuals with poor-prognosis cancer. Each pair included one person who was in hospice care and one person who was not in hospice care and matching was done based on location of residence, age, race, and time interval between poor-prognosis cancer diagnosis and death. In both groups, solid tumors were most common (91% of hospice, 88% of non-hospice) and individuals in hospice were more likely to be white and from high-income regions. Individuals not in hospice were more likely to be admitted to the hospital (RR 1.5; 95%CI 1.5-1.6), treated in the ICU (RR 2.4; 95%CI 2.3-2.5), undergo procedures (RR 1.9; 95%CI 1.9-2.0), and die in the hospital or a nursing facility (RR 5.3; 95%CI 5.1-5.5). Costs were also statistically significantly lower in the hospice group, with the difference in cost in the last year of life totaling $8,697 (95%CI $7560-$9835). The difference in costs began to diverge approximately one week after entering hospice care and the difference increased with time, with maximum savings observed at 5-8 weeks of enrollment.

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