Friday, April 29, 2011

Comparing Hospice and Nonhospice Patient Survival

Comparing Hospice and Nonhospice Patient Survival Among Patients Who Die Within a Three-Year Window

Journal of Pain and Symptom Management
Volume 33 | No. 3 | March 2007

Key Points

• There is a growing body of evidence to counter the argument that the use of opioid and sedative medications for symptom relief hastens death.
• Our findings suggest that hospice may indeed have a positive impact on patients’ longevity or at least not hasten death.
• For the five types of cancer and congestive heart failure (CHF) patient populations combined, the mean survival was 29 days longer for hospice patients than for nonhospice patients.
• CHF patients who eventually chose hospice had a mean survival of 402 days compared with 321 days for those who did not.
• The mean survival was also significantly longer for the hospice patients with lung cancer, pancreatic cancer, and marginally significant for colon cancer
• Patients in an already weakened condition avoid the risks of overtreatment when they make the decision to enter hospice.
• Entering hospice may improve monitoring and treatment patient receive.
• Several studies have suggested that psychosocial supports may tend to prolong life.
• Findings are important in helping dispel the myth that hospice care hastens a patient’s death.


There is a widespread belief by some health care providers and the wider community that medications used to alleviate symptoms may hasten death in hospice patients. Conversely, there is a clinical impression among hospice providers that hospice might extend some patients’ lives. We studied the difference of survival periods of terminally ill patients between those using hospice and those not using hospices. We performed retrospective statistical analysis on selected cohorts from large paid claim databases of Medicare beneficiaries for five types of cancer and congestive heart failure (CHF) patients. We analyzed the survival of 4493 patients from a sample of 5% of the entire Medicare beneficiary population for 1998-2002 associated with six narrowly defined indicative markers. For the six patient populations combined, the mean survival was 29 days longer for hospice patients than for nonhospice patients. The mean survival was also significantly longer for the hospice patients with CHF, lung cancer, pancreatic cancer, and marginally significant for colon cancer (P = 0.08). Mean survival was not significantly different (statistically) for hospice vs. nonhospice patients with breast or prostrate cancer. Across groups studied, hospice enrollment is not significantly associated with shorter survival, but for certain terminally ill patients, hospice is associated with longer survival times. The claims-based method used death within three years as a surrogate for a clinical judgment to recommend hospice, which means our findings apply to cases where a clinician is very sure the patient will die within three years, and it points to the need to validate these findings.

J Pain Symptom Manage 2007;33:238-246. © 2007 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Hospice care seemed to extend survival for some patients

From Atul Gawande, New Yorker:

Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldn’t live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year.

Read more

Thursday, April 21, 2011

Few Studies Delve Into Hospice Care in Nursing Homes

A new evidence review, Hall S, et al. Interventions for improving palliative care for older people living in nursing care homes. Cochrane Database of Systematic Reviews 2011, Issue 3. finds that there’s scant high-quality research on the best comprehensive strategies for nursing homes hoping to ease the suffering of older patients through hospice care.

Researchers only found three studies – all from the United States – that met their criteria to be included. While the findings offer “potentially promising results,” the studies aren’t strong enough to justify recommending their individual approaches, said review lead author Dr. Sue Hall, a palliative care specialist at King’s College London.

Still, the studies suggest that elements of the strategies such as teams of specialists and partnerships between nursing homes and hospice care services “are a key aspect” of care, Hall said.

Hospice care, the focus of the review, refers to care for patients who are dying. It focuses on relieving suffering — including physical, emotional and spiritual pain — and has become increasingly popular in the United States in recent decades.

At the same time, a higher percentage of people are dying in nursing homes, said Marianne Matzo, a professor of palliative care nursing at the University of Oklahoma. The problem, she said, is that “they were not built or set up as a place where people are going to end their lives, especially in these numbers.”

The authors of the Cochrane Library review sought to determine whether there is evidence to support specific hospice approaches at nursing homes for seniors.

The review was published by The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The review authors found little reliable research into approaches to hospice care in nursing homes. The three studies they analyzed comprised 735 participants, of whom 75 percent to 81 percent were women.

There were some helpful findings. Family members felt better about care for their relatives after the patients took part in a program that aimed to identify those who would benefit from hospice care. Dying patients with dementia seemed to have less discomfort when they were part of a program that included special units for them, education for staff and special individual plans of care. However, the review authors said there are questions about the reliability of both findings.

Two studies found that hospice care strategies improved the delivery of care, but they did not determine if patients actually fared better. None of the studies examined the cost effectiveness of the approaches used.

Cost, of course, is a crucial factor in health care. In the United States, current payment systems can hurt high-quality care at nursing homes, said Dr. R. Sean Morrison, director of the National Palliative Care Research Center at Mt. Sinai School of Medicine.

“If I have a patient in New York who develops an infection in the nursing home, I know that all the data tell me if I treat them in the nursing home, the patient is less likely to develop confusion or delirium, less likely to develop a pressure ulcer, more likely to recover,” Morrison said. “But if I transfer the patient to the hospital, Medicare pays for the ambulance and the entire hospitalization and everything else, and I can keep that bed empty at that nursing home and still be paid by Medicaid for that bed and not have to pay for nursing staff or for it to be cleaned.”

Hall, the review lead author, called for high-quality studies into comprehensive hospice strategies in nursing homes. She acknowledged that there is still a need to agree on how to figure out whether a strategy works. However, she said, funders will need to pay for the research.

Source: Health Behavior News Service, part of the Center for Advancing Health, is required.

Cancer Patients who Disenroll from Hospice have Increased Hospitalizations

They are less likely to Die at Home

Disenrollment can have a Physical and Financial Toll

According to a new study, patients with terminal cancer that disenrolled from hospice care had significantly higher rates of hospitalizations – including admission to the emergency department and intensive care unit – than patients who remained under the care of hospice. Furthermore, patients who disenrolled from hospice were more likely to die in the hospital than patients who remained with hospice until their deaths.

“Impact of Hospice Disenrollment on Healthcare Use and Medical Expenditures for Patients with Cancer” is published in the October 1, 2010 issue of Journal of Clinical Oncology.

The study, led by researchers at the Mount Sinai School of Medicine, found that:

• 33.9 percent of the patients who disenrolled from hospice care were admitted to an emergency department, in contrast with only 3.1 percent of hospice patients.
• 39.8 percent of disenrolled patients were admitted to the hospital as an inpatient, in contrast with only 1.6 percent of hospice patients.
• Disenrolled patients spent an average of 19.3 days in the hospital, whereas hospice patients spent an average of 6.7 days.
• 9.6 percent of disenrolled patients died in the hospital, compared to only 0.2 percent of hospice patients.
• Costs of care for patients with cancer who disenrolled from hospice were nearly five times higher than for patients who remained with hospice.

Wrote the study authors, “Policy makers have called for tightening eligibility restrictions for the MHB (Medicare Hospice Benefit) as part of a wider effort to reduce high Medicare expenditures; our results suggest that addressing hospice disenrollment may be an effective means of reducing Medicare expenditures for hospice users without restriction access to the MHB.”

Further recommendations suggest that oncologists explore outpatient palliative care services that offer multidisciplinary care, symptom control, and end-of-life planning expertise in a context that enables a patient and family to maintain contact with the oncology clinic.

Research Shows Patients May Live Longer with Hospice and Palliative Care

A new study released by the New England Journal of Medicine found that among patients with non-small-cell lung cancer, those who received palliative care lived, on average, almost two months longer than those who received standard care. Researchers also found that the patients receiving palliative care reported a higher quality of life through the final course of their illness.

The goals of palliative care are to improve the quality of a seriously ill person’s life and to support that person and their family during and after treatment. Sharing the same philosophy of hospice care which is usually provided in the final months of life, palliative care may be provided at any stage during a serious or life-limiting illness.

Researchers also found that when patients received palliative care services, they were also more likely to elect hospice services.

"With earlier referral to a hospice program, patients may receive care that results in better management of symptoms, leading to stabilization of their condition and prolonged survival," wrote the authors of the study released Wednesday in the New England Journal of Medicine.

This new study adds to the body of evidence showing that many patients live longer with hospice and palliative care.

A 2007 study that looked at Medicare beneficiaries with some of the most common diagnoses leading to death, found that patients who received hospice services lived on average, 29 days longer than those who did not receive hospice care. This study, published in the Journal of Pain and Symptom Management (March 2007) looked at 4,493 terminally ill patients with either congestive heart failure or cancer of the breast, colon, lung, pancreas, or prostate.

In an earlier study looking at patients with 16 of the most common terminal diagnoses, researchers found that hospice patients lived longer. On average, this ranged from 20 days for those with a diagnosis of gallbladder cancer to 69 days for the cohort of breast cancer patients (JPSM, September 2004).

“There’s an inaccurate perception among the American public that hospice means you’ve given up,” said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization. “Those of us who have worked in the field have seen firsthand how hospice and palliative care can improve the quality of and indeed prolong the lives of people receiving care.”

Hospice Care Saves Money for Medicare

Average Savings of $2,309 per Hospice Beneficiary

Findings of a major study of hospice care in America show that hospice services save money for Medicare and bring quality care to patients with life-limiting illness and their families. This provides useful evidence to support the many benefits of hospice, reports the National Hospice and Palliative Care Organization.

Researchers found that hospice reduced Medicare costs by an average of $2,309 per hospice patient. The new study from Duke University appears in the October 2007 issue of the professional journal “Social Science & Medicine.”

Additionally, Medicare costs would be reduced for seven out of 10 hospice recipients if hospice has been used for a longer period of time the study found.

“Given that hospice has been widely demonstrated to improve quality of life of patients and families...the Medicare program appears to have a rare situation whereby something that improves quality of life also appears to reduce costs,” writes lead author Don H. Taylor, Jr., assistant professor of public policy at Duke’s Sanford Institute of Public Policy.

For cancer patients, hospice use decreased Medicare costs up until 233 days of care. For non-cancer patients there were cost savings seen up until 154 days of care. While hospice use beyond these periods cost Medicare more than conventional care, the report’s authors wrote that “More effort should be put into increasing short stays as opposed to focusing on shortening long ones.”

The National Hospice and Palliative Care Organization reports that 1.3 million patients received care from one of the nation’s 4,500 hospice providers in 2006. This represents a steady increase of more than 100,000 patients than the previous year. Approximately 35 percent of all deaths in the US were under the care of a hospice program.

“The trends for increased usage of hospice are expected to continue as we see an aging generation of baby-boomers face end-of-life situations for themselves and their parents,” remarked J. Donald Schumacher, NHPCO president and CEO. “Hospice helps people live with dignity, comfort, and compassion during life’s final journey – to know definitively that it provides a cost savings to Medicare is an additional benefit.”

Hospice is not a place but a philosophy of care that provides pain management, symptom control, psychosocial support, and spiritual care to patients and their families.

This study is a landmark independent research effort, not only because it shows cost savings for hospice utilization, but because it also addresses research flaws and questionable analyses in previous hospice cost studies. The study used a methodology to match Medicare beneficiaries who used hospice and those who did not in a fashion that could be described as an “apples to apples” approach that yields sound results.

“Given that November is National Hospice Palliative Care Month, it’s most fitting that this valuable study come out now,” added Schumacher.

Patients with Dementia Benefit from Hospice Care

While dementia is one of the leading causes of death in the United States, it accounts for only 11 percent of hospice admissions and little is known about the quality of the care they receive, reports the National Hospice and Palliative Care Organization. Research published in the July issue of the Journal of Pain and Symptom Management, “Hospice Care for Patients with Dementia,” reinforces the value of hospice care for these patients and their family caregivers.

Researchers found that families of patients with dementia evaluated the care received from hospice as highly as patients with other diagnoses. Reports of unmet patient needs for treatment of symptoms were less frequent as well.

“What this tells hospice professionals is that in spite of the challenges of caring for patients with dementia, hospice is indeed beneficial,” said Stephen Connor, NHPCO vice president of research and co-author of the study. “Hospices can effectively help patients struggling with dementia at the end of their lives and providers need to continue reaching out to help those patients and families in need.”

Researchers used data from the Family Evaluation of Hospice Care, an Internet based repository and benchmarking tool that collects data from bereaved families regarding the quality of hospice care. A total of 77,123 surveys submitted by 796 hospices in 2005 were used in this study. Developed by Brown University and NHPCO, the Family Evaluation of Hospice Care lets researchers look at the relationship of length of stay, perceived timing of hospice referral, and quality of end-of-life care.

This research was led by Dr. Susan Mitchell at the Institute for Aging Research at Harvard University, was done in collaboration with the National Hospice and Palliative Care Organization and researchers at Brown University and was funded by the Alzheimer’s Association.

Hospice Patients Lived an Average 29 Days Longer

A study published in the March 2007 issue of the Journal of Pain and Symptom Management reports that hospice care may prolong the lives of some terminally ill patients.

Among the patient populations studied, the mean survival was 29 days longer for hospice patients than for non-hospice patients. In other words, patients who chose hospice care lived an average of one month longer than similar patients who did not choose hospice care.

Sponsored by the National Hospice and Palliative Care Organization, the study was conducted by NHPCO researchers in collaboration with the highly regarded consulting and actuarial firm, Milliman, Inc.

Researchers selected 4,493 terminally ill patients with either congestive heart failure (CHF) or cancer of the breast, colon, lung, pancreas, or prostate. They then analyzed the difference in survival periods between those who received hospice care and those who did not. Data came from the Centers for Medicare and Medicaid Services and represented a statistically valid five percent sampling from 1998-2002.

Longer lengths of survival were found in four of the six disease categories studied. The largest difference in survival between the hospice and non-hospice cohorts was observed in CHF patients where the mean survival period jumped from 321 days to 402 days. The mean survival period also was significantly longer for the hospice patients with lung cancer (39 days) and pancreatic cancer (21 days), while marginally significant for colon cancer (33 days).

“There’s an inaccurate perception among the American public that hospice means you’ve given up,” said J. Donald Schumacher, NHPCO president and CEO. “Those of us who have worked in the field have seen firsthand how hospice can improve the quality of and indeed prolong the lives of people receiving care. Benefits of hospice have been reinforced by positive stories like that of Art Buchwald who seemed to thrive under the care of hospice.”

Researchers cited several factors that may have contributed to longer life among patients who chose hospice. First, patients who are already in a weakened condition avoid the risks of over-treatment when they make the decision to receive hospice care. Second, hospice care may improve the monitoring and treatment patients receive. Additionally, hospice provides in-home care from an interdisciplinary team focused on the emotional needs, spiritual well-being, and physical health of the patient. Support and training for family caregivers is provided as well. This may increase the patient’s desire to continue living and may make them feel less of a burden to family members.

“There is a perception among some healthcare providers that symptom relief in hospice, especially the use of opioids and sedatives, could cause patients to die sooner than they would otherwise. This study provides important information to suggest that hospice is related to the longer, not shorter length of survival – by days or months – in many patients,” said Dr. Stephen Connor, NHPCO’s vice president of research and international development, and lead author of the study. “This additional time may be valuable to patients and families to give more time for resolution and closure.”

Co-author Bruce Pyenson, an actuary at Milliman in New York, added, “We believe this study helps support the growing quality movement within healthcare. For some patients, hospice care is not a choice about cure, it is a choice for the best care.”