Impact of Hospice Disenrollment on Health Care Use and Medicare Expenditures for Patients With Cancer

Abstract

Purpose Patients with cancer represent the largest diagnostic group of hospice users, with 560,000 referred for hospice in 2008. Oncologists rely on hospice teams to provide care for patients who have completed disease-directed treatment and desire to remain at home. However, 11% to 15% of hospice users disenroll from hospice, and little is known about their health care use and Medicare expenditures. Patients and Methods We used Surveillance, Epidemiology and End Results–Medicare data for hospice users who died as a result of cancer between 1998 and 2002 (N = 90,826) to compare rates of hospitalization, emergency department, and intensive care unit admission and hospital death for hospice disenrollees and those who remained with hospice until death. We also compared per-day and total Medicare expenditures across the two groups. Results Patients with cancer who disenrolled from hospice were more likely to be hospitalized (39.8% v 1.6%; P < .001), more likely to be admitted to the emergency department (33.9% v 3.1%; P < .001) or intensive care unit (5.7% v 0.1%; P < .001), and more likely to die in the hospital (9.6% v 0.2%; P < .001). Patients who disenrolled from hospice died a median of 24 days following disenrollment, suggesting that the reason for hospice disenrollment was not improved health. In multivariable analyses, hospice disenrollees incurred higher per-day Medicare expenditures than patients who remained with hospice until death (higher per-day expenditures of $124; P < .001). Conclusion Hospice disenrollment is a marker for higher health care use and expenditures for care. Strategies to manage a patient's care and support family caregivers following hospice disenrollment may be beneficial and should be explored.

The Effect of Comorbidity Burden on Health Care Utilization for Patients with Cancer Using Hospice

“…For patients who receive hospice until their death, only 11% of their total Medicare expenditures from hospice enrollment to death was for care outside of the Medicare Hospice Benefit. 23 This suggests that hospices are providing comprehensive care for patients regardless of the number comorbid conditions and without significant additional reimbursement from Medicare. It may be too difficult for hospice staff to attribute the underlying cause of pain and other symptoms to a primary versus secondary diagnosis.…”

“…The association between hospice disenrollment and health care utilization has been previously reported. 23 …”

“…Furthermore, although patients with comorbid dementia had only a moderate increase in the likelihood of being hospitalized, admitted to the emergency department, and disenrolled from hospice, the elevated risk is important given its potential negative impact on quality of life for patients 34,35 and its impact on health care expenditures. 23 A strength of this study is the large sample size, which enables us to evaluate outcomes that are relatively rare in a sample of hospice users; however, limitations of these data exist. Our sample includes individuals with cancer who used hospice and died in 2002 and thus does not evaluate the comorbidity burden of hospice users with a non-cancer primary diagnosis.…”

“…Patients were identified as having disenrolled from hospice if the date of their last hospice claim was before the date of their death, consistent with existing studies of hospice disenrollment. 20,23,24 …”

Hospice Eligibility in Patients Who Died in a Tertiary Care Center (719)

“…This is important since hospice has been shown in numerous studies to decrease costs at the end of life as well as decrease length of stay and intensive care utilization while subsequently increasing the quality and satisfaction of the care received. [20][21][22][23][24] There are no rigorously controlled studies examining hospice discussions. The majority of studies have been case controlled trials.…”