The Impact of Hospice Preferred Practices at the End of Life

The Affordable Care Act currently requires hospices to report quality measures for specific practices, but not information regarding how these practices affect patient outcomes. According to a recent study from Icahn School of Medicine at Mount Sinai researchers focusing on exactly this, 2 specific hospice practices were associated with lower patient hospitalizations: asking the patient upon admission where they would prefer dying, and monitoring patient symptoms on a frequent basis.

The study followed approximately 150,000 Medicare beneficiaries enrolled in a random sample of hospices across the United States from 2008 to 2011 until their deaths, measuring the proportion of patients who were admitted to the hospital (including emergency department [ED] visits and intensive care unit [ICU] stays) and died after enrollment.

Six hospice practices and characteristics were assessed for their impact. The hospices that asked their patients at admission where they preferred to die reported lower odds of hospital death and ED visits. Similarly, the hospices that monitored their patients’ symptoms at least every few days reported lower odds of ICU stays. The other 4 practices were not found to be significant.

The implications of these results are useful because identifying simple practices that hospices can implement to contribute to fewer future patient hospitalizations can not only save on hospitalization costs, but also benefit patient quality of life. Nearly half (45%) of terminally ill patients in the US currently die under hospice, and overall hospice enrollment has grown by more than 20% over the past decade.

“The substantial hospice level variation in hospitalization rates identified in this study underscores the need to better understand the drivers of inter-hospice variation, to develop quality measures based on these determinants, and to create incentives for high performance on quality measures to improve the experiences of patients and families at the end of life,” lead author Melissa Aldridge, PhD, MBA, said in a statement. Her goal was described as disseminating these study results to improve the quality of hospice care.

Interestingly, the study also found that regardless of what practices a hospice implemented, hospitalization rates remained consistently high if the hospice was for-profit. That is, a higher proportion of patients at for-profit hospices compared with non-profit hospices experienced a hospital admission (15.3% vs 10.9%, P <.001), ED visit (21.8% vs 15.6%, P <.001), and ICU stay (5.1% vs 3.0%, P <.001).

This particular finding can also offer useful insight. It suggests that the ownership of the hospice itself is what affects what practices are implemented—and leaves implications of which types of hospices may be most beneficial for patients.

“These results highlight the need to better understand the practices of for-profit hospices where the pattern of high hospitalization of patients is persistent,” said Aldridge. “Our data also suggests that the hospitalization of individuals who had enrolled with for-profit hospices may be a means of shifting costs of care from the hospice organization to Medicare, but more research is necessary to explore this issue.”