• HF Patients Actually Live Longer in Hospice, While Using Less Care

    But who actually enrolls was connected only to emergency visits in study

    Action Points


    • Advanced heart failure (HF) patients who received customized hospice care used less healthcare, lived longer, and were less likely to die in the hospital.
    • The study suggests that given these benefits of hospice for these patients, more patients should receive this comprehensive care -- especially if patient goals include living longer, dying at home, and focusing on comfort.

    Advanced heart failure (HF) patients who received HF-tailored hospice care used less healthcare, lived longer, and were less likely to die in the hospital, according to a propensity score-matched Medicare analysis.

    Hospice enrollees who had at least two heart failure discharges within 6 months had substantially less healthcare utilization in the next 6 months after second hospital discharge. Compared with propensity-matched HF patients not in hospice, they averaged fewer of the following:

    • Emergency department (ED) visits (2.64 versus 2.82, P=0.04)
    • ICU stays (1.25 versus 1.51, P<0.001)
    • Hospital days (3.90 versus 4.67, P<0.001)

    Moreover, hospice patients survived for a median of 80 days, versus 71 days for non-hospice patients (P=0.004). And only 3% of hospice patients died in a hospital setting compared with 56% of non-hospice patients (P<0.001), reported Laura Gelfman, MD, MPH, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues, online in JACC: Heart Failure.

    "Given these benefits of hospice for these patients, more patients should receive this comprehensive care," said Gelfman in an interview with MedPage Today.

    And it's a win-win, commented Craig D. Blinderman, MD, MA, of Columbia University Medical Center in New York City, who was not involved in the study.

    "While the study was not designed to assess whether hospice and dying at home was concordant with the patients' goals of care, the assumption is that it was, given that most Americans when asked about their preferred place to die would not want to die in the hospital, but prefer to die at home," he told MedPage Today.

    "Hospice care for patients with advanced HF is more likely to optimize patient goals if those goals include: living longer, dying at home, focusing on comfort, and avoiding hospitalizations," he added. "For health care administrators and economists, it also provides another model for reducing costs at the end of life in this population."

    However, who gets hospice proved hard to predict.

    "When we looked at patient characteristics, such as their symptoms, their ability to perform normal daily activities and the amount of healthcare they use, none of these predict if an individual will receive hospice. Based on these findings, it is unclear how we decide who receives hospice in this population," Gelfman said.

    The one characteristic that was independently predictive of getting hospice care was fewer ED visits in the 6 months before second heart failure discharge (average 2.38 versus 2.59 for non-hospice group, P=0.01).

    This was a counterintuitive finding, according to Haider Warraich, MD, and Joseph Rogers, MD, both of Duke University School of Medicine in Durham, North Carolina.

    As to the longer survival in hospice, they pointed out similar observations in other HF studies. "While these findings should be interpreted cautiously, the present data challenges the notion that hospice necessarily shortens lifespan in critically ill patients, including those with HF."

    Hospice for indications other than cancer has been modestly on the rise, but HF presents some unique challenges like challenging prognostication and payment models that make it difficult for hospice agencies to cover inotropes and IV or subcutaneous inotrops that some HF patients benefit from, they added.

    Even so, the editorialists said it is "incumbent" upon clinicians to champion end-of-life care to this population. "Collectively we need to improve communication about advanced care planning, changing goals of care, symptom management and bereavement."

    Regional differences exist with regard to the type of care various hospitals can provide to HF patients, Blinderman noted. At his institution, he said, "many patients who would otherwise enroll in hospice may be offered 'advanced therapies,' i.e. circulatory support devices, like left ventricular assist device (LVAD) to improve cardiac function, quality of life, and survival."

    "The paper does not mention whether these patients were not candidates for such therapies, or how to position such therapies in the complex decision making that comes up when considering hospice enrollment versus further disease modifying therapy," Blinderman added.

    For their study, Gelfman and colleagues compared hospitalizations, ICU stays, and ED visits for hospice patients and non-hospice patients based on Medicare data. The propensity score-matched sample consisted of 3,067 beneficiaries (mean age 82 years, 53% female, and 15% non-white) altogether.

    After the second heart failure discharge, 275 beneficiaries went to hospice within 1 week and 33.3% went within 30 days. Patients averaged 22 days between hospice enrollment and death; 45% died within 7 days.

    Looking ahead, the researchers concluded that further research is needed to evaluate the impact of a tailored model that would help older adults with advanced HF enroll in hospice care earlier.

    Gelfman, Warraich, and Rogers disclosed no relevant conflicts of interest.

    The study was funded by the National Institute on Aging, Mount Sinai Older Adults Independence Center, the Agency for Healthcare Research and Quality, and the National Palliative Care Research Center.

    • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner


    JACC: Heart Failure

    Source Reference: Warraich HJ, Rogers JG "It's time to discuss dying" JACC Heart Fail 2018.

    JACC: Heart Failure

    Source Reference: Gelfman LP, et al "Predictors of hospice enrollment for patients with advanced heart failure and effects on healthcare utilization" JACC Heart Fail 2018.


    Read the original article on Medpage Today:  HF Patients Actually Live Longer in Hospice, While Using Less Care

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