Advance Care Planning, Healthcare Reform, Hospice Eligibility
July 13, 2016

Is Hospice Being Used as an Add-On to Increasingly Aggressive Care at Life’s End?

U.S. regions with the highest rates of intensive care for terminally ill patients in the last six months of life also have the highest rate of very short hospice enrollments, suggesting that short-duration hospice use may help to explain the paradox of the rising use of aggressive end-of-life care while hospice use also continues to expand. This is according to a report published in Medical Care, the official journal of the Medical Care Section of the American Public Health Association.

“Our results help resolve the puzzle of increasing end-of-life care intensity while at the same time having increased hospice use by demonstrating that certain patterns of hospice use are linked to higher end-of-life care intensity,” the authors write.

“The finding supports the idea that much of the increases in hospice, especially the 30% of very short hospice use, may be as an ‘add-on’ to an otherwise high-intensity course of care.”

Investigators analyzed data from Medicare claims for beneficiaries aged ≥ 66 years who died in 2011 (n = 660,132) to determine the level of care intensity in the last six months of life across 306 hospital referral regions (HRRs) and its association with length of hospice enrollment: very short (≤ 7 days), medium (8–179 days) or very long (≥ 180 days).


  • Less than half (47.2%) of decedents used hospice in the last six months of life.
  • Among hospice users, 32.4% had very short hospice stays, while only 9.9% had stays of ≥ 6 months.

Length of Hospice Stay

  • Those with short hospice stays were more likely than those with no hospice to be hospitalized in the last six months of life (83.6% vs 68.4%) and to be hospitalized via emergency department use (74.4% vs 58.2%).
  • The 57.6% of decedents with medium length hospice stays were less likely than those with no hospice to receive any intensive end-of-life care (P < 0.001 for all measures).

“[N]onhospice users and very short hospice users experienced more intensive end-of-life care than medium or very long hospice users did,” write the authors.

“These findings suggest that nonhospice users and users of very short hospice may have important factors in common (e.g., absences of end-of-life planning), which could in turn drive both more intensive care and difficulty in timing hospice enrollment.”

The rates of overall hospice use and intensity of care in the last six months of life varied substantially across HRRs, note the authors. However, comparison of the highest and lowest quintiles for rates of end-of-life care intensity showed that HRRs in the highest quintile had significantly higher rates of very short hospice use.

Intensity of Care

High rates of the following measures of intensive end-of-life care were significantly associated with very short hospice stays:

  • Hospitalization (adjusted odds ratio [AOR], 1.14; 99% confidence interval [CI], 1.04 to 1.25)
  • Intensive care unit (ICU) admission (AOR, 1.25; 95% CI, 1.14 to 1.38
  • Number of ICU days (AOR, 1.20; 95% CI, 1.08 to 1.32)
  • Emergency department use (AOR, 1.23; 95% CI, 1.12 to 1.36)
  • Number of hospital days (AOR, 1.10; 95% CI, 1.00 to 1.21)

“[V]ery short hospice enrollment (i.e., within seven days of death) has been proposed as a measure of poor quality of end-of-life care, as short length of hospice enrollment has been linked to fewer hospice services received, increased unmet needs and clinical depression among family members,” the investigators note.

In contrast, the investigators also add that “very long hospice use may decrease patients’ suffering where end-of-life care intensity is concerned.”

“Effective efforts to reduce hospitalization and intensive care at the end of life would benefit from focusing not only on the use of hospice, but also on earlier introduction of hospice in the course of care.”

Source: “End-of-Life Care Intensity and Hospice Use: A Regional-Level Analysis,” Medical Care; Epub ahead of print, April 22, 2016; DOI: 10.1097/MLR.0000000000000547. Wang SY, et al; Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut.


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