Longer Survival Lower Costs Less Likelihood of Hospital Death Linked to Heart Failure

Older adults with advanced heart failure (HF) and two or more hospital discharges within the previous six months who enrolled in hospice experienced not only lower use of acute healthcare than those receiving usual care, but also longer median survival and a lower likelihood of hospital death, according to a report published in JACC: Heart Failure.

“These observations support several other studies demonstrating that patients who enroll in hospice experienced a longer survival, and that hospice enrollment reduced healthcare use and costs,” write the authors. There is an estimated average cost saving of $2,300 per Medicare beneficiary enrolled in hospice, they point out, yielding an overall savings of more than $3.5 billion per year.

Hospice Addresses the Needs of Patients with Heart Failure

Heart failure is a leading cause of death in the US, and about 80% of those hospitalized with HF are over 65 years of age, note the authors. Further, up to 44% of older adults admitted to hospitals with advanced HF are readmitted within six months of discharge.

“Hospice is a model of care that could address the needs of patients with advanced HF and their caregivers,” write the authors. “Although the use of hospice by patients with HF has almost doubled in the past decade, the proportion of HF decedents who use hospice remains lower than that of other major diseases. Cardiovascular professional societies have called for the increased and earlier integration of hospice care for patients with advanced heart disease.”

How Researchers Examined the Data

Investigators analyzed data on a subsample of individuals from a longitudinal observational study of patterns of care among HF patients, identifying a cohort of individuals who had two or more HF hospitalizations (i.e., were admitted with a principal diagnosis of HF) within a six-month period during 2009 and died within six months of the second hospital discharge (unmatched sample, n = 7810).

Multiple hospitalizations for HF within a six-month period have been found to be a marker of increased disease severity and risk of death, note the authors.

Using Medicare and patient assessment data gathered by home care clinicians for the Outcome and Assessment Information Set (OASIS) in 2009, with follow-up data gathered in 2010, the researchers examined predictors of hospice enrollment among two propensity score-matched samples of 3067 persons each: those who enrolled in hospice and those who received usual care (mean age, 82 years; female, 53%; non-white, 15%). 

Key Findings: Hospice Patients

• Those enrolled in hospice had longer median survival compared with usual care patients (80 days vs 71 days; P = 0.004).
• HF patients enrolled in hospice were less likely than those who received usual care to die in the hospital (3% vs 56%; P < 0.001) and less likely to die in a skilled nursing facility (1.0% vs 10%; P < 0.001).
• Among enrollees, 57% died with home hospice, 32% died in inpatient hospice and 4% died under hospice care in an unknown setting.  
• The median number of days from the second discharge to hospice enrollment was 51 days (SD = 47 days); 33.3% of patients enrolled within 30 days after the second HF discharge and  8.1% enrolled within seven days after the second HF discharge.  
• Nearly one-half (45%) died within seven days of hospice enrollment. 

Predictors of Hospice Enrollment

Those who enrolled in hospice were more likely than those receiving usual care to: 

• Be older than 85 years (45% vs 34%; P < 0.001)
• Be white (86% vs 78%; P < 0.001) 
• Have a higher median household income ($53,193 vs $50,761; P < 0.001) 
• Be sicker (metastatic cancer, 9% vs 6%; P < 0.001) 
• Have dementia (22% vs 18%; P < 0.001),
• Have dyspnea at rest or with minimal exertion (49% vs 44%; P < 0.001) 
• Have more functional dependencies (4.1 vs 3.8; P < 0.001) 

“Although those who enrolled in hospice after the second HF hospital discharge were older, more likely to be white, and less likely to have Medicaid and disability entitlement than those who received usual care, these trends are similar to national statistics about hospice enrollment across all diagnoses,” the authors write.

In the six months prior to the second HF hospitalization, subsequent hospice enrollees had:

• Fewer ED visits (3.1 vs 4.6; P < 0.001) than those who did not later enroll in hospice
• Fewer all-cause inpatient admissions (1.70 vs 1.88; P < 0.001)
• Fewer all-cause inpatient days (12.4 vs 14.0; P < 0.001)

There were no significant differences between the two groups for ICU days and SNF days in the six months before the second discharge. After propensity score analysis, only the mean number of ED visits remained a significant predictor of hospice use (2.38 vs 2.59; P = 0.01).

Propensity Score-Matched and Adjusted Findings

Within 30 days after the second HF discharge, those who enrolled in hospice had fewer ED visits (2.64 vs 2.82; P = 0.04) and spent fewer mean days in the hospital (3.90 vs 4.67; P < 0.001) and in the ICU (1.25 vs 1.51; P < 0.001) than did those not in hospice.

In the six months after the second HF discharge/hospitalization, those who enrolled in hospice had significantly fewer: 

• ED visits (4.25 vs 5.25; P < 0.001) 
• Inpatient stays (1.75 vs 2.18; P < 0.001) and inpatient days (11.7 vs 14.8; P < 0.001)
• ICU days (3.75 vs 4.86; P = 0.04) 
• Skilled nursing facility stays (4.38 vs 6.44; P = 0.04) 

Source:

“Predictors of Hospice Enrollment for Patients with Advanced Heart Failure and Effects on Health Care Use,” Journal of the American College of Cardiology: Heart Failure; September 2018; 6(9):780-789. Gelfman LP et al; Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY; Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York City; Independent Contractor, Bonny Doon, CA; and Divisions of Cardiology and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York City.