The "Spillover Effect"
Patients newly enrolled in hospice close
to hospital discharge were found to be
at low risk for rehospitalization within
30 days, as is consistent with hospice
goals. Further, all hospitalized patients
residing in geographic areas with high
utilization of hospice were found to be
at lower rehospitalization risk than were
patients living in areas of low hospice use,
according to a report published in the
Journal of Palliative Medicine.
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What the authors identify as the “spillover
effect” of hospice utilization density has
been previously observed in the nursing
home setting, on patterns of chemotherapy
use at the end of life, and among family
members of hospice patients, the authors
point out. This appears to suggest that the
presence of hospice has an impact not only
on individual enrollees, but also on and
through local systems of care and patterns
“This work suggests that hospice services
are of benefit to both hospice enrollees
as well as non-enrollees..., and may be
an important component in efforts to
improve post-hospital care,” write the
a critically important point where
discussions of care preferences can take
place, and where transitions to hospice
may improve the quality of care for select
patients for whom hospice is consistent
with their overall goals.”
Investigators assessed 1,997,506
hospitalizations between 2005 and 2009
from a 5% national sample of Medicare
fee-for-service beneficiaries (mean age,
79 years; female, 63%; white race, 87%).
Enrollment and claims data were linked
via patients’ zip codes to U.S. Census data
and Hospital Service Area (HSA), from
the Dartmouth Atlas of Health Care.
Hospice utilization was grouped into
tertiles according to the percentage of all
deaths occurring in hospice within each
HSA. Wide geographic variation was
found; the proportions of patients who
died in hospice, grouped by lowest, middle
and highest hospice utilization tertile, were
27%, 41% and 53%, respectively.
- 18.2% of patients were rehospitalized
within 30 days of discharge.
- Patients enrolled in hospice near or at
discharge had lower rates of 30-day
rehospitalization than did non-hospice
patients (2.2% vs 18.8%).
- Rehospitalization diagnoses were
similar among hospice enrollees and
non-enrollees, with congestive heart
failure, septicemia and pneumonia
being the most prevalent diagnoses.
- Hospice enrollment within 30 days
of hospital admission was associated
with a reduced risk of rehospitalization
(adjusted hazard ratio [HR], 0.12; 95%
confidence interval [CI], 0.12 to 0.13).
- Patients living in areas of low hospice
utilization had greater risk of
hospitalization compared with those
patients living in high-utilization areas
(19.1% vs 8.1%; HR, 1.05; 95% CI,
1.04 to 1.06).
- The effect of hospice enrollment
in reducing rehospitalization risk
remained constant, regardless of
the number of a patient’s prior
hospitalizations (P = < 0.001).
Recurrent hospitalizations at the end
of life and the high-intensity care that
accompanies them often serve only to
reduce patient quality of life and reduce
the likelihood that patient preferences
will be honored, such as for comfort care
and dying at home, note the authors.
Hospice care helps reduce unwanted
and burdensome rehospitalizations by
helping patients and families to realign
expectations for care.
“Hospice, by providing comprehensive
patient- and family-centered care for
seriously ill patients nearing the end of life,
facilitates a transition to primarily homebased,
holistic care focused on comfort
and quality of life that is personalized to
the individual patient’s goals of care,” the
“Hospice additionally provides an
immediate and always accessible on-call
service for symptom management and
acute changes in status that may preclude
emergency medical services activation,
emergency department evaluation, or
Source: “Hospice Enrollment, Local Hospice
Utilization Patterns, and Rehospitalization
in Medicare Patients,” Journal of Palliative
Medicine; July 2015; 18(7):601-612. Holden
TR, et al; Departments of Medicine, Population
Health Sciences, Family Medicine, Surgery and
Biostatistics and Medical Informatics, University
of Wisconsin School of Medicine and Public
Health, Madison, WI.