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Original Investigation
October 2018

Trends in Hospice Discharge and Relative Outcomes Among Medicare Patients in the Get With The Guidelines–Heart Failure Registry

Author Affiliations
  • 1Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
  • 2Duke Clinical Research Institute, Durham, North Carolina
  • 3Department of Medicine, Stanford University School of Medicine, Stanford, California
  • 4Palo Alto Veterans Affairs Health System, Palo Alto, California
  • 5Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 6Associate Editor, JAMA Cardiology
  • 7Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 8Deputy Editor, JAMA Cardiology
  • 9Department of Medicine, University of California, Los Angeles
  • 10Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
  • 11Department of Medicine, University of Colorado, Aurora
JAMA Cardiol. 2018;3(10):917-926. doi:10.1001/jamacardio.2018.2678
Key Points

Question  What is the state of hospice care in older patients hospitalized with heart failure?

Findings  In this cohort analysis of 121 990 Medicare beneficiaries in the American Heart Association Get With The Guidelines–Heart Failure registry, hospice discharges increased from 2% in 2005 to 5% in 2014. Patients discharged to hospice had a median survival of 11 days, and 4% of patients discharged to hospice were readmitted to the hospital; nonwhite race and younger age were the strongest predictors of hospital readmission.

Meaning  Hospice use remains infrequent in patients with heart failure, and those patients are referred late.

Abstract

Importance  While 1 in 10 older patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this population is not well described.

Objective  To assess rates of discharge to hospice, readmission after hospice, and survival in hospice in patients following hospital discharge.

Design, Setting, and Participants  In this observational cohort analysis of patients in the multicenter American Heart Association Get With The Guidelines (GWTG)–HF registry linked to Medicare fee-for-service claims data, we analyzed patients 65 years and older discharged alive from the hospital between 2005 and 2014. We compared 4588 patients discharged to hospice with 4357 patients with advanced HF (ejection fraction ≤25% and any of the following: inpatient inotrope use, serum sodium level ≤130 mEq/L, blood urea nitrogen level ≥45 mg/dL [to convert to micromoles per liter, multiply by 0.357], systolic blood pressure ≤90 mm Hg, or comfort measures during hospitalization) not discharged to hospice and with 113 045 other patients with HF in the GWTG-HF registry. Data were analyzed from October 2017 to June 2018.

Main Outcomes and Measures  Discharge to hospice, rehospitalization, and mortality.

Results  Of the 4588 patients discharged to hospice, 2556 (55.7%) were female and 4047 (88.2%) were white, and they had a median (interquartile range) age of 86 (80-90) years. Hospice accounted for 4588 of 121 990 discharges (3.8%), of which 2424 (52.8%) were discharges to home hospice and 2164 (47.2%) were to a hospice facility. Hospice discharges increased from 2.0% (109 of 5528) in 2005 to 4.9% (968 of 19 590) in 2014. Patients discharged to hospice were older, white, and more symptomatic compared with patients with advanced HF (n = 4357) and other patients in the GWTG-HF registry (n = 113 045). The median (interquartile range) postdischarge survival time in patients discharged to hospice was 11 (3-63) days compared with 318 (78-1105) days in patients with advanced HF and 754 (221-1868) days in other patients in the GWTG-HF registry. A total of 739 patients (34.1%) discharged to hospice facilities died in less than 72 hours, while 295 (12.2%) discharged to home hospice died in less than 72 hours; 690 patients (15.0%) discharged from hospice lived for 6 months or more. Among hospitals with more than 25 hospice discharges, the median (interquartile range) hospice discharge rate was 3.5% (2.0%-5.7%). Readmission at 30 days was lower in patients discharged to hospice (189 [4.1%]) compared with patients with advanced HF (1185 [27.2%]) and others in the GWTG-HF registry (25 022 [22.2%]). Nonwhite race and younger age were the strongest predictors of readmission from hospice.

Conclusions and Relevance  Hospice use has grown to about 4.9% of Medicare HF hospital discharges, with significant hospital-level variation. Almost a quarter of patients discharged to hospice die within 3 days of discharge, and about 4.1% of patients are readmitted to the hospital within 30 days.

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