Emergency Care Use and the Medicare Hospice Benefit for Individuals with Cancer with a Poor Prognosis

Abstract

Objectives: To compare patterns of emergency department (ED) use and inpatient admission rates for elderly adults with cancer with a poor prognosis who enrolled in hospice to those of similar individuals who did not.

Design: Matched case-control study.

Setting: Nationally representative sample of Medicare fee-for-service beneficiaries with cancer with a poor prognosis who died in 2011.

Participants: Beneficiaries in hospice matched to individuals not in hospice on time from diagnosis of cancer with a poor prognosis to death, region, age, and sex.

Measurements: Comparison of ED use and inpatient admission rates before and after hospice enrollment for beneficiaries in hospice and controls.

Results: Of 272,832 matched beneficiaries, 81% visited the ED in the last 6 months of life. At baseline, daily ED use and admission rates were not significantly different between beneficiaries in and not in hospice. By the week before death, nonhospice controls averaged 69.6 ED visits/1,000 beneficiary-days, versus 7.6 for beneficiaries in hospice (rate ratio (RR) = 9.7, 95% confidence interval (CI) = 9.3-10.0). Inpatient admission rates in the last week of life were 63% for nonhospice controls and 42% for beneficiaries in hospice (RR = 1.51, 95% CI = 1.45-1.57). Of all beneficiaries in hospice, 28% enrolled during inpatient stays originating in EDs; they accounted for 35.7% (95% CI = 35.4-36.0%) of all hospice stays of less than 1 month and 13.9% (95% CI = 13.6-14.2%) of stays longer than 1 month.

Conclusion: Most Medicare beneficiaries with cancer with a poor prognosis visited EDs at the end of life. Hospice enrollment was associated with lower ED use and admission rates. Many individuals enrolled in hospice during inpatient stays that followed ED visits, a phenomenon linked to shorter hospice stays. These findings must be interpreted carefully given potential unmeasured confounders in matching.

Keywords: Medicare; emergency medicine; end-of-life care; hospice.

Figure 1. Study population

(A) Generation of the matched cohort. We first identified all Medicare beneficiaries who died in 2011, then selected those diagnosed with poor-prognosis cancer. Beneficiaries with prior hospice enrollment suggesting a preceding terminal illness, as well as those with missing geographic or date of death information were excluded. The remaining set was divided by hospice enrollment and then matched, with 84.2% of the non-hospice group paired.

Figure 2. ED visit rate for non-hospice patients and hospice beneficiaries

The mean daily number of ED visits per 1000 beneficiaries for non-hospice patients and hospice beneficiaries, from 1 year before the start of the exposure period (week 0) until death. We separated beneficiaries into groups based on the length of exposure period (i.e., the length of hospice or non-hospice care before death). Because we could not show all 109 groups, and aggregating groups would obscure time trends, we show representative groups with exposure periods of 1, 2, and 4 weeks, which together make up 56.4% of the entire cohort, and then at 4 week intervals from 8 to 30 weeks, which make up 6.1% of the cohort. Crosses mark the week of death for each group of beneficiaries. The vertical dash line at week 0 marks hospice enrollment and the start of the exposure period. The shaded area around the lines indicates the 95% confidence interval for the mean daily visits.