Predictors of Hospice Enrollment for Patients With Advanced Heart Failure and Effects on Health Care Use

Abstract

Objectives: This study sought to: 1) identify the predictors of hospice enrollment for patients with heart failure (HF); and 2) determine the impact of hospice enrollment on health care use.

Background: Patients with HF rarely enroll in hospice. Little is known about how hospice affects this group's health care use.

Methods: Using a propensity score-matched sample of Medicare decedents with ≥2 HF discharges within 6 months, an Outcome and Assessment Information Set (OASIS) assessment, and subsequent death, we used Medicare administrative, claims, and patient assessment data to compare hospitalizations, intensive care unit stays, and emergency department visits for those beneficiaries who enrolled in hospice and those who did not.

Results: The propensity score-matched sample included 3,067 beneficiaries in each group with a mean age of 82 years; 53% were female, and 15% were Black, Asian, or Hispanic. For objective 1, there were no differences in the characteristics, symptom burden, or functional status between groups that were associated with hospice enrollment. For objective 2, in the 6 months after the second HF discharge, the hospice group had significantly fewer emergency department visits (2.64 vs. 2.82; p = 0.04), hospital days (3.90 vs. 4.67; p < 0.001), and intensive care unit stays (1.25 vs. 1.51; p < 0.001); they were less likely to die in the hospital (3% vs. 56%; p < 0.001), and they had longer median survival (80 days vs. 71 days; log-rank test p = 0.004).

Conclusions: Beneficiaries' characteristics, including symptom burden and functional status, do not predict hospice enrollment. Those patients who enrolled in hospice used less health care, survived longer, and were less likely to die in the hospital. A tailored hospice model may be needed to increase enrollment and offer benefits to patients with HF.

Keywords: health services; heart failure; palliative care; quality and outcomes.

Figure 1. Sample Selection flow diagram

The flow diagram describes (1) beneficiaries who were discarded from original sample and (2) describes the sample of Medicare fee-for-service beneficiaries in our final sample.

Figure 2. Number of days from 2nd HF Discharge to Death, by Hospice Use

This Kaplan-Meier curve of the days from second HF discharge to death for the propensity score matched sample. Those who enrolled in hospice after the second HF discharge had a median survival of 80 days as compared those who received usual care with a median survival of 71 days.