Pathway to Hospice: How Has Place of Care before Hospice Changed with the Growth of Hospice in the United States?

Abstract

Background: Hospice use among Medicare decedents increased from 21.6% in 2000 to 51.6% in 2019. Whether this growth has been accompanied by more referrals to hospice directly from the community is not known. Objective: To assess trends in place of care before hospice enrollment. Design: Retrospective cohort from 2011 to 2018. Subjects: Medicare decedents age ≥66 years. Measure: Location of care before hospice enrollment in the last 90 days of life, defined as: the community with and without home health, short- or long-term nursing facility, or inpatient hospital. A county-level random effects model examined changes in enrollment from the community after adjusting for admitting diagnosis, age, race/ethnicity, sex, and Medicaid participation. Results: Among hospice enrollees (N = 7,650,933), 27.7% transitioned to hospice from the community, 31.8% transitioned from the hospital, and 10.1% transitioned after short- or long-term nursing facility stay. Rates of enrollment to hospice from the community remained stable from 35.1% in 2011 to 34.3% in 2018. After adjustment, the proportion enrolling in hospice from the community decreased by 1.2% (95% confidence interval -1.0% to 1.4%). Place of care before hospice enrollment in 2018 varied by hospice admitting diagnosis, with patients with cancer more likely to enroll from the community (39.5%) and patients with cerebrovascular accidents from the hospital (53.2%). Prior place of care varied by state, with Florida having the highest rate of the enrollment following hospitalization (47.8%). Conclusion: Despite the growth of hospice, the site of care before hospice enrollment has remained relatively stable and was strongly influenced by region.

Keywords: hospice; time trends; utilization.

FIG. 1.

National trends in pathway to hospice from 2011 to 2018 for those decedents that entered hospice in the last 90 days of life.

FIG. 2.

(a) Pathway to hospice by disease in 2011 for all decedents that utilized hospice services. (b) Pathway to hospice by disease in 2018 for all decedents who utilized hospice services. *Note in these graphs those decedents who used hospice services, including those persons in hospice longer than 90 days, whereas Figure 1 documents only those persons who enrolled in final hospice stay in the last 90 days of life.

FIG. 3.

State variation in hospice enrollment from the community with or without prior home health services.

FIG. 4.

State variation in the hospital as the place of enrollment to hospice.