Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life

Abstract

The Medicare hospice benefit was originally designed around a cancer disease paradigm but increasingly serves people living with dementia. At this time, almost half of all older adults receiving hospice care have dementia. Yet there is minimal evidence as to whether hospice benefits people living with dementia outside of nursing facilities. We asked whether and how the perceived quality of last-month-of-life care differed between people with and without dementia and whether hospice use among people living with dementia was associated with perceived quality of care compared with the quality of care for those who did not use hospice. We used nationally representative data from the National Health and Aging Trends Study and Medicare claims from the period 2011-17 to examine the impact of hospice enrollment on proxy perceptions of last-month-of-life care quality. Proxies of people living with dementia enrolled in hospice compared with proxies of those not enrolled more often reported care to be excellent (predicted probability: 52 percent versus 41 percent), more often reported having anxiety or sadness managed (67 percent versus 46 percent), and less often reported changes in care settings in the last three days of life (10 percent versus 25 percent). There were no differences in the impact of hospice on proxy ratings of care for people with and without dementia. Policy makers should consider these benefits when weighing changes to hospice policy and regulations that may affect people living with dementia.

Exhibit 3:

Comparing associations of last-month-of-life care quality outcomes among Medicare beneficiaries ages 70 and older, 2011–17, by use of hospice for at least 1 day in the last month of life Source/Notes: SOURCE Authors’ analysis of the data from participants in the National Health and Aging Trends Study ages 70 and older who had a sample person interview and who died between 2011 and 2017. NOTES Analyses used covariate balancing propensity score methods to estimate the propensity for enrolling in hospice at least 1 day in the last month of life, estimated with variables known to affect hospice use: age; sex; race and ethnicity; education; marital status; number of children; income; comorbidities of cancer, heart disease, stroke, or diabetes; metropolitan area; census region; and year of death. From the propensity score model, we estimated normalized inverse probability of treatment weights. For each outcome measure we used postestimation commands to present the adjusted predicted probabilities. All analyses account for National Health and Aging Trends Study survey weights. Late transitions were defined as care setting changes in the last 3 days of life.

Exhibit 4:

Comparing associations of last-month-of-life care quality outcomes among Medicare beneficiaries ages 70 and older, 2011–17, by use of hospice for 30 continuous days in the last month of life (versus no hospice) and with hospice use of at least 1 day in the last month of life (versus no hospice) Source/Notes: SOURCE Authors’ analysis of the data from participants in the National Health and Aging Trends Study ages 70 and older who had a sample person interview and who died between 2011 and 2017. NOTES Analyses used covariate balancing propensity score methods to estimate the propensity for enrolling in hospice 30 continuous days in the last month of life and propensity for enrolling at least 1 day in the last month of life, estimated with variables known to affect hospice use: age; sex; race and ethnicity; education; marital status; number of children; income; comorbidities of cancer, heart disease, stroke, or diabetes; metropolitan area; census region; and year of death. From the propensity score model, we estimated normalized inverse probability of treatment weights. All analyses account for National Health and Aging Trends Study survey weights. We present the odds ratio of quality outcomes for use of hospice for 30 continuous days in the last month of life (versus no hospice) and at least 1 day in the last month of life (versus no hospice). Late transitions were defined as care setting changes in the last 3 days of life.