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Patient Issues Author: JAMA Last Updated: Sep 7, 2017 - 10:06:33 PM

Lower Proportion of Medicare Patients Dying in Hospitals

Feb 5, 2013 - 4:33:44 PM

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Increase Seen in Use of ICUs in Last Month of Life

( - CHICAGO - In a study that included data on more than 800,000 Medicare beneficiaries who died between 2000 - 2009, a lower proportion died in an acute care hospital in recent years, although both intensive care unit (ICU) use and the rate of health care transitions increased during the last month of life, according to a study appearing in the February 6 issue of JAMA.

"Site of death has been proposed as a quality measure for end-of-life care because, despite general population surveys indicating the majority of respondents and those with serious illness want to die at home, in actuality, most die in an institutional setting. One study found poorer quality of care in the institutional setting compared with care at home, especially with hospice services. The place of care and site of death have implications for the grief and posttraumatic stress disorders experienced by family members," according to background information in the article.

Joan M. Teno, M.D., M.S., of the Warren Alpert Medical School of Brown University, Providence, R.I., and colleagues analyzed Medicare claims data to document places of care and health care transitions for Medicare decedents in the last months of life to assess end-of-life care. The study consisted of a random 20 percent sample of fee-for-service Medicare beneficiaries, 66 years of age and older, who died in 2000 (n = 270,202), 2005 (n = 291,819), or 2009 (n = 286,282). Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. The main outcome measures for the study were site of death, place of care, rates of health care transitions, and potentially burdensome transitions (e.g., health care transitions in the last 3 days of life).

Among the findings of the researchers, the percentage of deaths that occurred in acute care hospitals decreased from 32.6 percent in 2000 to 24.6 percent in 2009. More decedents in 2009 than in 2000 had an ICU stay in the last month of life (from 24.3 percent to 29.2 percent). Hospice use at the time of death increased from 21.6 percent in 2000 to 42.2 percent in 2009.

"Short hospice stays increased from 22.2 percent in 2000 to 28.4 percent of hospice decedents using hospice for 3 days or less. Of these late hospice referrals in 2009, 40.3 percent were preceded by hospitalizations with an ICU stay," the authors write.

Transitions in the last 3 days of life increased from 10.3 percent to 14.2 percent in 2009. The average rate of health care transitions in the last 90 days of life increased from 2.1 per decedent in 2000 to 3.1 per decedent in 2009, with an increase in 2 types of potentially burdensome transitions: transitions in the last 3 days of life and multiple hospitalizations in the last 90 days of life.

"Our findings of an increase in the number of short hospice stays following a hospitalization, often involving an ICU stay, suggest that increasing hospice use may not lead to a reduction in resource utilization. Short hospice lengths of stay raise concerns that hospice is an ‘add-on' to a growing pattern of more utilization of intensive services at the end of life," the researchers write.
(JAMA. 2013;309(5):470-477)

Editor's Note: This research was funded by a National Institute on Aging grant and in part by the Robert Wood Johnson Foundation. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

Editorial: Changes in End-of-Life Care Over the Past Decade - More Not Better

In an accompanying editorial, Grace Jenq, M.D., and Mary E. Tinetti, M.D., of the Yale School of Medicine, New Haven, Conn., write that "site of death has been proposed as a measure of the quality of end-of-life care, perhaps based on studies showing that the majority of people, including those with serious illness, want to die at home."

"The study by Teno et al suggests that site of death is an insufficient metric given the many transitions endured, and intensive care services received, prior to the actual event of death. A more appropriate metric might be whether patients' goals were elicited and care predicated on meeting those goals was instituted soon enough to make a difference in end-of-life care."
(JAMA. 2013;309(5):489-490)

Editor's Note: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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