Hospice services provide comfort care for patients facing life-limiting illness, along with psychosocial care for their families. The first hospice center opened in 1974; in 2017, 4,515 Medicare-certified hospices were in operation [National Hospice and Palliative Care Organization (NHPCO), 2019]. While most hospice centers are independent, almost 20% are connected to a health system, home health agency, or nursing home. In 2017, 1.49 million Medicare beneficiaries received hospice services (NHPCO, 2019).
As hospice services have become more prominent, there has been an increase in discharges from hospital to hospice with a decrease in hospital deaths (Lin, Levine, & Scanlan, 2012). When patients are moved from hospital inpatient status to hospice status, they are discharged to hospice care (either at the same hospital or at another facility) or to home hospice. Subsequent death is not counted by the hospital as a mortality (Kozar, Holcomb, Xiong, & Nathens, 2014). This is the case even when a patient remains in the same hospital or, in what is called “scattered-bed hospice,” potentially even in the same bed. Documentation may artificially demonstrate improved survival to hospital discharge, which can affect research, quality, and performance programs as well as public reporting.
Discharge to hospice has been associated with a decrease in both crude- and risk-adjusted mortality and better performance status in a trauma population (Kozar et al., 2014). Using the National Inpatient Sample (NIS), this study aimed to explore changes over time in both mortality rates and hospice use in adults for several common acute and chronic diseases. Information from this study may provide insight into trends of in-hospital mortality and the impact of discharge to hospice care on reported mortality for several common hospital diagnoses.
Hospice use at time of death has increased from 21.6% in 2000 to 42.2% in 2009, together with a rise in short hospice stays (≤3 days) and healthcare transitions at end-of-life (Teno et al., 2013). The rise in hospice care has been correlated with a wider awareness of the benefits of hospice among beneficiary patients, families, and physicians and increased availability of hospice care facilities (NHPCO, 2019).
Most patients receive hospice care at home, which may be a private residence, nursing home, or residential facility (NHPCO, 2019). Care is also provided to hospice patients in hospice facilities and in inpatient hospitals (NHPCO, 2019; Teno et al., 2013). Inpatient models include scattered-bed and hospice unit models where a patient may remain at the discharging hospital to receive hospice care services (Chung, Richards, & Burke, 2015).
From 2007 to 2010, the number of Medicare beneficiaries discharged from acute care hospitals to hospice care increased by 66%. As defined in a 2013 report from the Department of Health and Human Services (HSS), an early discharge is more than 1 day earlier than the Medicare-established geometric mean length of stay (LOS) for a valid diagnosis-related group. Interestingly, for Medicare beneficiaries, septicemia (diagnosis-related group 871) was the top diagnosis of all hospital early discharges to hospice, with 10.4% reported in 2009 and 11.9% in 2010 (HHS, 2013). During these same 2 years, other diagnoses in the top 10 listing included acute myocardial infarction (AMI), chronic heart failure (CHF), shock, and lung neoplasm (HHS, 2013).
Epidemiology studies commonly use large databases to report hospital mortality. When a patient is discharged alive to a hospice setting, the patient is recorded as a hospital survivor; if this patient subsequently expires as a hospice patient either in the same hospital or in a hospice facility, the patient is recorded as hospice death, not a hospital death. This process, although appropriate in allowing the positive impact of hospice care, may induce deceiving changes in mortality reporting in several high-volume hospital diagnoses.
Hospice care has been linked to patients with terminal cancer. Over the past 10 years, there has been increased usage of hospice care with other end-stage disease states such as chronic obstructive pulmonary disease (COPD) and CHF (Buggey, Mentz, & Galanos, 2015; Lin et al., 2012). Although hospice care is not typically tied to acute disease processes, acute severe disease states such as cardiogenic and septic shock may be exceptions (Dietz, Jones, Small, Gaiski, & Mikkelsen, 2017; van Diepen et al., 2017).
This article examines whether the decline of in-hospital mortality is at least partially explained by the change in end-of-life care with an increased discharge to a hospice setting in several common high-volume acute and chronic hospital admission diagnoses over a 5-year period. Common in-hospital diagnoses of interest include AMI, CHF, AMI with cardiogenic shock, COPD, septic shock, and lung cancer. To our knowledge, no study has used a large public database to evaluate the association between decreased in-hospital mortality and increased hospice use in several acute and chronic high-volume hospital diagnoses.
Study Design and Data Source
This study was a retrospective analysis of hospital discharge data from the Healthcare Cost and Utilization Project NIS database over a 5-year period. Sponsored by the Agency for Healthcare Research and Quality (AHRQ), the NIS is the largest publicly available all-payer inpatient database in the United States with approximately 8 millionhospital stays per year (AHRQ, 2017). The NIS database includes both in-patient mortality and discharge dispositions such as hospice at hospital discharge. The study was considered exempt by the Institutional Review Board of Cooper University Healthcare.
We used the NIS database to identify patients who met one of the six selected diagnoses. Because of changes in recording hospital discharge location, data after 2011 do not provide details regarding discharge to hospice. Therefore, we chose to evaluate hospitalizations from 2007 to 2011. First, we divided the six diagnosis groups based on whether patients expired during hospitalization or were discharged to hospice. We based our group descriptions on patient and hospital characteristics. We used the Charlson Comorbidity Index to judge severity of illness. The Charlson Comorbidity Index is a prediction of 1-year mortality for a patient with comorbid conditions. Each condition was assigned a score of 1, 2, 3, or 6 based on risk of death for each condition (Charlson, Pompei, Ales, & MacKenzie, 1987).
All hospitalizations in patients ≥18 years of age were identified for six common acute and chronic diagnoses using the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9 CM) codes used at the time of data collection. The diagnoses included COPD (490–491, 492, 494, 496), CHF (428.xx), AMI (410.xx), AMI with cardiogenic shock (410.xx and 785.51), septic shock (785.52), and lung cancer (162.xx and 490–491, 492, 494, and 496). Patients were further categorized according to their discharge disposition as discharged to hospice care or expired.
Patient records from the NIS database for the selected diagnoses, discharged to hospice or expired, were characterized based on demographics (age, race, sex, etc.) and clinical characteristics. Variables were recorded as percentages or mean and standard deviation (SD). Data were analyzed using SAS v9.4 (SAS Institute, Cary, NC).
During this study period, 10,458,728 hospitalizations met our criteria; 2.72% of the patients received hospice care and 6.38% expired (hospital deaths).
Table 1 includes a comparison of patients who received hospice care versus those who expired for the six diagnoses combined. Patients discharged to hospice were older and had more comorbidities in comparison to those who expired without hospice. Individuals who expired in the hospital had a longer LOS in comparison to those discharged to hospice. Hospice use in the South was double that in the Midwest and more than triple that in the Northeast and West. Hospital mortality was highest in the South (38.26%) and lowest in the West (18.83%). White individuals were more likely to be discharged to hospice compared to nonwhites. The primary payer mix showed that non-Medicare individuals were less likely to be discharged to hospice. Medicaid patients died in the hospital at a rate three times greater than the rate of those discharged to hospice. Income quartile 4 (wealthiest population) individuals were less likely to be discharged to hospice compared to quartiles 1–3. Discharge to hospice was more common in non-academic medical centers (AMCs) (nonteaching hospitals) compared to AMCs, as shown in Table 1.
Supplemental Table 1 (provided as Appendix A to this article, published online as Supplemental Digital Content at http://links.lww.com/JHM/A39) includes an evaluation of hospital location, type, and region. Most patients were discharged from private not-for-profit hospitals in both rural (62%) and urban (72%) locations. Comparing hospital type by region in this cohort, there was a higher rate of private not-for-profit hospitals in the Northeast (92%) and Midwest 86%), with lower rates in the West (68%) and South (59%). In-hospital mortality was similar across hospital types, ranging from 6.4% to 6.7%. The rates for hospice use were similar in private not-for-profit (2.6%) and governmental-nonfederal hospitals (2.6%), while private for-profit hospitals had a higher rate (3.7%). (Supplemental Table 2, provided as Appendix A to this article, published online as Supplemental Digital Content at http://links.lww.com/JHM/A39).
During this 5-year period (2007–2011), for each of the six selected diagnoses, there was a steady rise in hospice usage associated with a decrease in mortality, as shown in Figure 1. Baseline characteristics for each of the six diagnoses are shown in Table 2. The most frequent diagnoses were COPD and CHF, with more than 4.3 million discharges each. Lung neoplasm (cancer) and AMI with shock cases were the least frequent, each accounting for approximately 45,000 hospitalizations. Septic shock patients were the youngest group (66 years), and CHF patients were the oldest (73 years). AMI or AMI with shock diagnoses were more common in males, while COPD and CHF were observed more often in females. White race accounted for the majority of the patients in all six diagnoses, ranging from 67.52% septic shock patients to 81.58% patients with COPD. In this study, the Charlson Comorbidity Index was above 5 for all diagnoses except septic shock, which was 4.40. Length of stay was longest in septic shock patients (14.27 days) and shortest for COPD (5.85 days). Hospitalization for each of the six diagnoses was highest in the low-income group and lowest in the high-income group, as shown in Table 2.
Most patients in this cohort were managed in urban hospitals. Across each of the six diagnoses, the South observed the highest percentage of hospice care ranging from 36.25% to 42.10%, as shown in Table 2. Excluding septic shock and AMI with shock, more than half of the patients in each of the six diagnosis groups were discharged from nonteaching hospitals (Table 2).
Table 3 describes the annual percentage of hospital mortality and hospice usage over time for all six diagnoses examined. The number of hospitalizations from 2007 to 2011 increased in all groups. There was a rise in hospice usage and a decrease in mortality over the 5-year period in all six diagnoses, as shown in Figure 2. Hospitalizations for lung cancer saw a 1.82% rise in hospice use and 1.2% decline in mortality. Interestingly, MI with cardiogenic shock mortality flattened from 2008 to 2011, with a 1.63% rise in hospice usage from 2007 to 2010 followed by a leveling off from 2010 to 2011. Mortality for patients with septic shock decreased by 6%, while hospice use increased from 3.5% to 5.4% over the 5-year period, as shown in Figure 2.
The primary finding in this study was that at least part of the decrease in in-hospital mortality for six major hospital diagnoses could be explained by increases in discharge to hospice for these patient groups. Hospice usage converts an in-hospital death to a hospice death and does not show up on reported hospital mortality data. We doubt that this is the primary motivating factor for the increased usage of hospice, although there is a secondary benefit to a hospital when reporting hospital mortality data. The finding could be another motivating factor for capturing the primary benefits of hospice, such as bringing experts on pain control, emotional and spiritual support for patients, and support for the patients’ loved ones (NHPCO, 2019). In addition, because considerable resources are used for the care of patients in the terminal stages of disease, hospice decreases health system costs (Lin et al., 2012).
The Affordable Care Act established risk-standardized 30-day mortality rates (RSMRs) for patients diagnosed with pneumonia, CHF, and AMI as a methodology for rewarding or penalizing hospitals for low or high mortality rates, respectively. The usage of RSMRs as an appropriate measure of hospital quality, as well as the potential to overuse or misuse hospice care for decreasing hospital mortality in patients with high risk of death, has been raised (Kupfer, 2013). Increases in palliative care coding in Canada have been observed to correlate with declines in hospital-standardized mortality rates between 2004 and 2010 (Chong, Nguyen, & Wilcox, 2012).
Decreasing mortality over time for acute illness may follow improved care (new treatment interventions, better organ support technologies) or factors unrelated to treatment. One possible cause of decreasing mortality in illness not related to improved treatment has been dubbed the “Will Rogers phenomenon” (also called “stage migration,” i.e., a change as to how a patient is grouped or classified among the continuum of a disease process) (Feinstein, Sosin, & Wells, 1985). Feinstein et al. noted that with increased awareness and diagnostic testing, milder stages of cancer previously not diagnosed were now diagnosed and added to the denominator for mortality calculation. With less advanced disease, an apparent decrease in mortality was credited to better treatment options when it actually was due to less severely ill patients being included in the denominator with lower mortality. Experts also have questioned whether the Will Rogers phenomenon is relevant to the decreasing mortality in severe sepsis (infection-induced organ dysfunction) (Lagu et al., 2012; Stevenson, Rubenstein, Radin, Wiener, & Walkey, 2014). How much of that decrease is because of improved treatment, and how much is related to the increased awareness and education programs on the importance of the early identification of severe sepsis? This hypervigilance for earlier detection and treatment of severe sepsis likely drives the denominator of the mortality calculation up in severe sepsis patients with less mortality, thus lowering mortality independent of any improvement in treatment (Iwashyna & Angus, 2014).
As noted earlier, patients discharged from the hospital who subsequently die while in hospice are not counted as hospital deaths. The association between increased hospice discharges and decreased hospital mortality, as described for multiple diagnoses in this study, might therefore at least partially explain the decreasing hospital mortality over time for these chronic disease states in the absence of a true treatment improvement.
Although it is not possible to discriminate different types of hospice care from the NIS database, Marks (2015) has raised concerns about the potential misuse of scattered-bed hospice, calling the practice “hospice flipping.” He implies the possibility that hospice flipping is driven more by financial investment for a healthcare system and less by services provided. In that circumstance, a dying patient who is expected to live only hours or days is transferred to scattered-bed hospice. The patient is discharged from the hospital alive from a data tracking perspective and admitted to hospice service while remaining in the same bed. Subsequent death is equated with a hospice death and not counted as a hospital mortality. In fairness to this practice, the patient and family get the benefits of specialized end-of-life care, including comfort-care expertise as well as grief counseling. The former may be particularly important when hospital death occurs after a long hospital stay. At the same time, the practice opens up the possibility that acute disease processes that enter a care period of medical futility could be moved to hospice status. If inequitable among hospitals, this practice would distort benchmarking for quality of care and be a variable to isolate and consider over time in hospital mortality changes.
We did not find it surprising that patients discharged to hospice were older and had more comorbidities compared to those who expired without hospice. Likewise, a longer LOS for patients expiring in the hospital compared to those entering hospice care would be expected because the decision to enter hospice ends hospital LOS. A decision to continue active treatment will, by definition, lead to an added stay in the hospital before death.
In this study, nonwhite and Medicaid patients were less likely to enter hospice care. These two groups share a likelihood of lower socioeconomic status. However, income quartile 4 (highest income) individuals were less likely to be discharged to hospice compared to quartiles 1–3. One must then postulate why race and primary payer status would drive less hospice care. Do the families lack support to negotiate hospice care as the best for a particular patient in the end stages of life? These families may be less likely to have the support for home hospice, but one would think that for in-hospital hospice, stand-alone hospice centers, or scattered-bed hospice, this would not be a factor. Is there more distrust of the system in the nonwhite Medicaid patients when hospice is offered to the family as an option? That would certainly have no impact on the secondary driver of hospice usage (i.e., decreasing hospital mortality) and would serve to support the notion that this motivation is not a primary factor for the increased hospice usage over time.
Why would the South have greater hospice use than other, more densely populated areas of the country? A previous study using the Standard Analytic File Hospice maintained by the Centers for Medicare & Medicaid Services found similar geographic variation in hospice use, with the South and Southwest having higher use and the Midwest and the Northeast having lower use (Connor, Elwert, Spence, & Christakis, 2007). That report used Medicare-based hospice use in the 12 months prior to deaths that occurred in 2002. Even more difficult to explain is why the overall data pool would show an association between increased hospice use and decreased hospital mortality while the reverse is shown in the South. Conceivably, the South (south Atlantic, east south central, and west south central areas) may have an older patient population including retirees from other regions.
Geographical differences are not unique to hospice use. Geographical factors associated with health disparities are reported with differences in treatment, access to care, and/or limited resources in prostate cancer care, management of COPD, and early-stage breast cancer (Gilbert, Pow-Sang, & Xiao, 2016; Croft, Lu, Zhang, & Holt, 2016; Goyal, Chandwani, Haffty, & Demissie, 2015). These differences support the premise that healthcare location, access to specialists, and distance traveled affect patient care and outcomes in many disease states at the regional, state, and county levels.
Why was discharge to hospice more common in non-AMCs compared to AMCs in this study? The reverse was found in a study of the cancer population; teaching hospitals were associated with greater usage of hospice (Earle et al., 2008). Further confounding this issue is the finding that in the Medicare population in one study, mortality was shown to be lower in teaching versus nonteaching hospitals with major teaching hospitals having a 1.5% lower mortality compared to nonteaching hospitals (Burke, Frakt, Khullar, Orav, & Jha, 2017). The difference may relate to provider experience in treating the conditions or early adoption of technologies.
One finding that has been reported is the great variability in AMCs as to end-of-life care (Wennberg et al., 2004). Wennberg et al. compared hospice use and end-of-life hospital care among 77 AMCs. They found a large difference in days in the hospital and physician visits during the last six months of life among these hospitals. For example, Medicare patients at NYU Langone Health, when compared to similar patients at Stanford University Medical Center, spent more than twice the time in the hospital (27.1 vs. 10.1 days) and had more than three times the number of physician visits (76.2 vs. 22.6) during the last six months of life. Among the 77 hospitals studied, enrollment in hospice was inversely correlated with hospital days in the last six months of life (r = –0.41), the chance of dying in a hospital (r = –0.51), and the percentage of deaths occurring in association with a stay in the intensive care unit (r = –0.28).
Study Limitations and Future Research
There are several limitations to this study. First, as with any large database, there are limitations related to coding, as we were reliant on specific ICD-9 codes for patient identification and accuracy of patient outcomes. Changes in coding practice rules may affect precision in ensuring that the patient meets both clinical and coding criteria for a specific diagnosis. Second, because of modifications in the NIS dataset, tracking trends in discharge disposition to hospice beyond 2011 is not possible. Third, we cannot determine causality from the NIS database. A well-designed prospective study may be needed to evaluate causative factors associated with the changes in hospice use and in-hospital mortality.
For six diagnoses (CHF, COPD, AMI, AMI with cardiogenic shock, septic shock, and lung neoplasm) in the NIS database evaluated from 2007 to 2011, hospice use rose steadily as observed mortality decreased. Because patients who would have died during hospitalization are transferred to hospice status and are no longer considered hospital mortalities, variability among hospitals as to hospice use could reward or penalize hospitals as to public reporting.
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