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Hospice referral occurs late in end-stage renal disease

In most patients with end-stage renal disease who were treated with hemodialysis, hospice care was received for 3 days or fewer which may translate to higher costs and lower quality of care, according to findings published in JAMA Internal Medicine.

“Hospice is a benefit available to people with a life expectancy of six months or less,” Melissa W. Wachterman, MD, MSc, MPH, palliative care physician, Brigham and Women’s Hospital and VA Boston Healthcare System, told Healio Internal Medicine. “Hospice has expertise in relieving pain and other symptoms and in providing emotional support to patients and their loved ones. Data show that patients receiving hospice have better quality of life, higher family satisfaction, and lower costs.”

Wachterman and colleagues performed a cross-sectional observational study to determine the association between hospice length of stay and end-of-life health care utilization and costs among patients on hemodialysis (mean age, 74.8 years; 53.7% male). The researchers included 770,191 fee-for-service Medicare beneficiaries who received hemodialysis and died between Jan. 1, 2000, and Dec. 31, 2014, from the United States Renal Data System registry.

Results showed that at the time of death, 20% of patients were receiving hospice care. Hospice care lasted 3 days or less for 41.5% of participants.

Patients who received hospice services for 3 or fewer days had a lower probability of dying in the hospital (13.5% vs. 55.1%) or receiving an intensive procedure in the last month of life (17.7% vs. 31.6%) and a higher probability of being hospitalized (83.6% vs. 74.4%) and admitted to the ICU (54% vs. 51%), compared with those who did not receive hospice. Medicare costs in the last week of life were similar among patients enrolled in hospice ($10,756) and those not enrolled ($10,871).

Progressively lower rates of utilization and costs were linked to longer stays in hospice (beyond 3 days), particularly among patients who were referred to hospice care 15 days prior to death (35.1% hospitalized; 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life, $3,221).

“We found that people with end-stage renal disease are much less likely to receive hospice than those with other serious advanced illnesses and when they do receive hospice it is almost always very last minute when patients are just on the brink of death or close to it,” Wachterman said. “As a result they are less able to reap all of the benefits that hospice has to offer.”

She added, “Allowing access to the Medicare Hospice Benefit for patients with end-stage renal disease on dialysis has the potential to better meet the triple aim of health care for this patient population: optimizing the patient experience of care including quality and satisfaction, improving population health and reducing per capita costs.”

Patients with ESRD may be required to stop dialysis when entering hospice care, which may not be an option for many patients; therefore, accessing palliative care is important, according to Wachterman.

“Palliative care provides much of the same symptom management and support to patients and families confronting serious advanced illness,” she said. “So we hope our study will raise awareness about not only hospice, but also palliative care for patients with kidney failure.”

Physicians may not recognize that patients with ESRD have a high pain burden that is similar to that of patients with advanced cancer and that patients on dialysis have a higher mortality rate than those with advanced cancer, according to Wachterman.

“For both of these reasons, physicians who care for patients with ESRD should be considering referring their patients to palliative care. And not just nephrologists, but also primary care physicians and the multitude of other specialists who come into contact with patients with ESRD,” she said.

In a related editorial, Margaret L. Schwarze, MD, from the University of Wisconsin-Madison, and colleagues, wrote that the findings by Wachterman and colleagues reveal critical holes in end-of-life care and raises the issue of how to improve care for patients with ESRD who are receiving dialysis.

“Because the etiology of this problem appears to be linked to both hospice policy and the social constructs of illness, a multipronged approach is required,” they wrote. “Palliative care concurrent with disease-modifying therapy has clearly demonstrated benefits for patients throughout the course of illness, promoting symptom relief and reducing invasive treatments near the end of life, without increasing mortality.”

“Provision of palliative care on initiation of hemodialysis would promote goal-concordant treatment decisions, support advance care planning, and help to address patients’ end-of-life care needs as their condition declines over time,” they added. “This in combination with policy modifications that permit patients whose terminal illness is ESRD to maintain coverage for hemodialysis, along with their hospice benefit, has potential to expand access to hospice, improve end-of-life care, and reduce costs.” – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures. Schwarze reports receiving support from Patient-Centered Outcomes Research Institute, National Institute on Aging, National Institutes of Health and Cambia Health Foundation.