Areas with High Hospice Use Lower Readmission Rates

The "Spillover Effect"

Patients newly enrolled in hospice close to hospital discharge were found to be at low risk for rehospitalization within 30 days, as is consistent with hospice goals. Further, all hospitalized patients residing in geographic areas with high utilization of hospice were found to be at lower rehospitalization risk than were patients living in areas of low hospice use, according to a report published in the Journal of Palliative Medicine. 

What the authors identify as the “spillover effect” of hospice utilization density has been previously observed in the nursing home setting, on patterns of chemotherapy use at the end of life, and among family members of hospice patients, the authors point out. This appears to suggest that the presence of hospice has an impact not only on individual enrollees, but also on and through local systems of care and patterns of practice.

“This work suggests that hospice services are of benefit to both hospice enrollees as well as non-enrollees..., and may be an important component in efforts to improve post-hospital care,” write the authors. “Hospitalizations...represent a critically important point where discussions of care preferences can take place, and where transitions to hospice may improve the quality of care for select patients for whom hospice is consistent with their overall goals.”

Investigators assessed 1,997,506 hospitalizations between 2005 and 2009 from a 5% national sample of Medicare fee-for-service beneficiaries (mean age, 79 years; female, 63%; white race, 87%). Enrollment and claims data were linked via patients’ zip codes to U.S. Census data and Hospital Service Area (HSA), from the Dartmouth Atlas of Health Care.

Hospice utilization was grouped into tertiles according to the percentage of all deaths occurring in hospice within each HSA. Wide geographic variation was found; the proportions of patients who died in hospice, grouped by lowest, middle and highest hospice utilization tertile, were 27%, 41% and 53%, respectively.

Key Findings

• 18.2% of patients were rehospitalized within 30 days of discharge.
• Patients enrolled in hospice near or at discharge had lower rates of 30-day rehospitalization than did non-hospice patients (2.2% vs 18.8%).
• Rehospitalization diagnoses were similar among hospice enrollees and non-enrollees, with congestive heart failure, septicemia and pneumonia being the most prevalent diagnoses.
• Hospice enrollment within 30 days of hospital admission was associated with a reduced risk of rehospitalization (adjusted hazard ratio [HR], 0.12; 95% confidence interval [CI], 0.12 to 0.13).
• Patients living in areas of low hospice utilization had greater risk of hospitalization compared with those patients living in high-utilization areas (19.1% vs 8.1%; HR, 1.05; 95% CI, 1.04 to 1.06).
• The effect of hospice enrollment in reducing rehospitalization risk remained constant, regardless of the number of a patient’s prior hospitalizations (P = < 0.001).

Recurrent hospitalizations at the end of life and the high-intensity care that accompanies them often serve only to reduce patient quality of life and reduce the likelihood that patient preferences will be honored, such as for comfort care and dying at home, note the authors. Hospice care helps reduce unwanted and burdensome rehospitalizations by helping patients and families to realign expectations for care.

“Hospice, by providing comprehensive patient- and family-centered care for seriously ill patients nearing the end of life, facilitates a transition to primarily home-based, holistic care focused on comfort and quality of life that is personalized to the individual patient’s goals of care,” the authors write.

“Hospice additionally provides an immediate and always accessible on-call service for symptom management and acute changes in status that may preclude emergency medical services activation, emergency department evaluation, or rehospitalization.”

Source: “Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients,” Journal of Palliative Medicine; July 2015; 18(7):601-612. Holden TR, et al; Departments of Medicine, Population Health Sciences, Family Medicine, Surgery and Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI.