Using population-based health care utilization data for the elderly, we characterized use of hospice, opiates, and acute care services in HF patients at end-of-life and compared it to that in cancer patients. Overall, use of opiates and hospice was not high and use of acute care services was high in both HF and cancer patients. Over time, hospice use has increased slowly in both patient groups, but the contribution of hospice remained lower in HF. Also, more HF patients died in acute care settings. Various components of effective end-of-life care may be provided in non-hospice settings that are not easily captured. However, we were able to assess opiate use in HF patients in non-hospice settings, which was low compared to that in cancer patients and remained low over the duration of study period. To our knowledge, this is the first population-based study described trends in the use of hospice, opiates, and acute care services in elderly HF patients near death and compared them to those in cancer patients.
Prior studies found that hospice utilization was lower in patients who died of heart disease compared to that in patients who died of cancer26-27
. Connor et al. found that 12% of patients died of heart disease used hospice compared to 65% in patients died of cancer26
using 100% Medicare hospice file in 2002. White race, female gender, and advanced age were shown to be associated with higher utilization of hospice 26, 28
. In our study, the enrollment to hospice in 2002 was 26% in HF patients, much higher than the national figure. This higher rate can be explained by the demographic characteristics of our study population. Our study population is dominated by older, White, and/or female patients Geographic variation in the use of hospice has been reported26-27
and PA is one of the states with relatively lower use of hospice compared to other states 26
However, it is possible that there is a within-state variation contributing to the higher use in our patients since our study patients are a subset of Medicare beneficiaries in PA.
Patients with advanced HF experience significant pain 2-7
, dyspnea2, 5-7
, and diminished quality of life 29
. While the specific causes of pain are unclear, 20 - 70% of patients with advanced HF report pain in a population based study 4
or in community dwelling representative samples 4-5
. No evidence exists on how to manage pain and symptomatic dispend at the end-of-life in HF patients 30
. Opiates are considered “essential” medications for palliative care by the World Health Organization31
. Opiates have been used to alleviate pain in cancer patients and can be effective in managing pain and dispend in patients with end stage HF8
. Hospice and other palliative care services can address various aspects of suffering at the end of life including physical, emotional, psychological and spiritual issues and provides caregiver support32
. Although patients with HF and cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being21
, we found that approximately 20% of HF patients were enrolled in hospice or dispensed opiates compared to approximately 50% of cancer patients.
Although our data do not provide insights on reasons and appropriateness of hospice, opiates, or acute care service use in end-of-life HF patients, they shed light on the current status of end-of-life care for HF patients. Several factors could have potentially contributed to the low use of hospice and opiates and high use of acute care services prior to death in our HF patients. First, physicians may be unsure about or underestimate the high mortality after multiple HF hospitalizations and feel reluctant to discuss limited prognosis with HF patients. According to a recent survey for physicians taking care of HF patients, only 16% of the physicians stated that they could predict death within 6 months well 33
. Thomas et al. showed that physicians overestimated the survival in 68% of HF patients vs. 11% of cancer patients34
. Secondly, physicians may not discuss with patients about their end-of-life preferences. While physicians’ discussion of hospice was independently associated with a large increase in the likelihood of hospice use (odds ratio = 5.3; 95% CI: 2.3-13) 34
, only 2.5%35
of HF patients had a discussion about resuscitation preferences or hospice. A recent study showed that patients often have a change in their preferences in survival during or following a recent hospitalization. However, their preferences tend to remain stable during the next 6 months36
where many HF patients with advanced symptoms are more interested in feeling well than in living longer 36
In addition, patients and families may be unwilling to hear about their limited life expectancy. However, in a survey conducted in elderly patients with cancer, HF, or chronic obstructive pulmonary disease and their caregivers37
, 55% of HF patients who had no discussion of their life expectancy with physicians reported that they wanted one. Also, 75% of the caregivers reported that they preferred to have a discussion on life expectancy37
. Finally, unwelcome connotations of “hospice” and “narcotics’ in non-cancer settings and limited availability of palliative care services for HF38
may have contributed to the lower utilization in HF patients.
Several limitations should be noted in interpreting our results. First, our data are limited to low to middle income Medicare beneficiaries who participated in the pharmacy benefit program. The findings in our study may not be generalizable to younger or wealthier patients. However, approximately a half of the states have similar pharmacy assistance programs providing services to patients similar to ours in socioeconomic status. Second, our data lack detailed clinical information and the study population may have included those who were hospitalized for HF but did not die of HF. However, sensitivity analyses using more stringent definition of end-of-life HF cohort requiring 2 HF hospitalizations +loop diuretic use + death due to HF) or less stringent definition requiring (2 HF hospitalizations + cardiac death) yielded very similar results. Also, this potential misclassification of including patients who might have not died of the disease applies to the cancer cohort and therefore is likely to be non-differential. Third, we could not assess whether patients were consulted to palliative care service as no specific procedure code was available to identify palliative care referrals. Finally, we could not assess opiate use after our patients entered a nursing home or enrolled in hospice because the dispensing information is incompletely recorded during their stay in a nursing home or hospice . Opiate use can be much higher in HF patients enrolled in hospice as it has been reported that 74% of HF patients in hospice were prescribed the medication6
We found that HF patients were less likely to be supported by a hospice or opiates prior to death and more likely to die in acute care hospitals than patients dying of cancer. More detailed studies are needed to understand the appropriateness and reasons of the low hospice and opiate use. Opportunities may exist to improve the end-of-life care in HF patients by recognizing limited prognosis in patients with repeated HF hospitalizations, communicating about the prognosis and the role of hospice and opiates, and improving availability of palliative care services in HF patients.