We characterized predictors of hospice use and aggressive end-of-life care in a population-based cohort of men dying of prostate cancer. Our study has several important findings. First, we found that over half of men dying of prostate cancer enrolled in hospice. The proportion of individuals using hospice increased over time, but the timing of hospice referral remained poor, with almost one-third of subjects enrolling either within 7 days of death or more than 180 days before dying. By 2004, when 61% of men dying of prostate cancer enrolled in hospice, 25% of those enrolled died within 7 days of referral, and 10% lived longer than 180 days. Almost all regions in the United States have access to hospice services, with the exception of a small number of rural areas.11
Hospice resources employ a multidisciplinary team of physicians, nurses, social workers, home health aids, speech therapists, volunteers, occupational counselors, physical therapists, nutritionists, and spiritual advisors who offer illness-related medical care, respite care, medical supplies, and family bereavement support for up to 12 months after an individual dies.25
Hospice stays shorter than 7 days are too brief to maximize the benefit of enrollment, and individuals making shorter stays receive fewer services and benefit less from the input of the full interdisciplinary team.5,24,26,27
Late hospice referral and low hospice enrollment indicate low-quality end-of-life care.28
Family members who perceive referrals as late report more concerns with the quality of care, lower overall satisfaction, and greater unmet needs.25,29
At the other end of the spectrum, the Medicare hospice benefit requires that a primary care physician and a hospice medical director certify than an individual’s expected prognosis does not exceed 180 days when he or she is enrolled in hospice.13,30
Despite these guidelines, physicians routinely overestimate their patients’ survival, with prognostic accuracy declining the longer the clinician has known the patient.31
The use rate we report builds on previous population-based studies of men dying of prostate cancer, in which use rates ranged from 18% to 43%, with a temporal trend toward increased use.5,7–10,21,22
While overall rates of hospice use by all patients with cancer, including those with prostate cancer, have improved over time, the timing of hospice referral has not changed significantly over the past 25 years.5,13
Our findings highlight both the successes of increased hospice use, to a zenith of 62% of men dying of prostate cancer in 2003, as well as avenues for improvement in the timing of hospice referral.
Second, we found that in the last 6 months of life, men not enrolled in hospice underwent more imaging studies and received more high-intensity care, which comprised inpatient hospital stays, ICU admissions, multiple emergency department visits, chemotherapy, cystoscopy, and ureteral stent or nephrostomy tube placement. Our hypothesis that stent or nephrostomy tube placement would represent the most frequent end-of-life intervention in men dying of prostate cancer was incorrect. Men enrolled in hospice were at least as likely as those not enrolled to make outpatient visits and to receive palliative radiation, suggesting that hospice enrollment did not prevent individuals from receiving primary or palliative care. Medicare expenditures for imaging services have risen approximately 17% per year in the last decade, from $3.6 billion in 2000 to $7.6 billion in 2006.32,33
No data endorse a connection between increased use of imaging studies and patient outcomes, especially at the end of life.34
Although the mean number of imaging studies performed on all men in our analysis was high overall, it was substantially higher in those not enrolled in hospice.
Likewise, the significant burden of high-intensity procedures performed in the last 6 months of life, particularly in men not enrolled in hospice, raises concern over what Emanuel35
has termed cost without benefit
. While our population-based analysis did not allow us to characterize the specific reason for each individual emergency department visit or hospital admission, a high number of emergency department visits and hospital admissions, including ICU stays, indicates poor-quality end-of-life care, according to the quality of care indicators proposed by Earle et al.28
Data from the National Hospice Study and other analyses suggest that hospice enrollment improves symptom management, quality of death, and quality of life at the end of life.3,4
While prospectively collected data are lacking, observational data suggest that hospice enrollment significantly reduces the cost of caring for individuals at the end of life.5,7,13,16,18–20
If hospice enrollment is associated with lower cost and higher quality of life at the end of life, and if, as our analysis shows, hospice enrollment portends the performance of fewer costly high-intensity interventions, hospice use may minimize resources spent with limited benefit. Approximately one-third of the total Medicare budget is expended on individuals at the end of life.13
The United States currently spends approximately $2.2 trillion per year on Medicare and Medicaid, accounting for 16% of the gross domestic product, and, as the current Director of the Office of Management and Budget pointed out in 2007, “The long-term fiscal balance of the United States will be determined primarily by the future rate of growth of health care costs.”36,37
(p1885) The Obama Administration’s fiscal year 2010 budget aims at reducing hospital admission rates as one way of controlling cost without sacrificing quality.38,39
Our findings suggest that increasing indicated hospice enrollment may aid in achieving this goal specifically. It also may provide other avenues for controlling cost and maximizing quality of life, by minimizing expensive interventions that improve neither the quality of care nor the quality of life at the end of life. Reducing the proportion of health care resources expended at the end of life might liberate resources that could then be used in other areas of need.
Third, several sociodemographic characteristics of our patients were associated with hospice use. In our multivariable model, white ethnicity, lower Charlson comorbidity index, higher socioeconomic status, and partnered relationship status were associated with increased hospice use. Retrospective analyses of population-based data reveal conflicting findings about sociodemographic variation in hospice use. Virnig et al12
found no sociodemographic predictors of hospice use, but Lackan et al7
noted variations in age, marital status, insurance type, cancer type, education level, income level, race, and sex. The analysis by Lackan et al7
demonstrated decreasing variation over time for subgroups defined by type of insurance, marital status, urban residence, and income, but increasing variation over time as a function of age and cancer type. Other analyses suggest that men who have never been married are less likely to enroll in hospice.8
We were surprised to find an inverse relationship between Charlson comorbidity index and hospice referral. It is possible that men who were sicker with multiple illnesses had more difficulty coping in a home setting with hospice and therefore did not get referred; this would be of interest for further study.
Several authors have expressed concern over misuse of hospice to manage acute complications in the last few days before death, as opposed to more appropriate use earlier in the end of life arc.7,9,15
That individuals with more comorbidity were less likely enroll in hospice suggests that they were not enrolled with the goal of palliating pain as death approached, although nuances in referral patterns stratified by comorbidity remains an intriguing area for future study. Inappropriate variation in use of medical treatments is considered poor-quality care,40
and identifying subgroups that use hospice resources less frequently may help target interventions aimed at increasing appropriate hospice use.
Our findings are limited by several methodological considerations. First, because our sample was restricted to Medicare enrollees older than 65 years, our findings may not apply to younger individuals. However, SEER-Medicare data are representative of the US population and allow valuable temporal analyses that are not feasible in many other data sets. Similarly, although many men are diagnosed as having prostate cancer at younger ages, the majority of men dying of prostate cancer are of Medicare age.21
Second, our analysis missed all hospice costs paid out of pocket, although this accounts for less than 20% of total hospice expenditures.13
The lost opportunity cost as well as the actual out of pocket cost was not accounted for in our analysis. Third, we could not incorporate patient preference for end-of-life care into our analysis. Prospective studies to examine patient preferences for hospice care at the end of life would be invaluable. Fourth, use of death certificates to establish prostate cancer as the cause of death risks attribution bias, although death certificates for men dying of prostate cancer have been shown to be accurate. We captured men dying of prostate cancer, not men with prostate cancer, but could not ascertain the acute reason leading to their final hospital admission or death.41
Fifth, by using SEER-Medicare claims data we did not capture all individuals dying of prostate cancer, but SEER-Medicare claims have been shown to be representative of trends for the overall population. Sixth, our model did not examine the temporal relationship between hospice use and high-intensity care, and our results reflect associations, not causation. Elucidating the aforementioned temporal relationships would be important in improving our understanding of end-of-life care for men with prostate cancer. Although we did not prove causality, we believe that the marked differences in the care received by men who did and did not enroll in hospice are important to note and should be further examined. Seventh, during the study period, standards of care regarding chemotherapy for advanced prostate cancer changed. Specifically, the benefit of docetaxel for those with good performance status was not fully appreciated until late in our study period.
We found that the proportion of men dying of prostate cancer who use hospice resources has increased over time, although the percentage of those enrolling very close to the end of life remains too high. Those who enroll in hospice are less likely to undergo imaging procedures and to receive high-intensity medical care at the end of life. Increasing appropriate hospice use may improve the quality of death for men at the end of life while rationalizing health care expenditures during this high-cost period.