Place of Death Different by Design Comment on “Association of Hospice Patients' Income and Care Level With Place of Death” Place of Death

Abarshi E. — Mon, 25 Mar 2013 00:00:00 GMT

Modern hospices deliver specialized care for dying patients in several settings where patients are cared for and die. The specialization of care is useful given that patients in general have complex needs, and their care requires a high level of education, staff, and other resources. Evidence suggests that specialist palliative care significantly improves pain and other symptom control for these patients and their family members. However, were hospices designed to meet the needs of all persons facing death? For a start, not all patients with specialized palliative care needs are eligible for hospice care. For instance, patients with hospice referrals must meet certain criteria, one of which is to have a shortened life expectancy (sometimes ≤90 days). This criterion means the typical hospice patient is at best one whose illness trajectory is predictable and perhaps unidirectional. Although we ideally wish to extend hospice use to all patients, proponents of this idea need to remember that the cancer trajectory is well suited for a hospice selection. Hospices are not always able to meet the needs of patients with very severe symptoms. They are not uniformly distributed in all regions and often have different styles of operation. Not all patients can afford hospice care. More important, hospices seldom appeal to every culture, religion, and generation. Barclay and colleagues have demonstrated in their article that the hospice simply cannot provide care for everyone. That said, patients with limited resources tend to have limited knowledge about the benefits of a specialized facility such as a hospice. They are less likely to die in a hospice, for a number of reasons, even if the services provided were free. Furthermore, these patients perhaps are less likely to enroll in a home-based program, because some have not embraced the culture of dying at home and thus would not choose a home death, irrespective of the content or the quality of the care package offered. In addition, age-related inequalities may account for variations in preferences.

Association of Hospice Patients' Income and Care Level With Place of Death Hospice Patients and Place of Death

Barclay JS, Kuchibhatla M, Tulsky JA, et al. — Mon, 25 Mar 2013 00:00:00 GMT

Importance

Terminally ill patients with lower incomes are less likely to die at home, even with hospice care.

Objectives

To examine the relationship between income and transfer from home before death and the interaction between income and level of hospice care as a predictor of transfer from home in patients admitted to routine home hospice care.

Design

We matched zip codes to US census tracts to generate median annual household incomes and divided the measure into $10 000 increments (≤$20 000 to >$50 000). We abstracted data from the central administrative and clinical database of a hospice care provider. We analyzed the relationship between income and transfer from home before death using logistic regression adjusted for demographics, diagnosis, region, and length of stay. Level of hospice care was examined as any continuous care vs none. Unlike routine care, which includes periodic visits by hospice, continuous care is a higher level of care used for short periods of crisis to keep a patient at home and includes hospice services in the home at least 8 hours in a 24-hour period.

Setting

A for-profit hospice provider, VITAS Healthcare, operating 26 programs in 8 states.

Participants

Hospice patients admitted to routine care in a private residence from January 1, 1999, through December 31, 2003.

Main Outcome Measure

Transfer from hospice care in a private residence to hospice care in a site outside the home before death.

Results

Of the 61 063 enrollees admitted to routine care in a private residence, 13 804 (22.61%) transferred from home to another location (ie, inpatient hospice unit or nursing home) with hospice care before death. Patients who transferred had a lower mean median household income ($42 585 vs $46 777; P < .001) and were less likely to have received any continuous care (49.38% vs 30.61%; P < .001). The median number of days of continuous care was 4. For patients who did not receive continuous care, the odds of transfer from home before death increased with decreasing median annual household incomes (odds ratio range, 1.26-1.76). For patients who received continuous care, income was not a predictor of transfer from home.

Conclusions and Relevance

Patients with limited resources may be less likely to die at home, especially if they are not able to access needed support beyond what is available with routine hospice care.

JAMA Internal Medicine: Socioeconomic Issues Topic Collection

Place of Death Different by Design Comment on “Association of Hospice Patients' Income and Care Level With Place of Death” Place of Death

Association of Hospice Patients' Income and Care Level With Place of Death Hospice Patients and Place of Death