Out-of-hospital death does not equal less aggressive care

By Sarah Guy, medwireNews Reporter

Rates of intensive care unit (ICU) use in the last month of life among patients aged 65 years and older increased between 2000 and 2009 in the USA, despite a reduction in rates of in-hospital death, conflating the notion that there is a trend toward less aggressive care, say researchers.

The findings emerge from data for 848,303 Medicare beneficiaries who died in 2000, 2005, and 2009. During this period the rate of in-hospital death fell from 32.6% to 24.6%.

However, Joan Teno (Warren Alpert School of Brown University, Providence, Rhode Island) and colleagues observed that 29.2% of decedents in 2009 had an ICU stay in the last month of life, compared with 24.3% in 2000, a significant difference.

Furthermore, the mean rate of healthcare transitions (a change in institutional healthcare provider) increased significantly from 2.1 per decedent in 2000 to 3.1 per decedent in 2009, including an increase in potentially burdensome transitions (eg, within the last 3 days of life).

Hospice use increased during the study period, by an average of 21.6% among decedents in 2000, 32.3% among those in 2005, and 42.2% in 2009. But short hospice stays of 3 days or less increased significantly from 22.2% in 2000 to 28.4% in 2009.

"For many patients, hospice is an 'add-on' to a very aggressive pattern of care during the last days of life," said Teno in a press release. "I suspect this is not what patients want."

The mean age of the patient sample used in the analysis was 82.3 years, with 57.9% female decedents and 88.1% of White ethnicity.

By 2009, 5.4% of deaths were in freestanding hospice inpatient units and 3.2% of patients were receiving General Inpatient Level of care (meant for short-term symptom management) at an acute care hospital.

Writing in JAMA, Teno and co-authors believe their results "suggest that increasing hospice use may not lead to a reduction in resource utilization."

Teno continued in her statement: "We need to transform our health care system, from one based on fee-for service medicine for the majority of Americans, to one where people are not paid for just one more ICU day.

"Instead, we need a system where doctors and hospitals are paid for delivering the high-quality, patient-centered care that understands the dying patient's needs and expectations and develops a care plan that honors them."

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