Medicare kidney failure patients enter hospice too late to reap full benefits

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Boston, MA– As they approach the end of their lives, many patients with end-stage renal disease face a harrowing choice: continue dialysis treatment or enter hospice care. Under current policy, Medicare will not simultaneously pay for dialysis and hospice care for patients with a terminal diagnosis of renal failure. This usually means that in order to receive hospice care, patients must first stop dialysis treatments. A new study by researchers at Brigham and Women's Hospital found that, nationally, only 20 percent of Medicare patients with end-stage renal disease who died used hospice, and those who did were almost twice as likely to have very short hospice stays (i.e., three days or less) compared to patients with other advanced chronic illnesses. Health care utilization and costs for these patients with very short hospice stays were similar to or higher than those for patients who had not been referred to hospice. The study's results are published in JAMA Internal Medicine.

"Since most patients die within a week of terminating dialysis, this Medicare requirement effectively bars hospice entry until the final days of life for many of these patients," said lead author Melissa Wachterman, MD, MSc, MPH, physician at BWH.

Hospice, covered by Medicare, Medicaid and most private insurers, is a benefit available to persons with a life expectancy of six months or less. Hospice has been associated with enhanced patient and family quality of life and satisfaction with care, improved bereavement outcomes, and reduced medical costs as compared to usual care. Nationally, almost 50 percent of people on Medicare who died received hospice care with a median length of stay of 23 days and an average of 70 days.

Wachterman et al.'s study found that approximately 42 percent of dialysis patients who used hospice were enrolled for three days or less. "These short hospice stays make it very difficult for patients dying of kidney disease and their families to fully benefit from the expertise in pain and symptom management that hospice can offer and the emotional support that hospice can provide," said Wachterman.

Though less likely to die in the hospital, costs for dialysis patients with very short hospice stays were similar to those not receiving hospice care. Longer lengths of stay in hospice beyond three days, on the other hand, were associated with progressively lower rates of health care utilization and costs.

Wachterman adds that in addition to the benefits that more timely hospice referral affords dialysis patients and their families, longer time in hospice care may also translate into meaningful reductions in costs near the end of life, thus achieving a triple aim of health care: improved patient experience of care (including quality and satisfaction); improved health of populations; and reduced per capita healthcare costs.

"We hope our work will spark discussions about potential changes to Medicare policy to better serve the needs of the ever-growing population with end-stage renal disease approaching the end of life," said Wachterman. "We believe that improving access to palliative care services for these patients will be pivotal in supporting the delivery of goal-concordant care and smoothing transitions to hospice as patients approach the end of life."

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This study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. Wachterman also received support from career development awards from the National Palliative Care Research Center and the National Institute on Aging.

Paper cited: Wachterman MW et al. "Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis" JAMA Internal Medicine DOI: 10.1001/jamainternmed.2018.0256

Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 4.2 million annual patient visits and nearly 46,000 inpatient stays, is the largest birthing center in Massachusetts and employs nearly 16,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 3,000 researchers, including physician-investigators and renowned biomedical scientists and faculty supported by nearly $666 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative as well as the TIMI Study Group, one of the premier cardiovascular clinical trials groups. For more information, resources and to follow us on social media, please visit BWH's online newsroom.

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Johanna Younghans
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http://www.brighamandwomens.org

http://dx.doi.org/10.1001/jamainternmed.2018.0256

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