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Observational Study
. 2018 Oct 1;3(10):917-926.
doi: 10.1001/jamacardio.2018.2678.

Trends in Hospice Discharge and Relative Outcomes Among Medicare Patients in the Get With The Guidelines-Heart Failure Registry

Haider J Warraich  1   2 , Haolin Xu  2 , Adam D DeVore  1   2 , Roland Matsouaka  2 , Paul A Heidenreich  3   4 , Deepak L Bhatt  5 , Adrian F Hernandez  1   2   6 , Clyde W Yancy  7   8 , Gregg C Fonarow  9   10 , Larry A Allen  11
Affiliations
Observational Study

Trends in Hospice Discharge and Relative Outcomes Among Medicare Patients in the Get With The Guidelines-Heart Failure Registry

Haider J Warraich et al. JAMA Cardiol. .

Abstract

Importance: While 1 in 10 older patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this population is not well described.

Objective: To assess rates of discharge to hospice, readmission after hospice, and survival in hospice in patients following hospital discharge.

Design, setting, and participants: In this observational cohort analysis of patients in the multicenter American Heart Association Get With The Guidelines (GWTG)-HF registry linked to Medicare fee-for-service claims data, we analyzed patients 65 years and older discharged alive from the hospital between 2005 and 2014. We compared 4588 patients discharged to hospice with 4357 patients with advanced HF (ejection fraction ≤25% and any of the following: inpatient inotrope use, serum sodium level ≤130 mEq/L, blood urea nitrogen level ≥45 mg/dL [to convert to micromoles per liter, multiply by 0.357], systolic blood pressure ≤90 mm Hg, or comfort measures during hospitalization) not discharged to hospice and with 113 045 other patients with HF in the GWTG-HF registry. Data were analyzed from October 2017 to June 2018.

Main outcomes and measures: Discharge to hospice, rehospitalization, and mortality.

Results: Of the 4588 patients discharged to hospice, 2556 (55.7%) were female and 4047 (88.2%) were white, and they had a median (interquartile range) age of 86 (80-90) years. Hospice accounted for 4588 of 121 990 discharges (3.8%), of which 2424 (52.8%) were discharges to home hospice and 2164 (47.2%) were to a hospice facility. Hospice discharges increased from 2.0% (109 of 5528) in 2005 to 4.9% (968 of 19 590) in 2014. Patients discharged to hospice were older, white, and more symptomatic compared with patients with advanced HF (n = 4357) and other patients in the GWTG-HF registry (n = 113 045). The median (interquartile range) postdischarge survival time in patients discharged to hospice was 11 (3-63) days compared with 318 (78-1105) days in patients with advanced HF and 754 (221-1868) days in other patients in the GWTG-HF registry. A total of 739 patients (34.1%) discharged to hospice facilities died in less than 72 hours, while 295 (12.2%) discharged to home hospice died in less than 72 hours; 690 patients (15.0%) discharged from hospice lived for 6 months or more. Among hospitals with more than 25 hospice discharges, the median (interquartile range) hospice discharge rate was 3.5% (2.0%-5.7%). Readmission at 30 days was lower in patients discharged to hospice (189 [4.1%]) compared with patients with advanced HF (1185 [27.2%]) and others in the GWTG-HF registry (25 022 [22.2%]). Nonwhite race and younger age were the strongest predictors of readmission from hospice.

Conclusions and relevance: Hospice use has grown to about 4.9% of Medicare HF hospital discharges, with significant hospital-level variation. Almost a quarter of patients discharged to hospice die within 3 days of discharge, and about 4.1% of patients are readmitted to the hospital within 30 days.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The Get With The Guidelines–Heart Failure program is provided by the American Heart Association, is sponsored in part by Amgen, and has been funded through support from Medtronic, GlaxoSmithKline, Ortho-McNeil Pharmaceutical, and the American Heart Association Pharmaceutical Roundtable. Dr DeVore has received research support from the American Heart Association, Amgen, the National Heart, Lung, and Blood Institute, and Novartis and has served as a consultant for Novartis. Dr Bhatt has served on the advisory boards of Cardax, Elsevier PracticeUpdate Cardiology, Medscape Cardiology, and Regado Biosciences; has served on the Board of Directors of the Boston Veterans Affairs Research Institute and the Society of Cardiovascular Patient Care; has served as chair of the American Heart Association Quality Oversight Committee, National Cardiovascular Data Registry ACTION Registry Steering Committee, and Veterans Affairs Clinical Assessment Reporting and Tracking Research and Publications Committee; has served on data monitoring committees for Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, and Population Health Research Institute; has received honoraria from the American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor and Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), and WebMD (CME steering committees); has served as Deputy Editor of Clinical Cardiology; has received research funding from Abbott, Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi Farmaceutici, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Eli Lilly and Company, Medtronic, PhaseBio Pharmaceuticals, Pfizer, Regeneron, Roche, Sanofi, Synaptics, and The Medicines Company; has received royalties from Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); has served as site co-investigator for Biotronik, Boston Scientific, St Jude Medical (now Abbott), and Svelte Medical; has served as a trustee for the American College of Cardiology; and has performed unfunded research for FlowCo, Merck & Co, PLx Pharma, and Takeda. Dr Hernandez has received personal fees from AstraZeneca, Amgen, Bayer, Boston Scientific, Merck & Co, Novartis, and Pfizer as well as grants from AstraZeneca, GlaxoSmithKline, Merck & Co, Novartis, Luitpold, and Bristol-Myers Squibb. Dr Fonarow has conducted research at the National Institute of Health and is a consultant for Amgen, Bayer, Janssen, Medtronic, Novartis, and St Jude Medical. Dr Allen has consulted for Novartis, Boston Scientific, Janssen, Cytokinetics/Amgen, ACI Clinical, and Duke Clinical Research Institute and has received research grants from the Patient-Centered Outcomes Research Institute, the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the American Heart Association. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Variation in Hospice Discharge Rate Among Hospitals
A, Hospice discharge rates from sites with 25 or more hospice discharges were included, leaving 350 sites and 120 923 patients. B, Only sites missing hospital characteristic data were excluded, leaving 383 sites and 111 584 patients.
Figure 2.
Figure 2.. Time-to-Event Comparisons Between Patients Discharged to Hospice, Patients With Advanced Heart Failure, and Other Patients With Heart Failure in the Get With The Guidelines–Heart Failure Registry
Figure 3.
Figure 3.. Time-to-Event Comparisons Between Patients Discharged to Home Hospice and a Hospice Facility
See this image and copyright information in PMC

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