In a large cohort study published in JAMA Internal Medicine, hospice visits in the last 2 days of life by professional staff varied by race, hospice program, and geographic region, with visits less likely if the patient was black, dying on a Sunday, or receiving care in a nursing home.

These results raise concerns that such patients are receiving less support in the last 2 days of life from hospice professional staff, write Joan M. Teno, MD, University of Washington, Seattle, and colleagues in the JAMA article.

“More than 1.6 million people who die in the US currently use hospice services every year.”

In the study, Dr Teno and colleagues analyzed Medicare administrative claims data on 661,557 patients cared for by 3935 hospice programs throughout the United States. The patients died between October 1, 2013, and September 30, 2014, while receiving routine home care.

The investigators found that, overall, 81,478 of these patients (12.3%) did not receive any visits from professional staff during the last 2 days of life.

Alaska was the state with the highest proportion of patients not receiving visits (97 of 492 patients; 19.7%), followed by Washington (2825 of 14,394 patients; 19.6%), New Jersey (3417 of 17,753 patients; 19.2%), and Rhode Island (486 of 2528 patients; 19.2%). The state in which most visits occurred was Wisconsin, where only 590 of 15,399 patients (3.8%) died without any visits from professional staff in the last 2 days of life.

Of all the hospice programs, in only 21 (0.6%) were visits made to 100% of patients during the last 2 days of life; 281 programs provided no visits. Blacks were less likely to receive visits than were whites (15.2% vs 12.0%; adjusted odds ratio [AOR], 1.30; 95% confidence interval [CI], 1.24 – 1.37).

Patients dying in a nursing home were 1.74 times less likely to receive visits than those dying at home; 16.5% of nursing home patients went without visits, compared with 10.6% of patients dying at home (95% CI, 1.62 – 1.88). Patients were also less likely to receive a visit if they died on a Sunday. Those who died on a Sunday were 3.35 times more likely to go without a visit in the last 2 days of life compared with those dying on a Tuesday (95% CI, 3.17 – 3.55).

Living in a rural area, being served by a newer hospice (in operation for 3 years or less), and being treated by a for-profit hospice were other factors associated with lack of visits.

Changes to Payment System

The authors comment that recent changes to the Medicare hospice payment system, whereby Medicare will give a “service intensity add-on payment” to hospices that provide visits during the last 7 days of life, may address these problems.

“The intent of the payment is to promote visits by professional staff at the end of life and to better align the payments hospices receive with the increased care and service requirements at the end of life for all dying patients and those who care for them,” they write.

The authors of the invited commentary agree. It is hoped that Medicare’s planned add-on payments for visits from a registered nurse or social worker during the last 7 days of life will be useful and will provide an incentive to hospice agencies to deliver skilled care in the last week of life, “when patients and caregivers need it the most,” they write.

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