From hospice to hospital: short-term follow-up study of hospice patient outcomes in a US acute care hospital surveillance system

1. Elizabeth Barnett Pathak1,
2. Sarah Wieten1,2,
3. Benjamin Djulbegovic1

+ Author Affiliations

1. ¹Division of Evidence-Based Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
2. ²Department of Philosophy, University of South Florida, Tampa, Florida, USA

BMJ Open 2014;4:e005196 doi:10.1136/bmjopen-2014-005196

Abstract

Objectives In the USA, there is little systematic evidence about the real-world trajectories of patient medical care after hospice enrolment. The objective of this study was to analyse predictors of the length of stay for hospice patients who were admitted to hospital in a retrospective analysis of the mandatorily reported hospital discharge data.

Setting All acute-care hospitals in Florida during 1 January 2010 to 30 June 2012.

Participants All patients with source of admission coded as ‘hospice’ (n=2674).

Primary outcome measures The length of stay and discharge status: (1) died in hospital; (2) discharged back to hospice; (3) discharged to another healthcare facility; and (4) discharged home.

Results Patients were elderly (median age=81) with a high burden of disease. Almost half died (46%), while the majority of survivors were discharged to hospice (80% of survivors, 44% of total).

 A minority went to a healthcare facility (5.6%) or to home (5.2%). 

 Only 9.2% received any procedure. 

 Respiratory services were received by 29.4% and 16.8% were admitted to the intensive care unit. The median length of stay was 1 day for those who died.

 In an adjusted survival model, discharge to a healthcare facility resulted in a 74% longer hospital stay compared with discharge to hospice (event time ratio (ETR)=1.74, 95% CI 1.54 to 1.97 p<0.0001), with 61% longer hospital stays among patients discharged home (ETR=1.61, 95% CI 1.39 to 1.86 p<0.0001). 

Total financial charges for all patients exceeded $25 million; 10% of patients who appeared to exit hospice incurred 32% of the charges. 

Conclusions 

 Our results raise significant questions about the ethics and pragmatics of end-of-life medical care, and the intentions and scope of hospices in the USA. Future studies should incorporate prospective linkage of subjective patient-centred data and objective healthcare encounter data.