Enrollment and Events of Hospice Patients With Heart Failure vs. Cancer

Context. Hospice care is traditionally used for patients with advanced cancer, but it is increasingly considered for patients with end-stage heart failure. Objectives. We compared enrollment patterns and clinical events of hospice patients with end-stage heart failure with those of patients with advanced cancer. Methods. Using Medicare data linked with pharmacy and cancer registry data, we identified patients who were diagnosed with either heart failure or advanced cancer between 1997 and 2004, admitted to hospice at least once after their diagnosis, and died during the study period. We compared patterns of referral, use of acute services, and site of death of hospice patients with heart failure with those of patients with advanced cancer. Logistic regression models were constructed to determine the factors associated with late hospice enrollment as well as the use of and death in acute care. Results. We identified 1580 heart failure patients and 3840 advanced cancer patients: mean ages were 86 and 80 years, 82% and 68% were women, and 97% and 94% were white, respectively. Compared with patients with advanced cancer, those with heart failure were more frequently referred to hospice from hospitals (35% vs. 24%) and nursing facilities (9% vs. 7%) (both P < 0.01). Discharge from hospice before death was similar for patients with heart failure and patients with advanced cancer (10% vs. 9%, P = 0.03). Among patients remaining in hospice, patients with heart failure were more likely to have been enrolled within three days of death (20% vs. 11%, P < 0.01). The prevalence of death in acute care settings was low in both groups after hospice enrollment (4% heart failure vs. 2% advanced cancer, P < 0.01). Although the median interval between enrollment and death was shorter for heart failure patients (12 vs. 20 days, P < 0.001), emergency department visits and hospitalizations after hospice enrollment were more frequent in patients with heart failure (13% vs. 10% and 9% vs. 6%, respectively, both P < 0.01). Conclusion. Compared with patients with advanced cancer, referral to hospice is more often initiated during acute care encounters for patients with end-stage heart failure, who also more frequently return to acute care settings even after hospice enrollment. J Pain Symptom Manage 2013;45:552-560. (C) 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.