Hospice Dropouts Risk Crushing Personal and Financial Trouble

On average, 11% of cancer patients drop out of hospice care, according to research conducted at the Mount Sinai School of Medicine. Many of these patients are in for rough sledding.

In research scheduled to be published October 1 in the Journal of Clinical Oncology, Melissa D.A. Carlson, PhD, and colleagues at Mount Sinai found that 39.8% of hospice dropouts were admitted as hospital inpatients compared with only 1.6% of patients who remained in hospice. Nearly 33.9% of the dropouts entered the hospital through the ER compared with only about 3.1% of those who remained in hospice care until they died.

The research paints a dark picture not only for the emotional and physical well being of patients who leave hospice care, but for the U.S. healthcare system, as well. Cancer patients who quit hospice care average nearly five times higher healthcare costs than patients who remained in hospice-$6,537 compared with $30,848 in expenses-from their admission to hospice to their deaths.

The soon to be published study, which is available ahead of time online, did not examine the reasons cancer patients quit hospice. Previous research by Carlson, an assistant professor of geriatrics and palliative medicine at Mount Sinai, and colleagues, however, looked at some of the surrounding issues.

They found that dropout rates can vary widely from one hospice to another. Some are as low as a few percent. Others as high as 30%. Newer, smaller hospices tend to have the highest dropout rates.

“In some cases perhaps there is a crisis situation where these patients can't be managed because a newer or smaller hospice doesn't have the staffing, maybe on weekends, to deal with it. So the individual then is told to go to the hospital, ends up in the emergency department, and is admitted,” she said.

Carlson recommends that oncologists should connect with palliative care teams where available and try to ensure that the patient and family are supported after they leave hospice.

“Oncologists might be still be involved in the care of these patients and they can help in this consultation-to clarify what the goals are and what the patient and family's preferences are for care,” she said.

The Mount Sinai study results were based on data from 90,826 cancer patients who had enrolled in 1,384 hospices between 1998 and 2002. The cases were included in the Surveillance, Epidemiology, and End Results (SEER)–Medicare database.

Many of the 11% who disenrolled had conditions that typically fit hospice care, leading the researchers to wonder why. Carlson recommends conducting patient and caregiver interviews to help understand the reasons.

The Mount Sinai researchers may not know why patients leave hospice, but Carlson feels certain that they should stay. Rather than looking for ways to cut Medicare expenditures by restricting access to the Medicare Hospice Benefit, policymakers should focus on keeping patients enrolled, she said. Doing so could reduce overall costs while improving patient welfare.

“We know that hospice saves money and we know that there are benefits to patients and family. If they disenroll, we know that they use healthcare at a very high rate,” she said. “So rather than talking about trying to reduce Medicare hospice benefit expenditures, we should try to support (these patients) to try to get them to stay with hospice until they die.”