Pathway to Hospice: How Has Place of Care before Hospice Changed with the Growth of Hospice in the United States?

Abstract

<b><i>Background:</i></b> Hospice use among Medicare decedents increased from 21.6% in 2000 to 51.6% in 2019. Whether this growth has been accompanied by more referrals to hospice directly from the community is not known. <b><i>Objective:</i></b> To assess trends in place of care before hospice enrollment. <b><i>Design:</i></b> Retrospective cohort from 2011 to 2018. <b><i>Subjects:</i></b> Medicare decedents age ≥66 years. <b><i>Measure:</i></b> Location of care before hospice enrollment in the last 90 days of life, defined as: the community with and without home health, short- or long-term nursing facility, or inpatient hospital. A county-level random effects model examined changes in enrollment from the community after adjusting for admitting diagnosis, age, race/ethnicity, sex, and Medicaid participation. <b><i>Results:</i></b> Among hospice enrollees (<i>N</i> = 7,650,933), 27.7% transitioned to hospice from the community, 31.8% transitioned from the hospital, and 10.1% transitioned after short- or long-term nursing facility stay. Rates of enrollment to hospice from the community remained stable from 35.1% in 2011 to 34.3% in 2018. After adjustment, the proportion enrolling in hospice from the community decreased by 1.2% (95% confidence interval -1.0% to 1.4%). Place of care before hospice enrollment in 2018 varied by hospice admitting diagnosis, with patients with cancer more likely to enroll from the community (39.5%) and patients with cerebrovascular accidents from the hospital (53.2%). Prior place of care varied by state, with Florida having the highest rate of the enrollment following hospitalization (47.8%). <b><i>Conclusion:</i></b> Despite the growth of hospice, the site of care before hospice enrollment has remained relatively stable and was strongly influenced by region.