Study: Heavier Patients Get Less Hospice Care

Bias may keep obese patients away from end-of-life care

Increasing obesity status was tied to less hospice use among community-dwelling individuals during the last 6 months of life, according to a retrospective cohort study.

An analysis of data from the Health and Retirement Study (HRS), showed a 6.7% lower rate of hospice enrollment among individuals with obesity (BMI=30), 95% CI -9.3% to -4.0%), and an average of 3.8 fewer day spent in hospice (-4.4 to -3.1 days), versus those who were not obese (BMI=20), reported John A. Harris, MD, of University of Pittsburgh School of Medicine, and colleagues.

Additionally, individuals with obesity had a 3.2% decreased chance of dying at home (-6.0 to -4.0%), they wrote online in the Annals of Internal Medicine.

Despite shorter duration of hospice, individuals with obesity experienced approximately $3,471 more in Medicare expenses during the last 6 months of life versus individuals without obesity ($955 to $5988), the authors noted.

"Obesity is a complex disease, and this study has shown another side of its effect on patients and the healthcare system. Patients with obesity are less likely to receive high quality end-of-life care," stated Harris in a press release. "These patients' voices, and those of their caregivers, need to be heard. They may need extra help. They deserve the best healthcare and better health outcomes."

Using the Medicare Provider Analysis and Review claims files, the researchers analyzed a cohort of 5,677 individuals over the age of 50 from HRS. All participants were Medicare fee-for-service beneficiaries living in a private residence, and died between 1998-2012. Data for measuring BMI status was self-reported.

Findings were not only similar, but also more significant among individuals with morbid obesity (BMI=40) compared with nonobese people:

• 15.2% decrease in hospice enrollment (-19.6 to -10.9%)
• 4.3 fewer days spent in hospice (-5.7 to -2.9 days)
• 6.3% decrease in rate of dying at home (-11.2 to -1.5%)
• $2,895 more in Medicare expenses (-$1,342 to $7,132)

The increase in Medicare expenses in the last 6 months of life consisted of inpatient, outpatient, and physician or supplier expenditures, which were associated with BMI status. These expenses were slightly offset by lower hospice rates, durable medical equipment, and skilled-nursing expenses.

The authors suggested variations in referrals for individuals with obesity may account for many of these hospice differences. Patients with obesity may not display "profound cachexia," and therefore, may not be recognized as a candidate for hospice sooner. Individuals with obesity may also experience a more rapid decline in health leading to more sudden deaths compared to individuals without obesity.

Variations in hospice enrollment policies may also moderate the difference reported in the analysis. Since patients with obesity may require more costly in-home hospice care, for example, the need for a mechanical lift or additional nurse support, access to care may be limited compared to nonobese individuals.

Co-author Jennifer Griggs, MD, MPH, of the University of Michigan in Ann Arbor, explained that "For hospice teams, as for hospital and home-health teams, it can require more staff to take care of people who are obese, but Medicare hospice reimbursement is capped no matter what a person's BMI."

Also, obesity may mask the signposts and changes that physicians might use to determine when it is time for a person to enter hospice. "To refer a patient for hospice, you have to believe that they are in the dying process," she said in a statement.

Because the analysis was limited to those in community-dwellings with a fee-for-service Medicare plan, the results should not be generalized to the larger population, particularly among those with a managed care Medicare plan, the authors cautioned.

Healthcare provider bias against obesity may also play a role in the quality of end-of-life care, they stressed. "There is an established record of negative provider aptitudes and implicit bias against obese persons, and these attitudes may continue to influence care for obese persons at the end of life," they wrote. "Each of these factors may impede the provision of optimal medical, nursing, and supportive care for obese persons, either independently or together, thus explaining the independent effect of obesity on end-of-life health care expenditures."

In order to mitigate the discrepancies among end-of-life care, the authors recommend turning focus toward addressing the issue sooner rather than later through policy-based intervention.

"Many policies focus on preventing or reducing obesity in the U.S., but we will also need policies to encourage the provision of high-quality care for people with obesity," Harris stated. "More attention should be paid to payment structures that recognize the challenges involved with healthcare for men and women with obesity."

The study was funded by the Robert Wood Johnson Foundation Clinical Scholars Program.

Harris and Griggs disclosed no relevant relationships with industry. One co-author disclosed support from the National Institute on Aging.

Reviewed by Henry A. Solomon, MD, FACP, FACC Clinical Associate Professor, Weill Cornell Medical College and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Primary Source: Annals of Internal Medicine: Source Reference: Harris J, et al. The relationship of obesity to hospice use and expenditures: a cohort study. Ann Intern Med2017; DOI: 10.7326/M16-0749.

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