Serious-Illness Care 2.0 — Meeting the Needs of Patients with Heart Failure

Objective To create and test three prospective, increasingly restrictive definitions of serious illness. Data Sources Health and Retirement Study, 2000–2012. Study Design We evaluated subjects’ 1‐year outcomes from the interview date when they first met each definition: (A) one or more severe medical conditions (Condition) and/or receiving assistance with activities of daily living (Functional Limitation); (B) Condition and/or Functional Limitation and hospital admission in the last 12 months and/or residing in a nursing home (Utilization); and (C) Condition and Functional Limitation and Utilization. Definitions are increasingly restrictive, but not mutually exclusive. Data Collection Of 11,577 eligible subjects, 5,297 met definition A; 3,151 definition B; and 1,447 definition C. Principal Findings One‐year outcomes were as follows: hospitalization 33 percent (A), 44 percent (B), 47 percent (C); total average Medicare costs $20,566 (A), $26,349 (B), and $30,828 (C); and mortality 13 percent (A), 19 percent (B), 28 percent (C). In comparison, among those meeting no definition, 12 percent had hospitalizations, total Medicare costs averaged $7,789, and 2 percent died. Conclusions Prospective identification of older adults with serious illness is feasible using clinically accessible criteria and may be a critical step toward improving health care value. These definitions may aid clinicians and health systems in targeting patients who could benefit from additional services.

Objectives 1) To identify the predictors of hospice enrollment for HF patients and 2) to determine the impact of hospice enrollment on healthcare utilization. Background Patients with heart failure (HF) rarely enroll in hospice. Little is known about how hospice effects this population’s healthcare utilization. Methods Using a propensity-score matched sample of Medicare decedents with > two HF discharges within six months, an OASIS assessment and subsequent death, we used Medicare administrative, claims and patient assessment data to compare hospitalizations, ICU stays and ED visits for those who enrolled in hospice and those who did not. Results The PSM sample included 3,067 beneficiaries in each group with a mean age of 82 years; 53% were female, and 15 % were non-white. For objective one, there were no differences in the characteristics, symptom burden or functional status between groups that were associated with hospice enrollment. For objective two, in the six months after the second HF discharge, the hospice group had significantly fewer ED visits (2.64 vs. 2.82, P=0.04), hospital days (3.90 vs. 4.67, P<0.001) and ICU stays ((1.25 vs. 1.51, P<0.001), were less likely to die in the hospital (3% vs. 56%, P <0.001), and had longer median survival (80 vs. 71 days; log-rank test p=0.004). Conclusions Beneficiary characteristics, including symptom burden and functional status, do not predict hospice enrollment. Those who enrolled in hospice utilized less healthcare, survived longer and were less likely to die in the hospital. A tailored hospice model may be needed to increase enrollment and offer benefits to a HF population.