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 After the U.S. Veterans Administration implemented its Comprehensive
End of Life Care Initiative in 2009, growth of enrollment of
terminally ill male war veterans in hospice care outstripped
enrollment growth in hospice programs for elderly men who did not
serve, according to the report in Health Affairs.
More veterans likely enrolled in hospice care because the initiative
allowed them to continue to have curative treatments, said Joanne
Spetz, a professor at the Institute for Health Policy Studies at the
University of California, San Francisco. Other hospice programs
require participants to cease disease-modifying treatment.
Spetz suspects that being able to use both hospice and concurrent
care motivated people to sign up for hospice care "because it wasn’t
an either/or decision,” she said in a phone interview.
Deciding to forego chemotherapy, radiation or any other possible
curative treatments can be difficult for patients and families, said
Spetz, who was not involved in the study.
“There’s fear that if I sign up for hospice, I’ve given up,” she
said. “It’s also hard for the physician, who’s trained that death is
a loss.”
Researchers compared hospice use among more than 1.1 million male
veterans ages 65 and older between 2007 and 2014 with more than
140,000 demographically similar Medicare beneficiaries not enrolled
in VA healthcare.
By 2011, they found that 44 percent of veterans who died in
hospitals took their last breaths in hospice beds, compared to 30
percent in 2008. By 2012, 71 percent of veterans dying of cancer
were enrolled in hospice.
Lead author Susan Miller, a professor at the Brown University School
of Public Health in Providence, Rhode Island, and her team
structured the study to examine whether the VA initiative drove
growth beyond that in the general Medicare population.
Before the initiative, veterans were 15 percent less likely than
non-veterans to go into hospice, Miller said in a phone interview.
Today, they’re 2.4 percent more likely.
The VA initiative focused on increases in palliative and hospice
care. By 2012, the VA had installed 54 new hospice and
palliative-care inpatient units, the authors write.
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Elderly men who were not veterans increased hospice use by 5.6
percent between 2007 and 2014, while older male veterans increased
hospice use by 7.6 percent, the study found.
Previous studies repeatedly document that dying people receive
higher-quality end-of-life care with hospice, the authors write.
“Numerous studies show hospice improves quality of care and results
in less aggressive and undesired care, such as emergency room visits
and hospitalizations near the end of life,” Miller said.
“The quality is better, and families feel it’s better,” she said.
Spetz applauded the VA initiative for its concerted effort to
provide palliative-care and hospice staff across the country. But
she wondered if the effort could be reproduced in other healthcare
systems.
“If you tried to implement this program in a community program, it
would be a lot harder,” she said. “It speaks well for integration of
care because many people have very, very fragmented care. Could you
really pull this off outside the VA?”
The U.S. Centers for Medicare and Medicaid Services is currently
testing a hospice program that allows curative care to continue,
called the Medicare Care Choices Model.
Miller believes conversations between patients and clinicians soon
after a diagnosis of serious illness are key.
“The VA’s having discussions with veterans earlier to understand
preferences and to meet their needs,” she said.
“It’s the conversations that are so important,” she said. “The VA is
trying to have more of these conversations and document the
preferences earlier.”
SOURCE: http://bit.ly/2tel1xX Health Affairs, online July 5, 2017.
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