Hospice Referral at Discharge Linked to Lower 30-Day All-Cause Readmissions among Heart Failure Patients

Approximately 25% of patients hospitalized for decompensated heart failure (HF) are readmitted within 30 days of discharge, making HF the leading cause for 30-day all-cause readmissions in the U.S. However, those HF patients enrolled in hospice at discharge are significantly less likely to be readmitted to hospital for any reason, according to a report published in Circulation: Heart Failure.

“To the best of our knowledge, this is the first study to report a robust independent association of discharge hospice referral and lower 30-day hospital readmission in Medicare beneficiaries with HF regardless of EF (ejection fraction),” write the authors.

“Furthermore, this beneficial association of hospice referral with readmission was observed throughout the entire six months post-discharge period and was unaffected by all-cause mortality,” they add.

Investigators analyzed data from patient medical records linked to Medicare utilization files for 8,032 beneficiaries hospitalized for decompensated HF from 1998 to 2001 (mean age, 79 years; female, 58%; non-white, 18%) in one of 106 Alabama facilities. Propensity scores were used to assemble a matched cohort of 179 patients referred to hospice at discharge (“hospice-referral patients”) and 179 patients who died within six months but had not been referred to hospice (“hospice-eligible” patients).

Overall Findings

• 22% of all patients died within six months; 8% of these patients were discharged to hospice.
• 2% overall were discharged to hospice.
• 21% of patients were readmitted for all causes within 30 days of discharge.

Outcomes: Hospice versus No Hospice

• 30-day all-cause readmission occurred in 41% of the patients not referred to hospice who died within six months (“hospice-eligible patients”) and 5% of hospice-referral patients (hazard ratio [HR] associated with hospice referral, 0.12; 95% confidence interval [CI], 0.06 to 0.24).
• Among patients who survived for the first 30 days, 30-day all-cause readmission occurred in 39% and 8% of hospice-eligible patients and hospice-referral patients, respectively (HR, 0.17; 95% CI, 0.08 to 0.36).
• Among those patients who died in the first 30 post-discharge days, 30-day all-cause readmission occurred in 47% of hospice-eligible patients and 1% of hospice-referral patients (HR, 0.03; 95% CI, 0.04 to 0.21).
• 30-day readmission for HF occurred in 17% of hospice-eligible patients and 2% of hospice-referral patients (HR, 0.14; 95% CI, 0.05 to 0.40).
• 90-day all-cause readmission occurred in 59% of hospice-eligible patients and 13% of hospice-referral patients (HR, 0.18; 95% CI, 0.12 to 0.29).
• Among patients who died within 90 days of discharge, 3-month all-cause readmission occurred in 56% of hospice-eligible patients and 7% of hospice-referral patients (HR, 0.15; 95% CI, 0.07 to 0.31).
• 6-month all-cause readmission occurred in 64% of hospice-eligible and 18% of hospice-referral patients (HR, 0.18; 95% CI, 0.12 to 0.28).
• Although mortality at 30 days was higher among the hospice-referral group compared with the hospice-eligible group (43% vs 27%), mortality was similar for both groups at 90 days (64% vs 67%).

“By 90 days post-discharge, mortality rates were similar between the groups and as a result, hospice referral was also associated with a significantly lower risk of the combined end point of 90-day all-cause readmission or 90-day all-cause mortality,” note the authors.

As HF progresses, patients commonly experience steadily worsening symptoms, as opposed to the periods of relative stability interrupted by acute exacerbations they experienced earlier in the disease course. Patients and families often lack prognostic awareness, point out the authors, and symptoms such as worsening dyspnea may prompt them to seek help from acute care facilities.

Among the many benefits of hospice is that the enrollment process includes explicit discussion of prognosis and goals of care, so that patients know what to expect and can choose how they want to be treated. Hospice care also aims to address dyspnea and other symptoms common in end-stage HF, such as pain, anxiety, and depression, the authors note.

“The substantially lower readmission rate in the hospice-referral group in our study suggests that the palliative care approach used by hospice teams may have been effective in alleviating HF symptoms, thus obviating needs for readmission,” they write.

Yet many patients with HF are not referred to hospice, or are referred too late to benefit from the comprehensive palliative approach. “National estimates suggest that hospice median length of stay is only 19 days overall and 17 days for patients with HF, and that 35% of patients die or are discharged within seven days of hospice admission,” write the authors. They point out that most HF patients in their study who died within six months of hospital discharge did not even receive hospice referral.

“These findings suggest that a more accurate identification of hospice eligible patients and a more appropriate hospice-referral approach may potentially lower 30-day all-cause readmission for hospitalized patients with HF,” the authors conclude.

Source: “Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure,” Circulation: Heart Failure; July 2015; 8(4):733- 740. Kheirbek RE, et al; Veterans Affairs Medical Center, Washington, DC; Department of Medicine, George Washington University, Washington, DC; Department of Medicine, Georgetown University, Washington, DC.