Americans are more often spending their final days at home or in other community-based settings instead of the hospital, a new study has found.
Overall, the proportion of deaths that occur in acute-care hospitals has fallen to below 20%, according to a retrospective cohort study published last month in JAMA. That’s a steep drop compared to 2000, when nearly one-third of deaths occurred in hospitals.
While hospital deaths are decreasing, the number of deaths in homes and community-based setting, including assisted living facilities, is sharply rising. About four out of every 10 deaths occur in home or community-based settings, the study, which looked at 15 years of data from 2000 to 2015, found.
Multiple surveys conducted over the past several years, including various efforts led by the U.S. Centers for Disease Control and Prevention, have widely found that people would much rather die in the comfort of their own homes than in a hospital. That preference is becoming even stronger as Americans become more aware of hospice services that are provided in residential settings.
“We’re on the right path,” Joan Teno, the study’s lead author a professor of medicine at Oregon Health & Science University, told Home Health Care News. “We’re listening to people who tell us they don’t want to die in a hospital setting as we’re expanding access to hospice and palliative care teams.”
As part of the study, Teno and fellow researchers analyzed records from roughly 1.4 million Medicare fee-for-service enrollees and more than 870,000 Medicare Advantage enrollees who died between 2000 and 2015.
Both groups had an average age of about 82 years old.
In addition to fewer people dying in hospitals, the JAMA study revealed that the proportion of patients admitted to the intensive care unit during their final month of life has largely stabilization after going up between 2000 and 2009.
Health care transitions during the last three days of life also appear to be on their way down, according to the study.
“For the first time, we’ve seen a stabilization around ICU use,” Teno, a former hospice medical director, said. “We’re also seeing some striking reductions in transitions.”
One possible reason for the decrease in hospital deaths and stabilization of end-of-life ICU stays is the implementation of the Affordable Care Act (ACA) in 2010, according to Teno. With ACA, hospitals had to adjust to new rules targeting quality of care improvement and focus more on post-acute care to avoid costly readmissions, she said.
The recent study was an update to a 2013 JAMA paper that previously found more people were dying shortly after staying in intensive care, being repeatedly hospitalized and experiencing care transitions deemed “burdensome” to patients and families.
The U.S. health care system seems to be doing a better job of caring for end-of-life patients in their preferred location at this point in time, but regulatory uncertainty means continued progress is far from guaranteed, Teno said.
“I’m concerned,” she said. “If people start losing health insurance coverage, if we start dismantling parts of ACA, we may see increasing fragmentation and some different trends. But I’m hopeful we’re going to still see a decline in people dying in the hospital and maybe a reduction of ICU use within the last 30 days of life.”
Analyzing where patients are dying is important, the researchers wrote in their study, because the cost of health care typically soars for high-need, seriously ill patients. About 5% of individuals account for about 60% of health care expenditures, past research has found, and about 80% of individuals are considered high-need patients prior to death.
The study found the use of hospice care skyrocketed from about 22 percent in 2000 to 50% in 2015.
The study relied predominately on Medicare billing data and Minimum Data Set assessments to determine the site of death based o the place of service recorded on submitted claims. Medicare billing data do not differentiate community deaths that are in a personal home, in an assisted living facility or at a foster care home except for individuals who died while receiving hospice care.
Research for the study was supported by the Robert Wood Johnson Foundation and the National Institute on Aging.
Written by Robert Holly
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