Hospice Remains Underutilized by Heart Failure Patients

Patients with heart failure are referred infrequently and often late for hospice care in the U.S., a recent study has found.

Over the last nine years, the number of Medicare heart failure patients discharged to hospice care has increased from 2% in 2005 to 5% in 2014. Despite the uptick in utilization, about 25% of heart failure patients discharged to hospice die within three days, unable to take full advantage of the Medicare hospice benefit.

Findings come from a study published in JAMA Cardiology in August. As part of the study, researchers analyzed 121,990 older heart failure patients in the American Heart Association’s Get with the Guidelines-Heart Failure registry.


There are several possible explanations for the low utilization rates and short durations of hospice stays, according to researchers. In general, multiple barriers exist to increasing hospice referrals. In the future, more advanced tools for assessing prognosis in heart failure patients may help clinicians in making more timely referrals.

“Studies have showed that hospice is associated with improved symptom management and overall improved satisfaction,” Shunichi Nakagawa and A. Reshad Garan, doctors from Columbia University, wrote in a JAMA editorial accompanying the study. “Dying at home with hospice — in a familiar environment, surrounded by loved ones, without burdensome symptoms — is commonly accepted as the best-case end-of-life scenario overall.”

Overall hospice admissions have been growing steadily for the last eight quarters, according to data from Excel Health, a source for post-acute outcomes and health industry performance analytics.


In the U.S., heart disease is the leading cause of death, but makes up only 18.7% of the principle diagnosis for hospice admissions, compared to 27.2% with cancer, according to the researchers.

The majority of patients analyzed during the study published in JAMA Cardiology were white and had a median age of 86. Over half of the total discharges that researchers studied were to home hospice. Patients discharged to hospice facilities had shorter survival rates, which could mean those patients in facilities were sicker, according to the study. Once discharged into hospice, very few patients were re-hospitalized.

Research was led by Haider J. Warraich of the division of cardiology at Durham, North Carolina-based Duke University Medical Center.

“This study confirmed that referral to hospice occurs very late and hospice remains underused in patients with heart failure,” Nakagawa and Garan said. “Multiple barriers to hospice referral have been identified, such as lack of knowledge about hospice care, hospice admission eligibility and ineligibility for hospice care under the Medicare Hospice Benefit.”

Diseases like heart failure are difficult to foresee, which could be the cause of the late referrals and the lack of representation within the hospice population compared to those with other diseases such as cancer, according to the study.

“Prognostication for patients with heart failure has been a challenge and may actually become more difficult,” Nakagawa and Garan said. “One difficulty relates to the disease trajectory of organ failure … [and] there is a relative lack of formally trained palliative care specialists.”

Early recognition of poor prognosis and palliative consultation could facilitate timely hospice referrals, according to the study.

Heart failure patients are not the only group to see an underutilization in hospice care. Research has shown that only 20% of Medicare patients with end-stage renal disease utilize hospice services prior to death.

Written by Kaitlyn Mattson