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Patterns of Hospice Care Among Military Veterans and Non-Veterans
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Original Article
Patterns of Hospice Care Among Military Veterans and Non-veterans Melissa W. Wachterman, MD, MPH, MSc, Stuart R. Lipsitz, ScD, Steven R. Simon, MD, MPH, Karl A. Lorenz, MD, MSHS, and Nancy L. Keating, MD, MPH Section of General Internal Medicine (M.W.W., S.R.S.), VA Boston Healthcare System; Department of Psychosocial Oncology and Palliative Care (M.W.W.), Dana Farber Cancer Institute, Boston, Massachusetts, USA; Division of General Internal Medicine (M.W.W., S.R.L., S.R.S., N.L.K.), Brigham and Women’s Hospital, Boston, Massachusetts; Division of General Internal Medicine and Division of Palliative Care (K.A.L.), VA Greater Los Angeles Healthcare System; Geffen School of Medicine at UCLA (K.A.L.), Los Angeles, California; and Department of Health Care Policy (N.L.K.), Harvard Medical School, Boston, Massachusetts, USA
Abstract Context. Historically, hospice use by veterans has lagged behind that of nonveterans. Little is known about hospice use by veterans at a population level. Objectives. To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization. Methods. Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression. Results. Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P ¼ 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P ¼ 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P ¼ 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than nonveterans (one every 5.3 days vs. one every 3.7 days; P ¼ 0.002). Conclusion. Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist. J Pain Symptom Manage 2013;-:-e-. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Address correspondence to: Melissa W. Wachterman, MD, MPH, MSc, VA Boston Health Care System, 150 South Huntington Avenue, Building 9 Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
(152G), Boston, MA 02130, USA. E-mail: melissa. [email protected] Accepted for publication: August 16, 2013. 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.08.013
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Key Words Hospice, veterans, clinical case mix, demographics, health care utilization, nationally representative data
Introduction The number of seriously ill patients who use hospice services at the end of life in the U.S. has increased dramatically over the past decade. Approximately 1.58 million people used hospice in 2010 (41.9% of all deaths), an increase from 1.06 million in 2004.1 Hospice enrollment is primarily concentrated among Medicare beneficiaries, with 83.8% of hospice care financed under the Medicare Hospice Benefit in 2010.1 When the hospice movement began in the U.S. in the 1970s, hospice served primarily patients with cancer who were living at home. However, these patterns have shifted in recent decades, such that in 2010, only 35.6% of hospice patients had a primary diagnosis of cancer and only 41.1% received care at home, with the rest in residential facilities such as nursing homes, hospitals, or hospice residences.1 Currently, about 642,000 U.S. military veterans die each year, accounting for one of four deaths in the U.S.2,3 Hospice use by veterans has historically lagged behind use in the overall U.S. population. In 2000, 21.6% of all Medicare decedents, compared with only 5% of all veterans in all settings, received hospice care.4,5 Responding to this disparity, the Veterans Health Administration (VA) began several initiatives during the past decade to expand veterans’ access to end-of-life care services, including hospice. In 2002e2003, the VA created a Hospice and Palliative Care program office, and in less than three years, the number of veterans receiving home hospice care financed by the VA tripled.4 In 2009, the VA designed the Comprehensive End of Life Care initiative, which funded a palliative care interdisciplinary team at every VA medical center and established partnerships with community hospices in every state in the country.2 Subsequently, growth in the use of hospice care among veterans in the VA has continued, with a recent study documenting more than a three-fold increase from 2006 to 2009.6
Importantly, with the exception of the statistic that 5% of all veterans used hospice in 2000, information about rates of hospice use comes from VA data and, therefore, reflects trends in hospice use of only veterans who use the VA for their health care.4e7 Overall, only about 13% of veterans report that they currently obtain medical care from the VA,8 and 28% report that they ever have.9 Thus, because most veterans do not receive care from the VA, little is known about the majority of veteran hospice users. It is unknown, for example, whether hospice use among veterans over time reflects a shift away from hospice’s traditional focus on treating patients with cancer living at home, similar to that for the population as a whole. Furthermore, VA patients who enroll in hospice, other than the relatively few who use inpatient hospice, are referred by the VA to community-based hospices, and thus, VA data sources do not include information about their care. Our objective was to use nationally representative data to compare veteran and nonveteran hospice users to determine whether demographics, primary diagnosis, location of care, and service utilization differed for these two populations.
Methods We used the 2007 National Home and Hospice Care Survey (NHHCS),10 conducted by the National Center for Health Statistics, to examine a nationally representative sample of patients discharged from hospice, predominantly because of death (84%). Data for the 2007 NHHCS, the most recently conducted version of the survey, were collected through face-to-face interviews with hospice or home health agency directors and their appointed staff, in consultation with patients’ medical records. Our primary variable of interest was U.S. military veteran status. Because more than 95% of veterans in the NHHCS were men, we limited our study population to the 1415
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male patients discharged from hospice for whom veteran status was known (483 veterans and 932 non-veterans), representing 287,620 hospice enrollees nationally. Veteran status was unknown for 702 male patients; these patients were excluded from our sample for our primary analyses but were included (and classified as non-veterans) in sensitivity analyses.
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Measures of Service Utilization Our primary measures for service utilization were hospice length of stay (LOS) and the number of visits per day from each major type of hospice provider (total number of visits divided by LOS), including nurses, social workers, and home health aides. We measured hospice LOS from the date of hospice enrollment until hospice discharge.
Characteristics of Hospice Users We categorized individuals’ primary hospice admission diagnosis as either ‘‘cancer’’ or ‘‘noncancer’’ based on whether they had a cancerrelated International Classification of Diseases, Ninth Edition (ICD-9) code (140-239). We then further subdivided patients with noncancer diagnoses into the following categories based on ICD-9 codes: ‘‘dementia,’’ ‘‘debility or adult failure to thrive,’’ ‘‘congestive heart failure,’’ ‘‘chronic pulmonary disease,’’ ‘‘cerebrovascular disease,’’ or ‘‘other’’ (specific codes available on request). We classified where the patients were residing when they began hospice as ‘‘home,’’ ‘‘nursing home,’’ ‘‘hospital,’’ ‘‘hospice residence,’’ or ‘‘other.’’ We categorized patients’ primary caregiver as ‘‘spouse/significant other’’ or ‘‘nonspouse,’’ which included child, parent, other family member, or nonfamily member. All secondary diagnoses in the survey data were used to measure comorbid disease, using the Charlson comorbidity index (CCI) score.11 We also characterized the number of activities of daily living (ADLs; eating, bathing, dressing, toileting, and transferring) with which the patient needed help (categorized as 0, 1e3, 4, and all 5) and mobility impairment (no assistance needed, needs assistance, and not mobile). Finally, we characterized reason for hospice discharge (death vs. other). The following demographic characteristics were categorized: age in years at hospice discharge (<50, 50e64, 65e74, 75e84, 85e89, and $90), race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and other), marital status (married/partnered vs. unmarrieddincluding widowed, divorced, separated, and never married), primary payment source (Medicare, Medicaid, private insurance, Department of Veterans Affairs, and other), and type of residential area (metropolitan, micropolitan, and neither). The NHHCS does not collect information about income or educational attainment.
Statistical Analyses All analyses were performed using SAS 9.2 (SAS Institute Inc., Cary, NC) and accounted for the complex sampling design; results were weighted to reflect national estimates. We first compared demographic and clinical characteristics of veteran and non-veteran hospice users using the chi-square test by Rao and Scott12 for categorical variables and complex survey t-tests for continuous variables. We then used logistic regression to model the association of veteran status with hospice diagnosis and multinomial logistic regression to model the association of veteran status with location of care. We dichotomized hospice diagnosis as cancer vs. noncancer for regression analyses because of the small numbers for other conditions. For our multivariate analysis of the association between veteran status and location of hospice care, we adjusted for all covariates described previously (Table 1). For the association of veteran status with hospice diagnosis, we included all covariates with the exception of ADLs and mobility impairment because the degree of impairment may be a result of the underlying diagnosis and, therefore, should not be adjusted for in the model. We then compared measures of service utilizationdhospice LOS and frequency of provider visitsdbetween veteran and non-veteran hospice users. We used log transformation for these outcomes to approximate normal distributions; because some patients had no provider visits of a particular type, 0.5 was added to the number of visits when using the log transformation, which is an appropriate statistical technique to avoid taking the logarithm of zero.13 We then assessed the association between veteran status and each outcome using linear regression to fit both unadjusted models and models adjusted for all covariates. For all covariates in which >0.5% of data were missing (i.e., ‘‘don’t know,’’ ‘‘not ascertained,’’ or
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‘‘refused’’), missing data were considered as a separate category.
Results The 483 veteran and 932 non-veteran male hospice users represented 287,620 hospice enrollees nationally in 2007. Table 1 shows demographic and clinical characteristics by veteran status. Most veteran and non-veteran hospice users were non-Hispanic whites (81.7% and 82.0%; P ¼ 0.72), married (70.1% vs. 61.0%; P ¼ 0.10), and lived in metropolitan areas (85.3% and 87.1%; P ¼ 0.22). Their CCI scores and the degree of ADL impairment were similar (P ¼ 0.57 and P ¼ 0.78, respectively). Almost half of veterans and nonveterans were dependent for all five ADLs (45.2% vs. 48.1%), yet approximately half of each group had CCI scores of 0 (46.4% vs. 51.7%). Veterans were, on average, significantly older than non-veterans (mean age 77.0 vs. 74.3 years; P ¼ 0.02), yet tended to be less likely to need assistance with walking (66.1% vs. 74.8%; P ¼ 0.06). Primary payment source was significantly different between the two groups (P < 0.001). Medicare was the most common payer for both veterans and non-veterans (77.2% vs. 76.4%), but not surprisingly, veterans were more likely than non-veterans to have the Department of Veterans Affairs as the primary payer (7.0% vs. 0.1%; latter likely the result of reporting error). Veterans were less likely to have Medicaid (0.1% vs. 5.5%) or private insurance (7.9% vs. 11.3%) as the primary payer. Veterans were less likely than non-veterans to stay in hospice until they died (80.2% vs. 86.1%), a difference of borderline statistical significance (P ¼ 0.07). As shown in Table 2, both diagnosis and location of care varied by veteran status. A higher proportion of veteran hospice users, compared with non-veterans, had a primary hospice diagnosis of cancer (56.4% vs. 48.4%; adjusted P ¼ 0.02). The distributions of the subcategories of noncancer diagnoses were similar for veterans and non-veterans, as shown in Table 2. A higher proportion of veteran hospice users, compared with nonveterans, lived at home while receiving hospice (68.4% vs. 57.6%) and a lower proportion received hospice services in the hospital (5.9%
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vs. 14.8%), differences that remained significant in adjusted analyses (P ¼ 0.007). Table 3 presents data on measures of service utilization. Median LOS did not differ by veteran status (adjusted P ¼ 0.23). Veterans and non-veterans received a similar number of nursing visits per day and social work visits per day (0.46 vs. 0.44 and 0.16 vs. 0.16, respectively; adjusted P > 0.10 for both). However, veterans, compared with non-veterans, received fewer visits per day from home health aides (0.19 [one visit every 5.3 days] vs. 0.27 [one visit every 3.7 days]; adjusted P ¼ 0.002). In sensitivity analyses that categorized those with unknown veteran status as non-veterans, the findings for all of our outcomes were similar in magnitude and were statistically significant, except for the association between veteran status and frequency of home health aide visits (adjusted P ¼ 0.052).
Discussion In this analysis of patterns of hospice care among a nationally representative cohort of male hospice users, we found that, with the exception of age and payment source for hospice, the demographic and clinical profile of veterans and non-veterans was quite similar. However, there were significant differences in patterns of hospice use between veterans and non-veterans. Veterans were more likely than non-veterans to have cancer and receive hospice services at home. Hospice LOS and visit rates from hospice nurses and social workers were similar for veterans and non-veterans, but veterans received significantly fewer visits from hospice home health aides than nonveterans. Veterans also tended to be more likely than non-veterans to disenroll from hospice, but this difference was of borderline statistical significance (P ¼ 0.07). To date, the literature on the characteristics of hospice use by veterans has come from VA data sources and, therefore, reflects the profile of veterans who use the VA for their health care. However, because most are enrolled in community-based hospices, the VA has little information about their experiences. Moreover, most veterans do not receive medical care through the VA, meaning VA data sources are inadequate to describe the profile of all
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Table 1 Characteristics of Hospice-Discharged Patients by Veteran Statusa
Age, years Mean (SE) Age (%) <50 50e64 65e74 75e84 85e89 $90 Race/ethnicity (%) Non-Hispanic white Non-Hispanic black Hispanic Other Missing Marital status (%) Married/partnered Not married Missing Primary caregiver (%) Spouse/significant other Non-spouse Missing Primary payment source (%) Medicare Medicaid Private insurance Department of Veteran Affairs Other Missing MSA (%) Metropolitan Micropolitan Neither Number of ADLs needing assistance (%) 0 1e3 4 5 Missing Mobility (%) No assistance needed Needs assistance Not mobile Missing Charlson comorbidity index (%) 0 1 2e3 >3 Reason for hospice discharge (%) Death Other
Veteran Hospice Users (n ¼ 483, Weighted n ¼ 90,456)
Non-veteran Hospice Users (n ¼ 932, Weighted n ¼ 197,164)
77.0 (0.9)
74.3 (0.8)
0.4 17.2 15.4 37.9 20.7 8.5
5.3 17.5 17.7 32.5 16.6 10.3
81.7 10.3 3.8 1.4 2.8
82.0 10.0 4.6 2.0 1.3
70.1 27.9 1.9
61.0 36.3 2.4
53.6 37.9 8.4
48.4 44.6 6.9
77.2 0.1 7.9 7.0 5.0 2.9
76.4 5.5 11.3 0.1b 3.5 3.3
85.3 9.1 5.6
87.1 9.4 3.6
P-Value 0.02 0.08
0.72
0.10
0.40
<0.001
0.22
0.78 12.2 15.8 16.0 45.2 10.8
8.7 13.9 17.5 48.1 11.8
22.3 38.6 27.5 11.7
12.3 46.0 28.8 12.9
46.4 21.5 23.1 9.0
51.7 16.2 23.2 8.9
80.2 19.8
86.1 13.9
0.06
0.57
0.07
SE ¼ standard error; MSA ¼ metropolitan statistical area; ADLs ¼ activities of daily living. a Continuous variables are given as means and categorical variables are given as percentages. Data are reported in weighted values using survey weights, strata, and cluster variables to obtain population estimates. Percentages have been rounded and might not total 100. b Likely the result of reporting error.
veteran hospice users. Therefore, our study is novel in its ability to provide nationally representative data contrasting veteran and nonveteran male hospice users.
Although we were unable to find national statistics on characteristics of veteran decedents, we contrasted the demographic characteristics of the overall population of veteran
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Table 2 Diagnosis and Location of Care by Veteran Statusa Proportion Among Veteran Hospice Users (n ¼ 483, Weighted n ¼ 90,456)
Proportion Among Non-Veteran Hospice Users (n ¼ 930,b Weighted n ¼ 197,164)
43.6 8.2 7.1
51.6 10.5 8.7
4.7 6.7 2.8 14.2 56.4
5.5 5.7 4.2 17.1 48.4
1.67 (1.09e2.57)
68.4 5.9 18.6 7.1 0.0
57.6 14.8 20.0 6.7 1.0
1.00 0.23 0.86 0.89 0.05
Diagnosisf,g Noncancer Dementia Debility or adult failure to thrive Congestive heart failure Chronic pulmonary disease Cerebrovascular disease Other Cancer Location of careh Home Hospital Nursing home Hospice residence Other
Adjusted Odds Ratioc,d,e 1.00 (reference)
(reference) (0.08e0.67) (0.40e1.83) (0.36e2.20) (0.00e0.78)
a Data are reported in weighted values using survey weights, strata, and cluster variables to obtain population estimates. Percentages have been rounded and might not total 100. b Two of the 932 non-veterans patients were missing data on diagnosis and location of care and were excluded from this analysis. c Adjusted odds ratios for veterans compared with non-veterans. d Model examining location of care adjusted for all covariates, which included age, race/ethnicity, marital status, primary caregiver, primary payment source, metropolitan statistical area, number of ADLs needing assistance, mobility needs, Charlson comorbidity index score, and reason for hospice discharge. e Model examining diagnosis adjusted for all covariates except number of ADLs needing assistance and mobility needs. f P ¼ 0.07 for unadjusted comparison by veteran status; P ¼ 0.02 for adjusted comparison by veteran status. g Disease categories based on ICD-9 codes. h P ¼ 0.02 for unadjusted comparison between home and hospital by veteran status; P ¼ 0.007 for adjusted comparison between home and hospital by veteran status.
hospice users in our study with published data on the characteristics of VA enrollees who died.2 These data suggest that veterans who use hospice are much more likely than VA decedents to be married (70% vs. 41%) and tend to more likely be non-Hispanic white (82% vs. 78%).2 Furthermore, the percentages of veterans in hospice who were non-Hispanic white and married were almost identical to Census statistics for the overall veteran population,14 suggesting that access to hospice among veterans does not vary notably by patient characteristics. Marital status is a key determinant of patterns of end-of-life care. Having a spouse
is associated with a greater likelihood of both enrolling in hospice and dying at home.15 Thus, while the demographic profile of VA users suggests that many may lack the social supports needed for home hospice, our data indicate that many veterans outside the VA likely do have such supports. Overall, these results caution against equating end-of-life care within the VA population as similar to patterns of care for all veterans more generally. We found that veterans were more likely than non-veterans to have a hospice diagnosis of cancer and receive hospice services at home. One possible explanation for these findings relates
Table 3 Median Hospice LOS and Median Visits Per Day by Hospice Staff by Veteran Statusa Veteran Hospice Users (n ¼ 483, Weighted n ¼ 90,456) LOS, median (Q1, Q3b), days Nursing visits per day Social work visits per day Home health aide visits per day
20 0.46 0.16 0.19
(5, 53) (0.28e0.96) (0.08e0.30) (0.05e0.50)
Non-veteran Hospice Users (n ¼ 932, Weighted n ¼ 197,164) 15 0.44 0.16 0.27
(4, 48) (0.28e0.81) (0.08e0.31) (0.10e0.50)
Adjusted P-Valuec 0.23 0.43 0.66 0.002
LOS ¼ length of stay; ADLs ¼ activities of daily living. a Unadjusted estimates. b (Q1, Q3) refers to (25th percentile, 75th percentile). c All models adjusted for all covariates, which included age, race/ethnicity, marital status, primary caregiver, primary payment source, metropolitan statistical area, number of ADLs needing assistance, mobility needs, Charlson comorbidity index, diagnosis, location of care, and reason for hospice discharge.
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to historical trends in hospice use. When the hospice movement began in the U.S. in the 1970s, most patients had cancer and received hospice care at home. However, over time, these numbers have shifted such that now most hospice patients have noncancer diagnoses and receive care in nursing homes or acute or subacute facilities.1,16 Meanwhile, hospice use by veterans, historically, lagged behind that of the overall U.S. population. Thus, as a population that has been a later adopter of hospice, veterans, along with their families and health care providers, may still view hospice as primarily for cancer patients living at home. One important alternative explanation for the differences in hospice diagnosis by veteran status is that cancer may be a more common cause of death for veterans than non-veterans. Unfortunately, the National Center for Health Statistics, which reports the leading causes of death in the U.S, does not provide veteran status as a measure in its public data file. Thus, there is limited information on causes of death for veterans vs. non-veterans, and the causes of death for VA inpatient decedents may not reflect those for veteran decedents who do not use VA services. Nevertheless, a study of VA inpatient decedents found that less than a third died of cancer,7 which may provide some support for the conclusion that the high prevalence of cancer we found among veteran hospice users (56%) is unlikely to be completely explained by a very high incidence of cancer as a cause of death among veterans. The finding that a higher proportion of veterans, compared with nonveterans, received hospice care in the home setting rather than in the hospital is encouraging as past research shows that, although most people die in institutional settings,16 in general, people prefer to die at home.17 Past research has shown that veterans, compared with non-veterans, are less likely to want heroic measures attempted at the end of life18 and, at least within the VA, receive less aggressive care at the end of life.19 This suggests that, at a population level, veterans’ goals at the end of life are more consistent with the hospice philosophy. As a result, one might expect that they would enroll in hospice earlier than nonveterans; however, we found no difference in hospice LOS by veteran status. This may suggest a missed opportunity to connect veterans with hospice care earlier in the course of life-
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limiting illness. This said, the decision to enroll in hospice is complex and influenced by multiple factors, including providers’ judgments about prognosis and perceptions of patient readiness to discuss hospice and patients’ and families’ knowledge and attitudes about hospice. Thus, the similar hospice lengths of stay for veterans and non-veterans may reflect similar barriers to hospice enrollment. It is notable that there was a nonsignificant trend toward veterans being more likely than non-veterans to disenroll from hospice before death. Whether this is because veterans changed their mind about hospice, were less satisfied with hospice care, because they clinically stabilized and thus became ineligible for hospice, or for some other reason is not clear. Finally, veterans had fewer home health aide visits than non-veterans. This may reflect differences in functional status as we found some suggestion that mobility impairment was less common among veterans than non-veterans, and functional status has been associated with health care service utilization.20 However, the difference in frequency of home health aide visits remained after adjustment for mobility and other factors. One possible explanation for this finding is that veterans may be less likely to request or accept aide visits, perhaps out of a sense of pride or because of less self-perceived need for assistance. An alternative explanation is that they may be less likely to be offered aide visits. Further study is needed to understand the sources of this difference and assess if it is associated with worse experiences among veteran hospice users. In assessing the clinical and policy implications of our findings, one key question is the extent to which hospice care for veterans overall is shaped by VA policy and practice. Unfortunately, the NHHCS does not ask respondents whether medical care was obtained through the VA, and thus, we were unable to assess the degree to which we compared non-veterans with veteran VA users vs. non-users. Past work suggests that 13% of all veterans receive care in the VA in a given year, and 28% of veterans ever have received care.8 It is important to note that although our data showed that the Department of Veterans Affairs was the primary payer for hospice for only 7% of veterans, other veterans may have been VA patients but used Medicare or another insurance source to pay
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for hospice. Prior research shows that 78.5% of veterans enrolled in the VA at the time of death also were enrolled in Medicare.2 With the VA’s increased access to hospice and palliative care in the 2000s, it is possible that a higher proportion of veteran hospice users may use the VA than these more general statistics suggest. Furthermore, the VA’s efforts to improve care for veterans at the end of life may affect veterans who are non-VA users as well. Therefore, acknowledging that we must be circumspect in our conclusions, considering the ways in which VA policy and practice may provide insight into our findings is, nonetheless, relevant. The VA is both a provider and a purchaser of hospice, which has important implications for our findings. Inpatient hospice care is provided directly by VA staff in both acute and subacute health care facilities. In contrast, the VA partners with non-VA community-based hospices that deliver all the hospice care for veterans outside VA health care facilities, often in the absence of pertinent clinical information from the VA. Although the VA may not have much impact on the quality of care that their patients enrolled in community-based hospices receive, the VA plays a central role in hospice referral, in terms of the types of patients who are referred and the location where they receive hospice care. Location of end-oflife care has been associated with quality, with one study demonstrating poorer quality outcomes in institutional vs. home settings.21 Thus, to the extent that the VA supports veterans and their families to enable veterans to stay at home at the end of life, the organization is promoting quality. However, the relative underrepresentation of noncancer diagnoses among veterans raises the concern that referral patterns for veterans may be lagging behind recent trends to broaden the populations receiving hospice care. In interpreting our finding that veteran hospice users received fewer home health aide visits than nonveterans, it is important to note that VA users may have access to home health aide services through the VA while they are enrolled in the Medicare Hospice Benefit. Thus, veteran hospice users in our sample who use the VA may have less need for hospice-provided home health aide visits. Our study has important limitations. First, veteran status was missing for approximately
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one-third of the NHHCS sample. However, sensitivity analyses in which all those with unknown veteran status were categorized as non-veterans had similar findings, supporting the robustness of our findings. Second, veterans who received hospice in VA inpatient facilities were not sampled in NHHCS. Therefore, the profile of this important group of veterans receiving hospice is not reflected in our data. However, with past work showing that most veterans never use the VA for health care,9 the proportion of veteran hospice users in VA inpatient facilities is likely very low and their non-inclusion in our data is unlikely to have a substantial impact on our findings. Third, although our data come from the most recent NHHCS, the survey was conducted in 2007. Hospice use has increased dramatically over the past decade; this growth may have had an important impact on the characteristics of veteran and non-veteran hospice users and their service utilization. Fourth, the extremely small number of female veteran hospice users (n ¼ 24) precluded inclusion of women in our analyses, and thus, our findings may not generalize to women. The number of women in the military is rapidly growing,22 and as this population ages over the coming decades, it will be critical to examine the profile of female veteran hospice users. In addition, given that there were only 211 veterans with noncancer diagnoses in our sample, the sample sizes for many of the subcategories of noncancer diagnoses were quite small. Therefore, for our regression models, we did not have sufficient power to include each as a distinct category. Finally, because the NHHCS only sampled hospice users, our analyses cannot address the important question of whether there are differences in the characteristics of veterans and non-veterans who do vs. do not use hospice.
Conclusion We found that although veteran and nonveteran hospice users were fairly similar on most demographic and clinical measures, differences in the patterns of hospice referral and utilization exist. Further research into the underlying causes for these differences will be essential in meeting the Department of Veterans Affairs’ charge to ‘‘honor and serve’’23 all America’s
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veterans and in improving end-of-life care for veterans both within and outside the VA system.
Disclosures and Acknowledgments We would like to acknowledge Drs. Ellen P. McCarthy, Roger B. Davis, and Edward R. Marcantonio for their scientific and methodological contributions to the analytic framework of this manuscript, which was based on a previous publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. This study was not funded, and none of the authors has any disclosures relevant to the content of this article. Benjamin Sommers, MD, PhD, Harvard School of Public Health, provided helpful feedback on an earlier version of this manuscript.
References 1. National Hospice and Palliative Care Organization. NHPCO facts and figures: Hospice care in America. Alexandria, VA: NHPCO, 2012. 2. U.S. Department of Veterans Affairs. Hospice and palliative care 2011 annual report. Washington, DC: Department of Veterans Affairs, 2011. 3. Principi A, Tobin D, Breckenridge J, Kussman M. Creating & expanding hospice & palliative care programs in VA. 2002. 4. Edes T, Shreve S, Casarett D. Increasing access and quality in Department of Veterans Affairs care at the end of life: a lesson in change. J Am Geriatr Soc 2007;55:1645e1649. 5. Teno JM, Gozalo PL, Bynum JPW, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013;309:470e477. 6. Frahm KA, Barnett SD, Brown LM. Trends in hospice utilization across age among the veteran population. Am J Hosp Palliat Care 2011;28: 424e428. 7. Duffy SA, Copeland LA, Hopp FP, Zalenski RJ. Diagnostic classifications and resource utilization of decedents served by the Department of Veterans Affairs. J Palliat Med 2007;10:1137e1145. 8. Nelson KM, Starkebaum GA, Reiber GE. Veterans using and uninsured veterans not using Veterans Affairs (VA) health care. Public Health Rep 2007;122:93e122. 9. Westat. National survey of veterans, active duty service members, demobilized national guard and
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reserve members, family members, and surviving spouses. Washington, DC: Department of Veterans Affairs, 2010. 10. Centers for Disease Control and Prevention. National Home and Hospice Care Survey. Available from http://www.cdc.gov/nchs/nhhcs.htm. Accessed February 5, 2013. 11. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373e383. 12. Rao J, Scott A. On simple adjustments to chisquare tests with sample survey data. Ann Stat 1987;15:385e397. 13. Agresti A. Categorical data analysis. New York: Wiley-Interscience, 2002. 14. U.S. Department of Veterans Affairs. Profile of veterans: 2009 data from the American Community Survey. Washington, DC: Department of Veterans Affairs, 2011. 15. Wachterman MW, Sommers BD. The impact of gender and marital status on end-of-life care: evidence from the National Mortality Follow-Back Survey. J Palliat Med 2006;9:343e352. 16. Brown Atlas. Facts on dying: site of death. Providence, RI: Center for Gerontology and Healthcare Research. 1989e1997. Available from http://as800. chcr.brown.edu/dying/BROWNATLAS.HTM. Accessed September 24, 2013. 17. Higginson IJ, Sen-Gupta GJ. Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med 2000;3: 287e300. 18. Duffy SA, Ronis D, Fowler K, Schim SM, Jackson FC. Differences in veterans’ and nonveterans’ end-of-life preferences: a pilot study. J Palliat Med 2006;9:1099e1105. 19. Keating NL, Landrum MB, Lamont EB, et al. End-of-life care for older cancer patients in the Veterans Health Administration versus the private sector. Cancer 2010;116:3732e3739. 20. Wiener JM, Hanley RJ, Clark R, Van Nostrand JF. Measuring the activities of daily living: comparisons across national surveys. J Gerontol 1990;45:S229eS237. 21. Teno JM, Clarridge BR, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA 2004;291:88e93. 22. Women in Military Service for America Memorial Foundation, Inc. Stat women mil. Available from http://www.womensmemorial.org/PDFs/StatsonWIM. pdf. Accessed February 5, 2013. 23. U.S. Department of Veterans Affairs. Mission, vision, core values, and goals. Available from http:// www.va.gov/about_va/mission.asp. Accessed February 4, 2013.
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Journal of Pain and Symptom Management 1
Original Article
Patterns of Hospice Care Among Military Veterans and Non-veterans Melissa W. Wachterman, MD, MPH, MSc, Stuart R. Lipsitz, ScD, Steven R. Simon, MD, MPH, Karl A. Lorenz, MD, MSHS, and Nancy L. Keating, MD, MPH Section of General Internal Medicine (M.W.W., S.R.S.), VA Boston Healthcare System; Department of Psychosocial Oncology and Palliative Care (M.W.W.), Dana Farber Cancer Institute, Boston, Massachusetts, USA; Division of General Internal Medicine (M.W.W., S.R.L., S.R.S., N.L.K.), Brigham and Women’s Hospital, Boston, Massachusetts; Division of General Internal Medicine and Division of Palliative Care (K.A.L.), VA Greater Los Angeles Healthcare System; Geffen School of Medicine at UCLA (K.A.L.), Los Angeles, California; and Department of Health Care Policy (N.L.K.), Harvard Medical School, Boston, Massachusetts, USA
Abstract Context. Historically, hospice use by veterans has lagged behind that of nonveterans. Little is known about hospice use by veterans at a population level. Objectives. To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization. Methods. Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression. Results. Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P ¼ 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P ¼ 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P ¼ 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than nonveterans (one every 5.3 days vs. one every 3.7 days; P ¼ 0.002). Conclusion. Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist. J Pain Symptom Manage 2013;-:-e-. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Address correspondence to: Melissa W. Wachterman, MD, MPH, MSc, VA Boston Health Care System, 150 South Huntington Avenue, Building 9 Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
(152G), Boston, MA 02130, USA. E-mail: melissa. [email protected] Accepted for publication: August 16, 2013. 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.08.013
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Key Words Hospice, veterans, clinical case mix, demographics, health care utilization, nationally representative data
Introduction The number of seriously ill patients who use hospice services at the end of life in the U.S. has increased dramatically over the past decade. Approximately 1.58 million people used hospice in 2010 (41.9% of all deaths), an increase from 1.06 million in 2004.1 Hospice enrollment is primarily concentrated among Medicare beneficiaries, with 83.8% of hospice care financed under the Medicare Hospice Benefit in 2010.1 When the hospice movement began in the U.S. in the 1970s, hospice served primarily patients with cancer who were living at home. However, these patterns have shifted in recent decades, such that in 2010, only 35.6% of hospice patients had a primary diagnosis of cancer and only 41.1% received care at home, with the rest in residential facilities such as nursing homes, hospitals, or hospice residences.1 Currently, about 642,000 U.S. military veterans die each year, accounting for one of four deaths in the U.S.2,3 Hospice use by veterans has historically lagged behind use in the overall U.S. population. In 2000, 21.6% of all Medicare decedents, compared with only 5% of all veterans in all settings, received hospice care.4,5 Responding to this disparity, the Veterans Health Administration (VA) began several initiatives during the past decade to expand veterans’ access to end-of-life care services, including hospice. In 2002e2003, the VA created a Hospice and Palliative Care program office, and in less than three years, the number of veterans receiving home hospice care financed by the VA tripled.4 In 2009, the VA designed the Comprehensive End of Life Care initiative, which funded a palliative care interdisciplinary team at every VA medical center and established partnerships with community hospices in every state in the country.2 Subsequently, growth in the use of hospice care among veterans in the VA has continued, with a recent study documenting more than a three-fold increase from 2006 to 2009.6
Importantly, with the exception of the statistic that 5% of all veterans used hospice in 2000, information about rates of hospice use comes from VA data and, therefore, reflects trends in hospice use of only veterans who use the VA for their health care.4e7 Overall, only about 13% of veterans report that they currently obtain medical care from the VA,8 and 28% report that they ever have.9 Thus, because most veterans do not receive care from the VA, little is known about the majority of veteran hospice users. It is unknown, for example, whether hospice use among veterans over time reflects a shift away from hospice’s traditional focus on treating patients with cancer living at home, similar to that for the population as a whole. Furthermore, VA patients who enroll in hospice, other than the relatively few who use inpatient hospice, are referred by the VA to community-based hospices, and thus, VA data sources do not include information about their care. Our objective was to use nationally representative data to compare veteran and nonveteran hospice users to determine whether demographics, primary diagnosis, location of care, and service utilization differed for these two populations.
Methods We used the 2007 National Home and Hospice Care Survey (NHHCS),10 conducted by the National Center for Health Statistics, to examine a nationally representative sample of patients discharged from hospice, predominantly because of death (84%). Data for the 2007 NHHCS, the most recently conducted version of the survey, were collected through face-to-face interviews with hospice or home health agency directors and their appointed staff, in consultation with patients’ medical records. Our primary variable of interest was U.S. military veteran status. Because more than 95% of veterans in the NHHCS were men, we limited our study population to the 1415
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male patients discharged from hospice for whom veteran status was known (483 veterans and 932 non-veterans), representing 287,620 hospice enrollees nationally. Veteran status was unknown for 702 male patients; these patients were excluded from our sample for our primary analyses but were included (and classified as non-veterans) in sensitivity analyses.
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Measures of Service Utilization Our primary measures for service utilization were hospice length of stay (LOS) and the number of visits per day from each major type of hospice provider (total number of visits divided by LOS), including nurses, social workers, and home health aides. We measured hospice LOS from the date of hospice enrollment until hospice discharge.
Characteristics of Hospice Users We categorized individuals’ primary hospice admission diagnosis as either ‘‘cancer’’ or ‘‘noncancer’’ based on whether they had a cancerrelated International Classification of Diseases, Ninth Edition (ICD-9) code (140-239). We then further subdivided patients with noncancer diagnoses into the following categories based on ICD-9 codes: ‘‘dementia,’’ ‘‘debility or adult failure to thrive,’’ ‘‘congestive heart failure,’’ ‘‘chronic pulmonary disease,’’ ‘‘cerebrovascular disease,’’ or ‘‘other’’ (specific codes available on request). We classified where the patients were residing when they began hospice as ‘‘home,’’ ‘‘nursing home,’’ ‘‘hospital,’’ ‘‘hospice residence,’’ or ‘‘other.’’ We categorized patients’ primary caregiver as ‘‘spouse/significant other’’ or ‘‘nonspouse,’’ which included child, parent, other family member, or nonfamily member. All secondary diagnoses in the survey data were used to measure comorbid disease, using the Charlson comorbidity index (CCI) score.11 We also characterized the number of activities of daily living (ADLs; eating, bathing, dressing, toileting, and transferring) with which the patient needed help (categorized as 0, 1e3, 4, and all 5) and mobility impairment (no assistance needed, needs assistance, and not mobile). Finally, we characterized reason for hospice discharge (death vs. other). The following demographic characteristics were categorized: age in years at hospice discharge (<50, 50e64, 65e74, 75e84, 85e89, and $90), race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and other), marital status (married/partnered vs. unmarrieddincluding widowed, divorced, separated, and never married), primary payment source (Medicare, Medicaid, private insurance, Department of Veterans Affairs, and other), and type of residential area (metropolitan, micropolitan, and neither). The NHHCS does not collect information about income or educational attainment.
Statistical Analyses All analyses were performed using SAS 9.2 (SAS Institute Inc., Cary, NC) and accounted for the complex sampling design; results were weighted to reflect national estimates. We first compared demographic and clinical characteristics of veteran and non-veteran hospice users using the chi-square test by Rao and Scott12 for categorical variables and complex survey t-tests for continuous variables. We then used logistic regression to model the association of veteran status with hospice diagnosis and multinomial logistic regression to model the association of veteran status with location of care. We dichotomized hospice diagnosis as cancer vs. noncancer for regression analyses because of the small numbers for other conditions. For our multivariate analysis of the association between veteran status and location of hospice care, we adjusted for all covariates described previously (Table 1). For the association of veteran status with hospice diagnosis, we included all covariates with the exception of ADLs and mobility impairment because the degree of impairment may be a result of the underlying diagnosis and, therefore, should not be adjusted for in the model. We then compared measures of service utilizationdhospice LOS and frequency of provider visitsdbetween veteran and non-veteran hospice users. We used log transformation for these outcomes to approximate normal distributions; because some patients had no provider visits of a particular type, 0.5 was added to the number of visits when using the log transformation, which is an appropriate statistical technique to avoid taking the logarithm of zero.13 We then assessed the association between veteran status and each outcome using linear regression to fit both unadjusted models and models adjusted for all covariates. For all covariates in which >0.5% of data were missing (i.e., ‘‘don’t know,’’ ‘‘not ascertained,’’ or
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‘‘refused’’), missing data were considered as a separate category.
Results The 483 veteran and 932 non-veteran male hospice users represented 287,620 hospice enrollees nationally in 2007. Table 1 shows demographic and clinical characteristics by veteran status. Most veteran and non-veteran hospice users were non-Hispanic whites (81.7% and 82.0%; P ¼ 0.72), married (70.1% vs. 61.0%; P ¼ 0.10), and lived in metropolitan areas (85.3% and 87.1%; P ¼ 0.22). Their CCI scores and the degree of ADL impairment were similar (P ¼ 0.57 and P ¼ 0.78, respectively). Almost half of veterans and nonveterans were dependent for all five ADLs (45.2% vs. 48.1%), yet approximately half of each group had CCI scores of 0 (46.4% vs. 51.7%). Veterans were, on average, significantly older than non-veterans (mean age 77.0 vs. 74.3 years; P ¼ 0.02), yet tended to be less likely to need assistance with walking (66.1% vs. 74.8%; P ¼ 0.06). Primary payment source was significantly different between the two groups (P < 0.001). Medicare was the most common payer for both veterans and non-veterans (77.2% vs. 76.4%), but not surprisingly, veterans were more likely than non-veterans to have the Department of Veterans Affairs as the primary payer (7.0% vs. 0.1%; latter likely the result of reporting error). Veterans were less likely to have Medicaid (0.1% vs. 5.5%) or private insurance (7.9% vs. 11.3%) as the primary payer. Veterans were less likely than non-veterans to stay in hospice until they died (80.2% vs. 86.1%), a difference of borderline statistical significance (P ¼ 0.07). As shown in Table 2, both diagnosis and location of care varied by veteran status. A higher proportion of veteran hospice users, compared with non-veterans, had a primary hospice diagnosis of cancer (56.4% vs. 48.4%; adjusted P ¼ 0.02). The distributions of the subcategories of noncancer diagnoses were similar for veterans and non-veterans, as shown in Table 2. A higher proportion of veteran hospice users, compared with nonveterans, lived at home while receiving hospice (68.4% vs. 57.6%) and a lower proportion received hospice services in the hospital (5.9%
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vs. 14.8%), differences that remained significant in adjusted analyses (P ¼ 0.007). Table 3 presents data on measures of service utilization. Median LOS did not differ by veteran status (adjusted P ¼ 0.23). Veterans and non-veterans received a similar number of nursing visits per day and social work visits per day (0.46 vs. 0.44 and 0.16 vs. 0.16, respectively; adjusted P > 0.10 for both). However, veterans, compared with non-veterans, received fewer visits per day from home health aides (0.19 [one visit every 5.3 days] vs. 0.27 [one visit every 3.7 days]; adjusted P ¼ 0.002). In sensitivity analyses that categorized those with unknown veteran status as non-veterans, the findings for all of our outcomes were similar in magnitude and were statistically significant, except for the association between veteran status and frequency of home health aide visits (adjusted P ¼ 0.052).
Discussion In this analysis of patterns of hospice care among a nationally representative cohort of male hospice users, we found that, with the exception of age and payment source for hospice, the demographic and clinical profile of veterans and non-veterans was quite similar. However, there were significant differences in patterns of hospice use between veterans and non-veterans. Veterans were more likely than non-veterans to have cancer and receive hospice services at home. Hospice LOS and visit rates from hospice nurses and social workers were similar for veterans and non-veterans, but veterans received significantly fewer visits from hospice home health aides than nonveterans. Veterans also tended to be more likely than non-veterans to disenroll from hospice, but this difference was of borderline statistical significance (P ¼ 0.07). To date, the literature on the characteristics of hospice use by veterans has come from VA data sources and, therefore, reflects the profile of veterans who use the VA for their health care. However, because most are enrolled in community-based hospices, the VA has little information about their experiences. Moreover, most veterans do not receive medical care through the VA, meaning VA data sources are inadequate to describe the profile of all
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Table 1 Characteristics of Hospice-Discharged Patients by Veteran Statusa
Age, years Mean (SE) Age (%) <50 50e64 65e74 75e84 85e89 $90 Race/ethnicity (%) Non-Hispanic white Non-Hispanic black Hispanic Other Missing Marital status (%) Married/partnered Not married Missing Primary caregiver (%) Spouse/significant other Non-spouse Missing Primary payment source (%) Medicare Medicaid Private insurance Department of Veteran Affairs Other Missing MSA (%) Metropolitan Micropolitan Neither Number of ADLs needing assistance (%) 0 1e3 4 5 Missing Mobility (%) No assistance needed Needs assistance Not mobile Missing Charlson comorbidity index (%) 0 1 2e3 >3 Reason for hospice discharge (%) Death Other
Veteran Hospice Users (n ¼ 483, Weighted n ¼ 90,456)
Non-veteran Hospice Users (n ¼ 932, Weighted n ¼ 197,164)
77.0 (0.9)
74.3 (0.8)
0.4 17.2 15.4 37.9 20.7 8.5
5.3 17.5 17.7 32.5 16.6 10.3
81.7 10.3 3.8 1.4 2.8
82.0 10.0 4.6 2.0 1.3
70.1 27.9 1.9
61.0 36.3 2.4
53.6 37.9 8.4
48.4 44.6 6.9
77.2 0.1 7.9 7.0 5.0 2.9
76.4 5.5 11.3 0.1b 3.5 3.3
85.3 9.1 5.6
87.1 9.4 3.6
P-Value 0.02 0.08
0.72
0.10
0.40
<0.001
0.22
0.78 12.2 15.8 16.0 45.2 10.8
8.7 13.9 17.5 48.1 11.8
22.3 38.6 27.5 11.7
12.3 46.0 28.8 12.9
46.4 21.5 23.1 9.0
51.7 16.2 23.2 8.9
80.2 19.8
86.1 13.9
0.06
0.57
0.07
SE ¼ standard error; MSA ¼ metropolitan statistical area; ADLs ¼ activities of daily living. a Continuous variables are given as means and categorical variables are given as percentages. Data are reported in weighted values using survey weights, strata, and cluster variables to obtain population estimates. Percentages have been rounded and might not total 100. b Likely the result of reporting error.
veteran hospice users. Therefore, our study is novel in its ability to provide nationally representative data contrasting veteran and nonveteran male hospice users.
Although we were unable to find national statistics on characteristics of veteran decedents, we contrasted the demographic characteristics of the overall population of veteran
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Table 2 Diagnosis and Location of Care by Veteran Statusa Proportion Among Veteran Hospice Users (n ¼ 483, Weighted n ¼ 90,456)
Proportion Among Non-Veteran Hospice Users (n ¼ 930,b Weighted n ¼ 197,164)
43.6 8.2 7.1
51.6 10.5 8.7
4.7 6.7 2.8 14.2 56.4
5.5 5.7 4.2 17.1 48.4
1.67 (1.09e2.57)
68.4 5.9 18.6 7.1 0.0
57.6 14.8 20.0 6.7 1.0
1.00 0.23 0.86 0.89 0.05
Diagnosisf,g Noncancer Dementia Debility or adult failure to thrive Congestive heart failure Chronic pulmonary disease Cerebrovascular disease Other Cancer Location of careh Home Hospital Nursing home Hospice residence Other
Adjusted Odds Ratioc,d,e 1.00 (reference)
(reference) (0.08e0.67) (0.40e1.83) (0.36e2.20) (0.00e0.78)
a Data are reported in weighted values using survey weights, strata, and cluster variables to obtain population estimates. Percentages have been rounded and might not total 100. b Two of the 932 non-veterans patients were missing data on diagnosis and location of care and were excluded from this analysis. c Adjusted odds ratios for veterans compared with non-veterans. d Model examining location of care adjusted for all covariates, which included age, race/ethnicity, marital status, primary caregiver, primary payment source, metropolitan statistical area, number of ADLs needing assistance, mobility needs, Charlson comorbidity index score, and reason for hospice discharge. e Model examining diagnosis adjusted for all covariates except number of ADLs needing assistance and mobility needs. f P ¼ 0.07 for unadjusted comparison by veteran status; P ¼ 0.02 for adjusted comparison by veteran status. g Disease categories based on ICD-9 codes. h P ¼ 0.02 for unadjusted comparison between home and hospital by veteran status; P ¼ 0.007 for adjusted comparison between home and hospital by veteran status.
hospice users in our study with published data on the characteristics of VA enrollees who died.2 These data suggest that veterans who use hospice are much more likely than VA decedents to be married (70% vs. 41%) and tend to more likely be non-Hispanic white (82% vs. 78%).2 Furthermore, the percentages of veterans in hospice who were non-Hispanic white and married were almost identical to Census statistics for the overall veteran population,14 suggesting that access to hospice among veterans does not vary notably by patient characteristics. Marital status is a key determinant of patterns of end-of-life care. Having a spouse
is associated with a greater likelihood of both enrolling in hospice and dying at home.15 Thus, while the demographic profile of VA users suggests that many may lack the social supports needed for home hospice, our data indicate that many veterans outside the VA likely do have such supports. Overall, these results caution against equating end-of-life care within the VA population as similar to patterns of care for all veterans more generally. We found that veterans were more likely than non-veterans to have a hospice diagnosis of cancer and receive hospice services at home. One possible explanation for these findings relates
Table 3 Median Hospice LOS and Median Visits Per Day by Hospice Staff by Veteran Statusa Veteran Hospice Users (n ¼ 483, Weighted n ¼ 90,456) LOS, median (Q1, Q3b), days Nursing visits per day Social work visits per day Home health aide visits per day
20 0.46 0.16 0.19
(5, 53) (0.28e0.96) (0.08e0.30) (0.05e0.50)
Non-veteran Hospice Users (n ¼ 932, Weighted n ¼ 197,164) 15 0.44 0.16 0.27
(4, 48) (0.28e0.81) (0.08e0.31) (0.10e0.50)
Adjusted P-Valuec 0.23 0.43 0.66 0.002
LOS ¼ length of stay; ADLs ¼ activities of daily living. a Unadjusted estimates. b (Q1, Q3) refers to (25th percentile, 75th percentile). c All models adjusted for all covariates, which included age, race/ethnicity, marital status, primary caregiver, primary payment source, metropolitan statistical area, number of ADLs needing assistance, mobility needs, Charlson comorbidity index, diagnosis, location of care, and reason for hospice discharge.
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to historical trends in hospice use. When the hospice movement began in the U.S. in the 1970s, most patients had cancer and received hospice care at home. However, over time, these numbers have shifted such that now most hospice patients have noncancer diagnoses and receive care in nursing homes or acute or subacute facilities.1,16 Meanwhile, hospice use by veterans, historically, lagged behind that of the overall U.S. population. Thus, as a population that has been a later adopter of hospice, veterans, along with their families and health care providers, may still view hospice as primarily for cancer patients living at home. One important alternative explanation for the differences in hospice diagnosis by veteran status is that cancer may be a more common cause of death for veterans than non-veterans. Unfortunately, the National Center for Health Statistics, which reports the leading causes of death in the U.S, does not provide veteran status as a measure in its public data file. Thus, there is limited information on causes of death for veterans vs. non-veterans, and the causes of death for VA inpatient decedents may not reflect those for veteran decedents who do not use VA services. Nevertheless, a study of VA inpatient decedents found that less than a third died of cancer,7 which may provide some support for the conclusion that the high prevalence of cancer we found among veteran hospice users (56%) is unlikely to be completely explained by a very high incidence of cancer as a cause of death among veterans. The finding that a higher proportion of veterans, compared with nonveterans, received hospice care in the home setting rather than in the hospital is encouraging as past research shows that, although most people die in institutional settings,16 in general, people prefer to die at home.17 Past research has shown that veterans, compared with non-veterans, are less likely to want heroic measures attempted at the end of life18 and, at least within the VA, receive less aggressive care at the end of life.19 This suggests that, at a population level, veterans’ goals at the end of life are more consistent with the hospice philosophy. As a result, one might expect that they would enroll in hospice earlier than nonveterans; however, we found no difference in hospice LOS by veteran status. This may suggest a missed opportunity to connect veterans with hospice care earlier in the course of life-
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limiting illness. This said, the decision to enroll in hospice is complex and influenced by multiple factors, including providers’ judgments about prognosis and perceptions of patient readiness to discuss hospice and patients’ and families’ knowledge and attitudes about hospice. Thus, the similar hospice lengths of stay for veterans and non-veterans may reflect similar barriers to hospice enrollment. It is notable that there was a nonsignificant trend toward veterans being more likely than non-veterans to disenroll from hospice before death. Whether this is because veterans changed their mind about hospice, were less satisfied with hospice care, because they clinically stabilized and thus became ineligible for hospice, or for some other reason is not clear. Finally, veterans had fewer home health aide visits than non-veterans. This may reflect differences in functional status as we found some suggestion that mobility impairment was less common among veterans than non-veterans, and functional status has been associated with health care service utilization.20 However, the difference in frequency of home health aide visits remained after adjustment for mobility and other factors. One possible explanation for this finding is that veterans may be less likely to request or accept aide visits, perhaps out of a sense of pride or because of less self-perceived need for assistance. An alternative explanation is that they may be less likely to be offered aide visits. Further study is needed to understand the sources of this difference and assess if it is associated with worse experiences among veteran hospice users. In assessing the clinical and policy implications of our findings, one key question is the extent to which hospice care for veterans overall is shaped by VA policy and practice. Unfortunately, the NHHCS does not ask respondents whether medical care was obtained through the VA, and thus, we were unable to assess the degree to which we compared non-veterans with veteran VA users vs. non-users. Past work suggests that 13% of all veterans receive care in the VA in a given year, and 28% of veterans ever have received care.8 It is important to note that although our data showed that the Department of Veterans Affairs was the primary payer for hospice for only 7% of veterans, other veterans may have been VA patients but used Medicare or another insurance source to pay
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for hospice. Prior research shows that 78.5% of veterans enrolled in the VA at the time of death also were enrolled in Medicare.2 With the VA’s increased access to hospice and palliative care in the 2000s, it is possible that a higher proportion of veteran hospice users may use the VA than these more general statistics suggest. Furthermore, the VA’s efforts to improve care for veterans at the end of life may affect veterans who are non-VA users as well. Therefore, acknowledging that we must be circumspect in our conclusions, considering the ways in which VA policy and practice may provide insight into our findings is, nonetheless, relevant. The VA is both a provider and a purchaser of hospice, which has important implications for our findings. Inpatient hospice care is provided directly by VA staff in both acute and subacute health care facilities. In contrast, the VA partners with non-VA community-based hospices that deliver all the hospice care for veterans outside VA health care facilities, often in the absence of pertinent clinical information from the VA. Although the VA may not have much impact on the quality of care that their patients enrolled in community-based hospices receive, the VA plays a central role in hospice referral, in terms of the types of patients who are referred and the location where they receive hospice care. Location of end-oflife care has been associated with quality, with one study demonstrating poorer quality outcomes in institutional vs. home settings.21 Thus, to the extent that the VA supports veterans and their families to enable veterans to stay at home at the end of life, the organization is promoting quality. However, the relative underrepresentation of noncancer diagnoses among veterans raises the concern that referral patterns for veterans may be lagging behind recent trends to broaden the populations receiving hospice care. In interpreting our finding that veteran hospice users received fewer home health aide visits than nonveterans, it is important to note that VA users may have access to home health aide services through the VA while they are enrolled in the Medicare Hospice Benefit. Thus, veteran hospice users in our sample who use the VA may have less need for hospice-provided home health aide visits. Our study has important limitations. First, veteran status was missing for approximately
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one-third of the NHHCS sample. However, sensitivity analyses in which all those with unknown veteran status were categorized as non-veterans had similar findings, supporting the robustness of our findings. Second, veterans who received hospice in VA inpatient facilities were not sampled in NHHCS. Therefore, the profile of this important group of veterans receiving hospice is not reflected in our data. However, with past work showing that most veterans never use the VA for health care,9 the proportion of veteran hospice users in VA inpatient facilities is likely very low and their non-inclusion in our data is unlikely to have a substantial impact on our findings. Third, although our data come from the most recent NHHCS, the survey was conducted in 2007. Hospice use has increased dramatically over the past decade; this growth may have had an important impact on the characteristics of veteran and non-veteran hospice users and their service utilization. Fourth, the extremely small number of female veteran hospice users (n ¼ 24) precluded inclusion of women in our analyses, and thus, our findings may not generalize to women. The number of women in the military is rapidly growing,22 and as this population ages over the coming decades, it will be critical to examine the profile of female veteran hospice users. In addition, given that there were only 211 veterans with noncancer diagnoses in our sample, the sample sizes for many of the subcategories of noncancer diagnoses were quite small. Therefore, for our regression models, we did not have sufficient power to include each as a distinct category. Finally, because the NHHCS only sampled hospice users, our analyses cannot address the important question of whether there are differences in the characteristics of veterans and non-veterans who do vs. do not use hospice.
Conclusion We found that although veteran and nonveteran hospice users were fairly similar on most demographic and clinical measures, differences in the patterns of hospice referral and utilization exist. Further research into the underlying causes for these differences will be essential in meeting the Department of Veterans Affairs’ charge to ‘‘honor and serve’’23 all America’s
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veterans and in improving end-of-life care for veterans both within and outside the VA system.
Disclosures and Acknowledgments We would like to acknowledge Drs. Ellen P. McCarthy, Roger B. Davis, and Edward R. Marcantonio for their scientific and methodological contributions to the analytic framework of this manuscript, which was based on a previous publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. This study was not funded, and none of the authors has any disclosures relevant to the content of this article. Benjamin Sommers, MD, PhD, Harvard School of Public Health, provided helpful feedback on an earlier version of this manuscript.
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