Survival Heterogeneity in U.S. Hospice Patients: A Retrospective Cohort Study

Hospice has become an important component of End-of-life care in the United States. The use of hospice, however, remains subject to many forces, including the patient, providers, families and cultural beliefs. One consequence of these forces is significant variability of survival of patients in hospice. In a recent study, the authors reported a median survival of approximately 24 days after enrollment. However, a significant minority of patients survive for more than 180 days (the target set by CMS for the Medicare hospice benefit). We examine the factors contributing to the variability of hospice patient survival, including demographics, diagnoses, care setting, and patient drug prescriptions. We apply Cox proportional hazards models to assess the effect of covariates on time-to-event (in this case death in hospice). A high hazard ratio is associated with a shorter life expectancy. In addition to these factors we evaluated medication exposure variables. Medications are strongly associated with the mortality hazard: analgesic use is associated with a nearly three-fold higher hazard (HR = 2.977), and anxiolytic use with a roughly two-fold higher hazard (HR = 1.910) when compared with the group without any anxiolytic use. We provide a detailed understanding of medication use near the end of life that serve as an indicator that medication trajectories can serve as an additional indicator of symptom burden and individualized care planning.