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(Reuters Health) - An initiative to enroll dying veterans in hospice care appears to be working, and its success may offer clues for how to persuade others who are terminally ill to join the highly lauded end-of-life program, a new study shows.
After the U.S. Veterans Administration implemented its Comprehensive End of Life Care Initiative in 2009, growth of enrollment of terminally ill male war veterans in hospice care outstripped enrollment growth in hospice programs for elderly men who did not serve, according to the report in Health Affairs.
More veterans likely enrolled in hospice care because the initiative allowed them to continue to have curative treatments, said Joanne Spetz, a professor at the Institute for Health Policy Studies at the University of California, San Francisco. Other hospice programs require participants to cease disease-modifying treatment.
Spetz suspects that being able to use both hospice and concurrent care motivated people to sign up for hospice care "because it wasn’t an either/or decision,” she said in a phone interview.
Deciding to forego chemotherapy, radiation or any other possible curative treatments can be difficult for patients and families, said Spetz, who was not involved in the study.
“There’s fear that if I sign up for hospice, I’ve given up,” she said. “It’s also hard for the physician, who’s trained that death is a loss.”
Researchers compared hospice use among more than 1.1 million male veterans ages 65 and older between 2007 and 2014 with more than 140,000 demographically similar Medicare beneficiaries not enrolled in VA healthcare.
By 2011, they found that 44 percent of veterans who died in hospitals took their last breaths in hospice beds, compared to 30 percent in 2008. By 2012, 71 percent of veterans dying of cancer were enrolled in hospice.
Lead author Susan Miller, a professor at the Brown University School of Public Health in Providence, Rhode Island, and her team structured the study to examine whether the VA initiative drove growth beyond that in the general Medicare population.
Before the initiative, veterans were 15 percent less likely than non-veterans to go into hospice, Miller said in a phone interview. Today, they’re 2.4 percent more likely.
The VA initiative focused on increases in palliative and hospice care. By 2012, the VA had installed 54 new hospice and palliative-care inpatient units, the authors write.
Elderly men who were not veterans increased hospice use by 5.6 percent between 2007 and 2014, while older male veterans increased hospice use by 7.6 percent, the study found.
Previous studies repeatedly document that dying people receive higher-quality end-of-life care with hospice, the authors write.
“Numerous studies show hospice improves quality of care and results in less aggressive and undesired care, such as emergency room visits and hospitalizations near the end of life,” Miller said.
“The quality is better, and families feel it’s better,” she said.
Spetz applauded the VA initiative for its concerted effort to provide palliative-care and hospice staff across the country. But she wondered if the effort could be reproduced in other healthcare systems.
“If you tried to implement this program in a community program, it would be a lot harder,” she said. “It speaks well for integration of care because many people have very, very fragmented care. Could you really pull this off outside the VA?”
The U.S. Centers for Medicare and Medicaid Services is currently testing a hospice program that allows curative care to continue, called the Medicare Care Choices Model.
Miller believes conversations between patients and clinicians soon after a diagnosis of serious illness are key.
“The VA’s having discussions with veterans earlier to understand preferences and to meet their needs,” she said.
“It’s the conversations that are so important,” she said. “The VA is trying to have more of these conversations and document the preferences earlier.”
SOURCE: bit.ly/2tel1xX Health Affairs, online July 5, 2017.