A national study of live discharges from hospice

BACKGROUND: Live discharges from hospice can occur because patients decide to resume curative care, their condition improves, or hospices may inappropriately use live discharge to avoid costly hospitalizations.

OBJECTIVE: Describe the variation, outcomes, and organizational characteristics associated with live discharges.

DESIGN: Retrospective cohort study.

SETTING/SUBJECTS: Medicare fee-for-service hospice beneficiaries.

MEASUREMENT: Overall rate, timing, and health care transitions of live discharges.

RESULTS: In 2010, 182,172 of 1,003,958 (18.2%) hospice discharges were alive. Hospice rate of live discharges varied by hospice program with interquartile range of 9.5% to 26.4% and by geographic regions with the lowest rate in Connecticut (12.8%) and the highest in Mississippi (40.5%). Approximately 1 in 4 (n=43,889; 24.1%) beneficiaries discharged alive were hospitalized within 30 days. Nearly 8% (n=13,770) had a pattern of hospice discharge, hospitalization, and hospice readmission. These latter cases account for $126 million in Medicare reimbursement. Not-for-profit hospice programs had a lower rate of live discharges compared to for-profit programs (14.6% versus 22.4%; adjusted odds ratio [AOR] 0.84, 95% confidence interval [CI] 0.77-0.91). More mature hospice programs (over 21 years in operation) had lower rates of live discharge compared to programs in operation for 5 years or less (14.2% versus 26.7%; AOR 0.71, 95% CI 0.65-0.77). Small for-profits in operation 5 years or less had a higher live discharge rate than older, for-profit programs (31.5% versus 14.3%, p<0.001).

CONCLUSIONS: Approximately 1 in 5 hospice patients are discharged alive with variation by geographic regions and hospice programs. Not-for-profit hospices and older hospices have lower rates of live discharge.