2023 HSR&D/QUERI National Conference

1053 — Concurrent Receipt of Hospice and Dialysis Among Veterans with End-Stage Kidney Disease

Lead/Presenter: Melissa Wachterman
All Authors: Wachterman MW (Center for Healthcare Organization and Implementation Research (CHOIR Boston-Bedford)), Corneau EE (Center for Long Term Services and Supports, Providence) O'Hare AM (Center for Veteran-Centered and Value-Driven Care, Seattle-Denver) Keating NL (Harvard Medical School, Department of Healthcare Policy) Mor V (Center for Long Term Services and Supports, Providence)

Hospice offers benefits to patients nearing the end of life. Rates of hospice use are low among patients with end-stage kidney disease (ESKD), and most who receive hospice enroll only after discontinuing dialysis. Medicare will not pay for disease-focused therapies once a patient enrolls in hospice. For the majority of patients with ESKD, this includes dialysis, a treatment that is quite literally keeping them alive, and without which most will die within a week. In contrast to Medicare, VA is committed to ensuring that seriously-ill Veterans have access to hospice services regardless of whether they are receiving disease-focused treatments. While rates of concurrent hospice and chemotherapy among Veterans with cancer have been examined, rates of concurrent hospice and dialysis among Veterans with ESKD have not. Our objective was to compare rates of concurrent hospice and dialysis among VA-enrolled Veterans with ESKD who received hospice provided by the VA directly, through VA Community Care, and through Medicare, respectively.

We conducted a retrospective observational study that included all 70,577 VA-enrolled Veterans who were registered in a national registry of ESKD patients (the United States Renal Data System) and who initiated dialysis and died between 2007 and 2016. We examined the proportion who used hospice, and, among hospice users, the proportion who received dialysis at least once after hospice enrollment (“concurrent care”). We also examined hospice length of stay, defined as time from hospice enrollment to death, by concurrent care use. We then categorized Veterans based on which payer financed their hospice – VA, for care delivered either in a VA facility (“VA Hospice”) or by a non-VA community hospice agency (“VA Community Care”); or Medicare. We used multivariable logistic regression to compare the proportion who received concurrent care by hospice payer, adjusted for age, race, and sex.

Among 70,577 VA-enrolled Veterans with ESKD, 18,420 (26%) received hospice services, primarily financed by Medicare (89%) rather than VA (11%). A total of 5,231 (28%) hospice users continued to receive dialysis after hospice enrollment. The adjusted proportion of Veterans receiving this concurrent care was substantially higher for those enrolled in VA hospice or VA Community Care hospice than for those in Medicare hospice (24% vs. 57% and 56%, respectively; both P < 0.001). Median hospice length of stay was 43 days for hospice users who continued dialysis versus 4 days for those who did not.

Rates of concurrent hospice and dialysis among Veterans with ESKD were more than two-fold higher under VA-financed hospice as compared with Medicare-financed hospice. Hospice users who continued to receive dialysis after hospice enrollment had substantially longer hospice stays than those who did not.

These findings suggest that VA is upholding its commitment to concurrent care for Veterans with ESKD who receive hospice through VA or VA-Community Care. However, this policy is not reaching the vast majority of VA-enrolled Veterans with ESKD because most receive hospice through Medicare, which restricts access to hospice. To truly increase access, a shift in hospice payer for Veterans with ESKD or in Medicare policy would be necessary.