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Health Aff (Millwood). 2018 Jun;37(6):980-987. doi: 10.1377/hlthaff.2017.1181.

Hospice Use And End-Of-Life Spending Trajectories In Medicare Beneficiaries On Hemodialysis.

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Ann M. O'Hare ( ) is a professor of medicine at the University of Washington; a core investigator at the Kidney Research Institute, a collaboration between Northwest Kidney Centers and UW Medicine; and a staff physician in nephrology at the Veterans Affairs (VA) Puget Sound Health Care System, all in Seattle, Washington.
Susan M. Hailpern is a statistical analyst (retired) at the Kidney Research Institute and University of Washington.
Melissa Wachterman is an assistant professor of medicine at Harvard Medical School and a staff physician in general medicine and palliative care with joint appointments at Dana Farber Cancer Institute, Brigham and Women's Hospital, and the VA Boston Healthcare System, in Massachusetts.
William Kreuter is a research consultant in the Department of Pharmacy at the University of Washington.
Ronit Katz is a research associate professor at the University of Washington School of Medicine.
Yoshio N. Hall is an associate professor of medicine at the University of Washington and core investigator at the Kidney Research Institute.
Maria Montez-Rath is a biostatistician and director of the Biostatistics Core of the Division of Nephrology at Stanford University School of Medicine, in Palo Alto, California.
Manjula Kurella Tamura is a professor of medicine at Stanford University and a staff physician at the VA Palo Alto Health Care System.
Kenn B. Daratha is an associate professor in the Washington State University College of Nursing and School of Anesthesia at Providence Health & Services, in Spokane.


Infrequent and late referral to hospice among patients on dialysis likely reflects the impact of a Medicare payment policy that discourages the concurrent receipt of these services, but it may also reflect these patients' less predictable illness trajectories. Among a national cohort of patients on hemodialysis, we identified four distinct spending trajectories during the last year of life that represented markedly different intensities of care. Within the cohort, 9 percent had escalating spending and 13 percent had persistently high spending throughout the last year of life, while 41 percent had relatively low spending with late escalation, and 37 percent had moderate spending with late escalation. Across the four groups, the percentages of patients enrolled in hospice at the time of death were uniformly low ranging from only 19 percent of those with persistently high costs to 21 percent of those with moderate costs and the median number of days spent in hospice during the last year of life was virtually the same (either five or six days). These findings signal the need for greater flexibility in the provision of end-of-life care in this population.


Cost of Health Care; dialysis; end-of-life; hospice; trajectory

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