Obese Persons Receive Lower-Quality End-of-Life-Care, Study Shows

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Research published this week in Annals of Internal Medicine reveals that obesity is linked to reduced hospice enrollment rates, fewer in-home deaths and greater Medicare expenditures six months before death. The research was published by John A. Harris, MD, MSc, from the University of Michigan, Ann Arbor and colleagues. The team conducted the first study examining the association between obesity and hospice use.

Nearly 70 percent of adults over age 60 are overweight or obese, according to Harris and his colleagues. “And for obese persons, technical and logistical issues arise during hospitalizations, surgery, and end-of-life care that require special attention,” they said.

Body Mass Index Linked to Hospice Care

The study was a retrospective cohort investigation of 5,677 Medicare fee-for-service beneficiaries who participated in the U.S. Health and Retirement Study (HRS) and died between 1998 and 2012. Data examined included participants’ body mass index (BMI); hospice enrollment; days enrolled in hospice; in-home death rates; and Medicare expenditures during the patients’ last six months of life. The data drawn from the HRS looked at Medicare spending during the last 180 days of life. Spending sources included inpatient, outpatient, physicians or suppliers, durable medical equipment, hospice, home health and skilled nursing costs. Each measure was analyzed at five BMI levels — 20, 25, 30, 35, and 40. (A BMI of 20 is considered “normal weight.” A BMI of 30 is considered obese.) Researchers found that obese persons with a BMI of at least 40 had a predicted hospice enrollment rate of 23 percent. Those whose BMI was 20 had a 38 percent predicted hospice enrollment rate.

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In the United States, hospice care is an insurance benefit that allows for more in-home nursing and home health visits at the end of life. The Medicare Hospice Benefit requirements state that patients must have a terminal illness and be 65 years or older to enter hospice care. Additionally, the patient’s doctor and a hospice medical director must certify that the patient has six months or less to live. Authors of the study suggested a number of possible reasons for the differences in hospice care between patients with varying BMIs.

Possible Explanations

One possible factor, they explained, is “cachexia,” a metabolic condition that causes extreme weight loss and muscle wasting in people who are chronically or terminally ill. When cachexia isn’t present (for example, in obese persons) the patient’s doctor may not realize that the person’s condition is grave. Thus, they are less likely to refer them for hospice care. The authors also noted that some hospice providers are reluctant to accept patients with higher-cost medical needs. Thus, obese persons, who might require greater nursing assistance or lifting equipment, may be denied access to hospice care.

John Harris and his team note in their article that, “All people — regardless of body size — and their families should have equal opportunities to experience the benefits of high-quality end-of-life healthcare.” Shedding a positive light on the results of their groundbreaking study, they write, “The disparities in hospice use and Medicare expenditures by patient BMI provide an excellent opportunity for improvement.” Let’s hope our healthcare system seizes that opportunity soon.