The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study

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Abstract

Background:

Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown.

Objective:

To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life.

Design:

Retrospective cohort.

Setting:

The HRS (Health and Retirement Study).

Participants:

5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012.

Measurements:

Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. Body mass index was modeled as a continuous variable with a quadratic functional form.

Results:

For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3% (CI, 59.4% to 63.2%), and total Medicare expenditures were $42 803 (CI, $41 085 to $44 521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, −9.3 to −4.0 percentage points), hospice duration decreased by 3.8 days (CI, −4.4 to −3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, −6.0 to −0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI ≥40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, −19.6 to −10.9 percentage points), hospice duration decreased by 4.3 days (CI, −5.7 to −2.9 days), and in-home death decreased by 6.3 percentage points (CI, −11.2 to −1.5 percentage points) versus decedents with BMI of 20 kg/m2.

Limitation:

Baseline data were self-reported, and the interval between reported BMI and time of death varied.

Conclusion:

Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life.

Primary Funding Source:

Robert Wood Johnson Foundation Clinical Scholars Program.

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