VA End-of-Life Initiative Increases Veterans' Use of Hospice

BACKGROUND:
In 2002, VA began a system-wide hospice and palliative care program to improve end-of-life care for Veterans, and in FY2009 VA implemented the Comprehensive End of Life Care (CELC) Initiative that increased the numbers of VAMC inpatient hospice units and palliative care staff members, as well as the amount of palliative care training, quality monitoring, and community outreach. This study sought to determine whether this substantial VA investment in palliative care led to increased use of hospice for older male enrolled Veterans. Using VA and Medicare data, investigators identified 1,129,803 enrolled male Veterans and a 5% sample of 141,166 male non-Veteran Medicare beneficiaries who died in FY2007 through FY2008 or FY2010 through FY2014. Variables included age, race, ethnicity, diagnoses, nursing home use in the last year of life, and residence (urban vs. rural, geographic region).

FINDINGS:

• After adjusting for variables, the CELC Initiative was shown to be effective in increasing hospice use for older male enrolled Veterans beyond that observed for non-Veteran Medicare decedents. These differentials increased over time and were even larger among Veterans who had stays in hospitals – where substantial CELC Initiative investment occurred – in the last year of life.
• Rates of hospice use increased in the years after implementation of the CELC Initiative for all of the study groups. For enrolled Veterans, the increases were 6.9 to 7.9 percentage points (relative increases of 20-42%) depending on VA and Medicare enrollment and use, while the increase for non-Veterans was 5.6 percentage points (relative increase of 16%).
• Adjusting for Veteran factors, findings suggest hospice use by enrolled Veterans increased subsequent to CELC at a rate that surpassed increases in hospice use by non-Veteran decedents.
• Enrolled Veteran decedents who were not enrolled in Medicare and used VA hospital care in the last year of life had a 50% increase in unadjusted hospice use (from 24% in FY2007 to 36% in FY2014) compared to a 16% increase for non-Veteran Medicare decedents (40% to 46%). However, their hospice use rate remained lower than among other Veteran groups.

IMPLICATIONS:

• The largest challenge moving forward (CELC Initiative's targeted financial investments ended in September 2012) is the need to maintain momentum given competing priorities (i.e., Veterans Choice Act), while improving the care of Veterans who choose VA or non-VA hospice care.

LIMITATIONS:

• Although investigators used population-based VA and Medicare administrative data and identified all decedents, the range of sociodemographic, clinical, and social support variables is limited.
• The CELC Initiative included numerous strategic efforts, and investigators were unable to determine whether specific effort(s) might be associated with the changes they observed.

AUTHOR/FUNDING INFORMATION:
Dr. Intrator is part of HSR&D's Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, located in Providence, RI. Dr. Intrator directs the Geriatrics & Extended Care Data Analysis Center (GECDAC) of the Offices of Geriatrics & Extended Care that is affiliated with the Providence COIN.

Miller SC, Intrator O, Scott W, Shreve S, Phibbs C, Kinosian B, Allman R, Edes T. Increasing Veterans’ Hospice Use: The Veterans Health Administration’s Focus on Improving End-of-Life Care. Health Affairs. July 1, 2017;36(7):1274-1282.