Characteristics of patients hospitalized with acute decompensated heart failure who are referred for hospice care

Background: Hospice is a potential option for patients with end-stage heart failure whose symptoms and clinical status have progressed despite maximal medical therapy. However, little is known about hospice referral practices when patients are admitted because of acute decompensated heart failure. Methods: Data from the Acute Decompensated Heart Failure Registry (ADHERE) were analyzed from October 1, 2001, to December 31, 2005, accounting for 182 898 patient episodes with known disposition from 307 hospitals. Demographic data, clinical characteristics, and medical management were compared in the group discharged to hospice vs patients discharged to home or to intermediate-care facilities. Hospitals, stratified by frequency of discharge of patients to hospice, were evaluated for adherence to performance measures. Temporal trends according to discharge category were analyzed using analysis of variance, and predictors of hospice referral were determined by multivariate analysis. Results: The hospice cohort composed 1.6% (n=3010) of the total sample. Patients referred to hospice were generally older, more likely to have been admitted because of antecedent heart failure in the preceding 6 months, more likely to receive intravenous inotropic therapy, less likely to receive angiotensin-converting enzyme inhibitors, and less likely to undergo a procedure (eg, dialysis or cardiac catheterization) during the hospitalization. The median rate of hospice referral increased from 0.8% in 2001 to 1.3% in 2005 (P<.008). Hospitals in the upper quartile of hospice referrals had comparable or higher rates of adherence to quality indicators for heart failure than did hospitals in the lowest quartile. Variables obtained at admission that were associated with hospice referral included older age (per 10-year increment; odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57-1.68), lower serum sodium concentration (per 5-mEq/L [to convert to millimoles per liter, multiply by 1.0] increment; OR, 0.81; 95% CI, 0.78-0.83), lower systolic blood pressure (per 10-mm. Hg increment; OR, 0.86; 95% CI, 0.85-0.88), higher serum urea nitrogen concentration (per 10-mg/dL to convert to millimoles per liter, multiply by 0.375] increment; OR, 1.20; 95% Cl, 1.18-1.21), and absence of lipid-lowering drug therapy (use of drug OR, 0.69; 95% Cl, 0.63-0.75). Conclusions: A small percentage of patients admitted to acute care hospitals with decompensated heart failure are referred to hospice at rates increasing with time. Hospitals that refer patients to hospice are more likely to be in compliance with heart failure performance measures. Further investigation is required to determine if the hospice option is appropriately selected and if it should be offered to a broader cohort of patients.