Patterns and Predictors of Home Health and Hospice Use by Older Adults with Cancer

Cancer disproportionately affects older adults, with age being the most significant risk factor for cancer. Currently, approximately 35 million people (13% of the total population) in the United States are aged 65 and older. This number is expected to increase to nearly 80 million by 2050.1 The incidence rate for cancer is nearly 10 times greater in persons aged 65 and older than in those younger than 65 (2,208 vs 225 per 100,000 cases).2 Cancer is the second leading cause of death in persons aged 65 and older and is the primary cause of death in those aged 65 to 74.3 Despite declining or stabilizing cancer incidence rates across all age groups, the tremendous growth of the older population will contribute to a doubling of the current number of cancer cases by 2050, with the overwhelming majority of those cases occurring in older adults.4 Home health and hospice services can play a vital role in providing treatment for older cancer patients throughout the continuum of care of the disease, and both are covered under Medicare Part A.5 Home health services may be more appropriate during the earlier stages of illness, and hospice services may be more appropriate during the latter stages of illness. This is primarily because of the different emphases of the programs and the services that are offered. Home health services are provided for persons who are in need of care because of an acute illness, a chronic condition, a permanent disability, or a terminal illness. Care is limited to part-time or intermittent skilled nursing care, home health aide services, physical therapy, occupational therapy, speech-language services, medical social services, and some medical supplies and durable equipment. Hospice benefits are allowable only to persons with a terminal illness, and services provided include all of those offered under the home health benefit and many more, including coverage of drugs for symptom control and pain relief, grief counseling, respite care, and other services. Patients who are terminally ill may receive either type of service, but they may not receive home health and hospice services simultaneously. Previous research has shown that a primary diagnosis of cancer accounts for 7.5% of all home health admissions for Medicare home health patients and that women and nonwhites are more likely to use home health services (not specific to cancer diagnosis) than men and whites,6,7 although this may significantly underestimate the proportion of older cancer patients receiving home health services, because the primary diagnosis recorded for a particular home health event may be related to sequelae or treatment of the cancer rather than the cancer itself. Additionally, many cancer patients have comorbid or chronic conditions, and these increase with age.8–10 The cancer or its treatment may exacerbate these conditions, and this may ultimately be the reason for referral to home health services. Adults with a prior history of cancer also have higher levels of disability than the general population of adults.11,12 Thus, a significant number of older adults with cancer receive home health services or could benefit from receipt of those services, although the precise numbers of older adults with cancer receiving these services is not known. The majority (79.6%) of patients who receive hospice services are aged 65 and older, and about half (51.0%) of all Medicare hospice patients have a primary diagnosis of cancer.13 Previous estimates of hospice use by Medicare fee-for-service beneficiaries range from 19.8% to 30.2%.14,15 There is variation in the use of hospice services between patient subgroups; utilization has been found to be higher in patients who are married, female, and non-Hispanic white.15 It is not known whether persons who are terminally ill who do not receive hospice services also do not receive other services, such as home health services. The Balanced Budget Act of 1997 (BBA) changed the reimbursement systems for home health and hospice services. After implementation of the BBA, which introduced a prospective payment system for home health services, use of home health services decreased and of hospice services increased until 2003 (the most recent year for which data are available from the Center for Medicare and Medicaid Services).6,16 The extent to which these utilization trends are related is not known. Although hospice utilization rates are known for older adults with cancer, their home health utilization rates are not known. The primary aim of this article is to describe patterns of home health and hospice use by older cancer patients and a comparison group of older persons without cancer. Patterns of utilization are described for older cancer patients generally and for two phases of disease—immediately after diagnosis and immediately before death for patients who died. Patterns of utilization are described separately for a comparison group of older persons without cancer generally and immediately before death. Patterns of utilization are described in terms of total utilization and the proportion of utilization attributable directly to cancer. A secondary aim is to identify predictors of home care and hospice utilization, including cancer site and patient demographic characteristics of sex, marital status, and ethnicity.