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How Does Obesity Affect Care at End-of-Life?

February 06, 2017

According to a study published in Annals of Internal Medicine, increasing obesity is associated with reduced hospice use and in-home death as well as lower-quality end-of-life care (published online February 7, 2017; doi:10.7326/M16-0749).

Current research suggests that 70% of US adults aged 60 years or older are overweight or obese; obesity can complicate nursing and medical care delivery, but its effect on hospice use and Medicare expenditures is less known.

A retrospective cohort study was conducted by John A Harris, MD, MSc, University of Pittsburgh (Pittsburgh, PA), using the Health and Retirement Study— a nationally representative panel survey that biennially interviews US adults older than age 50 about health and financial issues. The cohort consisted of 5677 community-dwelling, Medicare fee-for-service beneficiaries who died between 1998 and 2012.
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Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death were measured. BMI was modeled as a continuous variable with a quadratic functional form.

Dr Harris and colleagues found that obesity was a risk factor for lower-quality end-of-life care, which they defined as enrollment in hospice, longer length of hospice stay, and in-home death. The predicted probability of hospice enrollment was 40% lower for decedents with a BMI of 40 kg/m2 than for those with a BMI of 20 kg/m2.

In addition, increasing BMI was associated with higher expenditures for inpatient, outpatient, and physician claims, although these were partially offset by lower hospice, durable medical equipment, and skilled-nursing expenditures in this community-dwelling population.

Authors hypothesized that obesity may affect hospice enrollment through 2 mechanisms: referral behaviors and enrollment policies. Obese patients may have a more sudden decline in performance status or increase in metabolic abnormalities, which may lead to more sudden deaths than in non-obese patients. And enrollment policies vary among hospice services, and some restrict access to care for persons with higher-cost medical needs.

Authors concluded that BMI was independently associated with decreased hospice enrollment, duration of hospice services, and in-home death and increased Medicare expenditures in the last 6 months of life, after adjustment for key sociodemographic, medical, functional status, and geographic factors.

Two limitations were noted in the article: the baseline data was self-reported, and the interval between reported BMI and time of death varied.—Amanda Del Signore

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