Vol.
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No.
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2013
Journal of Pain and Symptom Management 1
Original Article
Patterns of Hospice Care Among Military Veterans and Non-veterans Melissa W. Wachterman, MD, MPH, MSc, Stuart R. Lipsitz, ScD, Steven R. Simon, MD, MPH, Karl A. Lorenz, MD, MSHS, and Nancy L. Keating, MD, MPH Section of General Internal Medicine (M.W.W., S.R.S.), VA Boston Healthcare System; Department of Psychosocial Oncology and Palliative Care (M.W.W.), Dana Farber Cancer Institute, Boston, Massachusetts, USA; Division of General Internal Medicine (M.W.W., S.R.L., S.R.S., N.L.K.), Brigham and Women’s Hospital, Boston, Massachusetts; Division of General Internal Medicine and Division of Palliative Care (K.A.L.), VA Greater Los Angeles Healthcare System; Geffen School of Medicine at UCLA (K.A.L.), Los Angeles, California; and Department of Health Care Policy (N.L.K.), Harvard Medical School, Boston, Massachusetts, USA
Abstract Context. Historically, hospice use by veterans has lagged behind that of nonveterans. Little is known about hospice use by veterans at a population level. Objectives. To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization. Methods. Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression. Results. Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P ¼ 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P ¼ 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P ¼ 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than nonveterans (one every 5.3 days vs. one every 3.7 days; P ¼ 0.002). Conclusion. Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist. J Pain Symptom Manage 2013;-:-e-. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Address correspondence to: Melissa W. Wachterman, MD, MPH, MSc, VA Boston Health Care System, 150 South Huntington Avenue, Building 9 Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
(152G), Boston, MA 02130, USA. E-mail: melissa. [email protected] Accepted for publication: August 16, 2013. 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.08.013
2
Wachterman et al.
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2013
Key Words Hospice, veterans, clinical case mix, demographics, health care utilization, nationally representative data
Introduction The number of seriously ill patients who use hospice services at the end of life in the U.S. has increased dramatically over the past decade. Approximately 1.58 million people used hospice in 2010 (41.9% of all deaths), an increase from 1.06 million in 2004.1 Hospice enrollment is primarily concentrated among Medicare beneficiaries, with 83.8% of hospice care financed under the Medicare Hospice Benefit in 2010.1 When the hospice movement began in the U.S. in the 1970s, hospice served primarily patients with cancer who were living at home. However, these patterns have shifted in recent decades, such that in 2010, only 35.6% of hospice patients had a primary diagnosis of cancer and only 41.1% received care at home, with the rest in residential facilities such as nursing homes, hospitals, or hospice residences.1 Currently, about 642,000 U.S. military veterans die each year, accounting for one of four deaths in the U.S.2,3 Hospice use by veterans has historically lagged behind use in the overall U.S. population. In 2000, 21.6% of all Medicare decedents, compared with only 5% of all veterans in all settings, received hospice care.4,5 Responding to this disparity, the Veterans Health Administration (VA) began several initiatives during the past decade to expand veterans’ access to end-of-life care services, including hospice. In 2002e2003, the VA created a Hospice and Palliative Care program office, and in less than three years, the number of veterans receiving home hospice care financed by the VA tripled.4 In 2009, the VA designed the Comprehensive End of Life Care initiative, which funded a palliative care interdisciplinary team at every VA medical center and established partnerships with community hospices in every state in the country.2 Subsequently, growth in the use of hospice care among veterans in the VA has continued, with a recent study documenting more than a three-fold increase from 2006 to 2009.6
Importantly, with the exception of the statistic that 5% of all veterans used hospice in 2000, information about rates of hospice use comes from VA data and, therefore, reflects trends in hospice use of only veterans who use the VA for their health care.4e7 Overall, only about 13% of veterans report that they currently obtain medical care from the VA,8 and 28% report that they ever have.9 Thus, because most veterans do not receive care from the VA, little is known about the majority of veteran hospice users. It is unknown, for example, whether hospice use among veterans over time reflects a shift away from hospice’s traditional focus on treating patients with cancer living at home, similar to that for the population as a whole. Furthermore, VA patients who enroll in hospice, other than the relatively few who use inpatient hospice, are referred by the VA to community-based hospices, and thus, VA data sources do not include information about their care. Our objective was to use nationally representative data to compare veteran and nonveteran hospice users to determine whether demographics, primary diagnosis, location of care, and service utilization differed for these two populations.
Methods We used the 2007 National Home and Hospice Care Survey (NHHCS),10 conducted by the National Center for Health Statistics, to examine a nationally representative sample of patients discharged from hospice, predominantly because of death (84%). Data for the 2007 NHHCS, the most recently conducted version of the survey, were collected through face-to-face interviews with hospice or home health agency directors and their appointed staff, in consultation with patients’ medical records. Our primary variable of interest was U.S. military veteran status. Because more than 95% of veterans in the NHHCS were men, we limited our study population to the 1415
Vol.
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No.
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2013
Veterans’ and Non-veterans’ Hospice Use
male patients discharged from hospice for whom veteran status was known (483 veterans and 932 non-veterans), representing 287,620 hospice enrollees nationally. Veteran status was unknown for 702 male patients; these patients were excluded from our sample for our primary analyses but were included (and classified as non-veterans) in sensitivity analyses.
3
Measures of Service Utilization Our primary measures for service utilization were hospice length of stay (LOS) and the number of visits per day from each major type of hospice provider (total number of visits divided by LOS), including nurses, social workers, and home health aides. We measured hospice LOS from the date of hospice enrollment until hospice discharge.
Characteristics of Hospice Users We categorized individuals’ primary hospice admission diagnosis as either ‘‘cancer’’ or ‘‘noncancer’’ based on whether they had a cancerrelated International Classification of Diseases, Ninth Edition (ICD-9) code (140-239). We then further subdivided patients with noncancer diagnoses into the following categories based on ICD-9 codes: ‘‘dementia,’’ ‘‘debility or adult failure to thrive,’’ ‘‘congestive heart failure,’’ ‘‘chronic pulmonary disease,’’ ‘‘cerebrovascular disease,’’ or ‘‘other’’ (specific codes available on request). We classified where the patients were residing when they began hospice as ‘‘home,’’ ‘‘nursing home,’’ ‘‘hospital,’’ ‘‘hospice residence,’’ or ‘‘other.’’ We categorized patients’ primary caregiver as ‘‘spouse/significant other’’ or ‘‘nonspouse,’’ which included child, parent, other family member, or nonfamily member. All secondary diagnoses in the survey data were used to measure comorbid disease, using the Charlson comorbidity index (CCI) score.11 We also characterized the number of activities of daily living (ADLs; eating, bathing, dressing, toileting, and transferring) with which the patient needed help (categorized as 0, 1e3, 4, and all 5) and mobility impairment (no assistance needed, needs assistance, and not mobile). Finally, we characterized reason for hospice discharge (death vs. other). The following demographic characteristics were categorized: age in years at hospice discharge (0.5% of data were missing (i.e., ‘‘don’t know,’’ ‘‘not ascertained,’’ or
4
Wachterman et al.
‘‘refused’’), missing data were considered as a separate category.
Results The 483 veteran and 932 non-veteran male hospice users represented 287,620 hospice enrollees nationally in 2007. Table 1 shows demographic and clinical characteristics by veteran status. Most veteran and non-veteran hospice users were non-Hispanic whites (81.7% and 82.0%; P ¼ 0.72), married (70.1% vs. 61.0%; P ¼ 0.10), and lived in metropolitan areas (85.3% and 87.1%; P ¼ 0.22). Their CCI scores and the degree of ADL impairment were similar (P ¼ 0.57 and P ¼ 0.78, respectively). Almost half of veterans and nonveterans were dependent for all five ADLs (45.2% vs. 48.1%), yet approximately half of each group had CCI scores of 0 (46.4% vs. 51.7%). Veterans were, on average, significantly older than non-veterans (mean age 77.0 vs. 74.3 years; P ¼ 0.02), yet tended to be less likely to need assistance with walking (66.1% vs. 74.8%; P ¼ 0.06). Primary payment source was significantly different between the two groups (P < 0.001). Medicare was the most common payer for both veterans and non-veterans (77.2% vs. 76.4%), but not surprisingly, veterans were more likely than non-veterans to have the Department of Veterans Affairs as the primary payer (7.0% vs. 0.1%; latter likely the result of reporting error). Veterans were less likely to have Medicaid (0.1% vs. 5.5%) or private insurance (7.9% vs. 11.3%) as the primary payer. Veterans were less likely than non-veterans to stay in hospice until they died (80.2% vs. 86.1%), a difference of borderline statistical significance (P ¼ 0.07). As shown in Table 2, both diagnosis and location of care varied by veteran status. A higher proportion of veteran hospice users, compared with non-veterans, had a primary hospice diagnosis of cancer (56.4% vs. 48.4%; adjusted P ¼ 0.02). The distributions of the subcategories of noncancer diagnoses were similar for veterans and non-veterans, as shown in Table 2. A higher proportion of veteran hospice users, compared with nonveterans, lived at home while receiving hospice (68.4% vs. 57.6%) and a lower proportion received hospice services in the hospital (5.9%
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vs. 14.8%), differences that remained significant in adjusted analyses (P ¼ 0.007). Table 3 presents data on measures of service utilization. Median LOS did not differ by veteran status (adjusted P ¼ 0.23). Veterans and non-veterans received a similar number of nursing visits per day and social work visits per day (0.46 vs. 0.44 and 0.16 vs. 0.16, respectively; adjusted P > 0.10 for both). However, veterans, compared with non-veterans, received fewer visits per day from home health aides (0.19 [one visit every 5.3 days] vs. 0.27 [one visit every 3.7 days]; adjusted P ¼ 0.002). In sensitivity analyses that categorized those with unknown veteran status as non-veterans, the findings for all of our outcomes were similar in magnitude and were statistically significant, except for the association between veteran status and frequency of home health aide visits (adjusted P ¼ 0.052).
Discussion In this analysis of patterns of hospice care among a nationally representative cohort of male hospice users, we found that, with the exception of age and payment source for hospice, the demographic and clinical profile of veterans and non-veterans was quite similar. However, there were significant differences in patterns of hospice use between veterans and non-veterans. Veterans were more likely than non-veterans to have cancer and receive hospice services at home. Hospice LOS and visit rates from hospice nurses and social workers were similar for veterans and non-veterans, but veterans received significantly fewer visits from hospice home health aides than nonveterans. Veterans also tended to be more likely than non-veterans to disenroll from hospice, but this difference was of borderline statistical significance (P ¼ 0.07). To date, the literature on the characteristics of hospice use by veterans has come from VA data sources and, therefore, reflects the profile of veterans who use the VA for their health care. However, because most are enrolled in community-based hospices, the VA has little information about their experiences. Moreover, most veterans do not receive medical care through the VA, meaning VA data sources are inadequate to describe the profile of all
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2013
Veterans’ and Non-veterans’ Hospice Use
5
Table 1 Characteristics of Hospice-Discharged Patients by Veteran Statusa
Age, years Mean (SE) Age (%) 3 Reason for hospice discharge (%) Death Other
Veteran Hospice Users (n ¼ 483, Weighted n ¼ 90,456)
Non-veteran Hospice Users (n ¼ 932, Weighted n ¼ 197,164)
77.0 (0.9)
74.3 (0.8)
0.4 17.2 15.4 37.9 20.7 8.5
5.3 17.5 17.7 32.5 16.6 10.3
81.7 10.3 3.8 1.4 2.8
82.0 10.0 4.6 2.0 1.3
70.1 27.9 1.9
61.0 36.3 2.4
53.6 37.9 8.4
48.4 44.6 6.9
77.2 0.1 7.9 7.0 5.0 2.9
76.4 5.5 11.3 0.1b 3.5 3.3
85.3 9.1 5.6
87.1 9.4 3.6
P-Value 0.02 0.08
0.72
0.10
0.40
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No.
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2013
Journal of Pain and Symptom Management 1
Original Article
Patterns of Hospice Care Among Military Veterans and Non-veterans Melissa W. Wachterman, MD, MPH, MSc, Stuart R. Lipsitz, ScD, Steven R. Simon, MD, MPH, Karl A. Lorenz, MD, MSHS, and Nancy L. Keating, MD, MPH Section of General Internal Medicine (M.W.W., S.R.S.), VA Boston Healthcare System; Department of Psychosocial Oncology and Palliative Care (M.W.W.), Dana Farber Cancer Institute, Boston, Massachusetts, USA; Division of General Internal Medicine (M.W.W., S.R.L., S.R.S., N.L.K.), Brigham and Women’s Hospital, Boston, Massachusetts; Division of General Internal Medicine and Division of Palliative Care (K.A.L.), VA Greater Los Angeles Healthcare System; Geffen School of Medicine at UCLA (K.A.L.), Los Angeles, California; and Department of Health Care Policy (N.L.K.), Harvard Medical School, Boston, Massachusetts, USA
Abstract Context. Historically, hospice use by veterans has lagged behind that of nonveterans. Little is known about hospice use by veterans at a population level. Objectives. To determine whether veteran and non-veteran hospice users differ by demographics, primary diagnosis, location of care, and service utilization. Methods. Using the 2007 National Home and Hospice Care Survey, we identified 483 veteran and 932 non-veteran male hospice users representing 287,620 hospice enrollees nationally. We used chi-square and t-tests to compare veterans and non-veterans by demographic characteristics, primary diagnosis, and location of hospice care. We used multivariate regression to assess for differences in hospice diagnosis and location of care, adjusting for demographic and clinical factors. We also compared length of stay and number of visits by hospice personnel between veterans and non-veterans using multivariate regression. Results. Veteran hospice users were older than non-veterans (77.0 vs. 74.3 years, P ¼ 0.02) but did not differ by other demographics. In adjusted analyses, cancer was a more common primary diagnosis among veterans than non-veterans (56.4% vs. 48.4%; P ¼ 0.02), and veteran hospice users were more likely than non-veterans to receive hospice at home (68.4% vs. 57.6%; P ¼ 0.007). The median adjusted length of stay and number of nurse or social worker visits did not differ by veteran status (all P > 0.10), but veterans received fewer home health aide visits than nonveterans (one every 5.3 days vs. one every 3.7 days; P ¼ 0.002). Conclusion. Although veteran and non-veteran hospice users were similar on most demographic measures, important differences in hospice referral patterns and utilization exist. J Pain Symptom Manage 2013;-:-e-. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Address correspondence to: Melissa W. Wachterman, MD, MPH, MSc, VA Boston Health Care System, 150 South Huntington Avenue, Building 9 Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
(152G), Boston, MA 02130, USA. E-mail: melissa. [email protected] Accepted for publication: August 16, 2013. 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.08.013
2
Wachterman et al.
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No.
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2013
Key Words Hospice, veterans, clinical case mix, demographics, health care utilization, nationally representative data
Introduction The number of seriously ill patients who use hospice services at the end of life in the U.S. has increased dramatically over the past decade. Approximately 1.58 million people used hospice in 2010 (41.9% of all deaths), an increase from 1.06 million in 2004.1 Hospice enrollment is primarily concentrated among Medicare beneficiaries, with 83.8% of hospice care financed under the Medicare Hospice Benefit in 2010.1 When the hospice movement began in the U.S. in the 1970s, hospice served primarily patients with cancer who were living at home. However, these patterns have shifted in recent decades, such that in 2010, only 35.6% of hospice patients had a primary diagnosis of cancer and only 41.1% received care at home, with the rest in residential facilities such as nursing homes, hospitals, or hospice residences.1 Currently, about 642,000 U.S. military veterans die each year, accounting for one of four deaths in the U.S.2,3 Hospice use by veterans has historically lagged behind use in the overall U.S. population. In 2000, 21.6% of all Medicare decedents, compared with only 5% of all veterans in all settings, received hospice care.4,5 Responding to this disparity, the Veterans Health Administration (VA) began several initiatives during the past decade to expand veterans’ access to end-of-life care services, including hospice. In 2002e2003, the VA created a Hospice and Palliative Care program office, and in less than three years, the number of veterans receiving home hospice care financed by the VA tripled.4 In 2009, the VA designed the Comprehensive End of Life Care initiative, which funded a palliative care interdisciplinary team at every VA medical center and established partnerships with community hospices in every state in the country.2 Subsequently, growth in the use of hospice care among veterans in the VA has continued, with a recent study documenting more than a three-fold increase from 2006 to 2009.6
Importantly, with the exception of the statistic that 5% of all veterans used hospice in 2000, information about rates of hospice use comes from VA data and, therefore, reflects trends in hospice use of only veterans who use the VA for their health care.4e7 Overall, only about 13% of veterans report that they currently obtain medical care from the VA,8 and 28% report that they ever have.9 Thus, because most veterans do not receive care from the VA, little is known about the majority of veteran hospice users. It is unknown, for example, whether hospice use among veterans over time reflects a shift away from hospice’s traditional focus on treating patients with cancer living at home, similar to that for the population as a whole. Furthermore, VA patients who enroll in hospice, other than the relatively few who use inpatient hospice, are referred by the VA to community-based hospices, and thus, VA data sources do not include information about their care. Our objective was to use nationally representative data to compare veteran and nonveteran hospice users to determine whether demographics, primary diagnosis, location of care, and service utilization differed for these two populations.
Methods We used the 2007 National Home and Hospice Care Survey (NHHCS),10 conducted by the National Center for Health Statistics, to examine a nationally representative sample of patients discharged from hospice, predominantly because of death (84%). Data for the 2007 NHHCS, the most recently conducted version of the survey, were collected through face-to-face interviews with hospice or home health agency directors and their appointed staff, in consultation with patients’ medical records. Our primary variable of interest was U.S. military veteran status. Because more than 95% of veterans in the NHHCS were men, we limited our study population to the 1415
Vol.
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No.
- -
2013
Veterans’ and Non-veterans’ Hospice Use
male patients discharged from hospice for whom veteran status was known (483 veterans and 932 non-veterans), representing 287,620 hospice enrollees nationally. Veteran status was unknown for 702 male patients; these patients were excluded from our sample for our primary analyses but were included (and classified as non-veterans) in sensitivity analyses.
3
Measures of Service Utilization Our primary measures for service utilization were hospice length of stay (LOS) and the number of visits per day from each major type of hospice provider (total number of visits divided by LOS), including nurses, social workers, and home health aides. We measured hospice LOS from the date of hospice enrollment until hospice discharge.
Characteristics of Hospice Users We categorized individuals’ primary hospice admission diagnosis as either ‘‘cancer’’ or ‘‘noncancer’’ based on whether they had a cancerrelated International Classification of Diseases, Ninth Edition (ICD-9) code (140-239). We then further subdivided patients with noncancer diagnoses into the following categories based on ICD-9 codes: ‘‘dementia,’’ ‘‘debility or adult failure to thrive,’’ ‘‘congestive heart failure,’’ ‘‘chronic pulmonary disease,’’ ‘‘cerebrovascular disease,’’ or ‘‘other’’ (specific codes available on request). We classified where the patients were residing when they began hospice as ‘‘home,’’ ‘‘nursing home,’’ ‘‘hospital,’’ ‘‘hospice residence,’’ or ‘‘other.’’ We categorized patients’ primary caregiver as ‘‘spouse/significant other’’ or ‘‘nonspouse,’’ which included child, parent, other family member, or nonfamily member. All secondary diagnoses in the survey data were used to measure comorbid disease, using the Charlson comorbidity index (CCI) score.11 We also characterized the number of activities of daily living (ADLs; eating, bathing, dressing, toileting, and transferring) with which the patient needed help (categorized as 0, 1e3, 4, and all 5) and mobility impairment (no assistance needed, needs assistance, and not mobile). Finally, we characterized reason for hospice discharge (death vs. other). The following demographic characteristics were categorized: age in years at hospice discharge (0.5% of data were missing (i.e., ‘‘don’t know,’’ ‘‘not ascertained,’’ or
4
Wachterman et al.
‘‘refused’’), missing data were considered as a separate category.
Results The 483 veteran and 932 non-veteran male hospice users represented 287,620 hospice enrollees nationally in 2007. Table 1 shows demographic and clinical characteristics by veteran status. Most veteran and non-veteran hospice users were non-Hispanic whites (81.7% and 82.0%; P ¼ 0.72), married (70.1% vs. 61.0%; P ¼ 0.10), and lived in metropolitan areas (85.3% and 87.1%; P ¼ 0.22). Their CCI scores and the degree of ADL impairment were similar (P ¼ 0.57 and P ¼ 0.78, respectively). Almost half of veterans and nonveterans were dependent for all five ADLs (45.2% vs. 48.1%), yet approximately half of each group had CCI scores of 0 (46.4% vs. 51.7%). Veterans were, on average, significantly older than non-veterans (mean age 77.0 vs. 74.3 years; P ¼ 0.02), yet tended to be less likely to need assistance with walking (66.1% vs. 74.8%; P ¼ 0.06). Primary payment source was significantly different between the two groups (P < 0.001). Medicare was the most common payer for both veterans and non-veterans (77.2% vs. 76.4%), but not surprisingly, veterans were more likely than non-veterans to have the Department of Veterans Affairs as the primary payer (7.0% vs. 0.1%; latter likely the result of reporting error). Veterans were less likely to have Medicaid (0.1% vs. 5.5%) or private insurance (7.9% vs. 11.3%) as the primary payer. Veterans were less likely than non-veterans to stay in hospice until they died (80.2% vs. 86.1%), a difference of borderline statistical significance (P ¼ 0.07). As shown in Table 2, both diagnosis and location of care varied by veteran status. A higher proportion of veteran hospice users, compared with non-veterans, had a primary hospice diagnosis of cancer (56.4% vs. 48.4%; adjusted P ¼ 0.02). The distributions of the subcategories of noncancer diagnoses were similar for veterans and non-veterans, as shown in Table 2. A higher proportion of veteran hospice users, compared with nonveterans, lived at home while receiving hospice (68.4% vs. 57.6%) and a lower proportion received hospice services in the hospital (5.9%
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2013
vs. 14.8%), differences that remained significant in adjusted analyses (P ¼ 0.007). Table 3 presents data on measures of service utilization. Median LOS did not differ by veteran status (adjusted P ¼ 0.23). Veterans and non-veterans received a similar number of nursing visits per day and social work visits per day (0.46 vs. 0.44 and 0.16 vs. 0.16, respectively; adjusted P > 0.10 for both). However, veterans, compared with non-veterans, received fewer visits per day from home health aides (0.19 [one visit every 5.3 days] vs. 0.27 [one visit every 3.7 days]; adjusted P ¼ 0.002). In sensitivity analyses that categorized those with unknown veteran status as non-veterans, the findings for all of our outcomes were similar in magnitude and were statistically significant, except for the association between veteran status and frequency of home health aide visits (adjusted P ¼ 0.052).
Discussion In this analysis of patterns of hospice care among a nationally representative cohort of male hospice users, we found that, with the exception of age and payment source for hospice, the demographic and clinical profile of veterans and non-veterans was quite similar. However, there were significant differences in patterns of hospice use between veterans and non-veterans. Veterans were more likely than non-veterans to have cancer and receive hospice services at home. Hospice LOS and visit rates from hospice nurses and social workers were similar for veterans and non-veterans, but veterans received significantly fewer visits from hospice home health aides than nonveterans. Veterans also tended to be more likely than non-veterans to disenroll from hospice, but this difference was of borderline statistical significance (P ¼ 0.07). To date, the literature on the characteristics of hospice use by veterans has come from VA data sources and, therefore, reflects the profile of veterans who use the VA for their health care. However, because most are enrolled in community-based hospices, the VA has little information about their experiences. Moreover, most veterans do not receive medical care through the VA, meaning VA data sources are inadequate to describe the profile of all
Vol.
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No.
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2013
Veterans’ and Non-veterans’ Hospice Use
5
Table 1 Characteristics of Hospice-Discharged Patients by Veteran Statusa
Age, years Mean (SE) Age (%) 3 Reason for hospice discharge (%) Death Other
Veteran Hospice Users (n ¼ 483, Weighted n ¼ 90,456)
Non-veteran Hospice Users (n ¼ 932, Weighted n ¼ 197,164)
77.0 (0.9)
74.3 (0.8)
0.4 17.2 15.4 37.9 20.7 8.5
5.3 17.5 17.7 32.5 16.6 10.3
81.7 10.3 3.8 1.4 2.8
82.0 10.0 4.6 2.0 1.3
70.1 27.9 1.9
61.0 36.3 2.4
53.6 37.9 8.4
48.4 44.6 6.9
77.2 0.1 7.9 7.0 5.0 2.9
76.4 5.5 11.3 0.1b 3.5 3.3
85.3 9.1 5.6
87.1 9.4 3.6
P-Value 0.02 0.08
0.72
0.10
0.40
