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Hospice Use After ICD in Older Patients
Study Questions:
What is the hospice utilization rate among Medicare patients following implantation of an implantable cardioverter-defibrillator (ICD)?
Methods:
Medicare patients ages >65 years matched to data in the National Cardiovascular Data Registry (NCDR) ICD Registry from 2006 to 2010 were eligible for analysis (n = 194,969). The proportion of ICD recipients enrolled in hospice, cumulative incidence of hospice admission, and factors associated with time to hospice enrollment were analyzed.
Results:
Over 5 years, 52,990 (27%) patients died and 22,336 (12%) were enrolled in hospice. Five years after device implantation, 51% of patients were either deceased or in hospice. Among decedents, 37% received hospice services. The cumulative incidence of hospice enrollment, accounting for the competing risk of death, was 4.7% within 1 year and 21% at 5 years. Factors most strongly associated with shorter time to hospice enrollment were: older age (adjusted hazard ratio [AHR], 1.8), class IV heart failure (vs. class I) (AHR, 1.8), ejection fraction <20% (AHR, 1.6), and greater hospice use among decedents in the patients’ health referral region.
Conclusions:
The authors concluded that over one-third of older patients dying with ICDs receive hospice care, and 5 years after implantation, one-half of the ICD recipients are either dead or in hospice. This highlights the need for hospice providers to be prepared to deal with issues surrounding ICD management.
Perspective:
Prior studies suggest that many patients and their families are unaware of the possibility of deactivating shock therapy, and at least one report suggested that only 10% of hospice facilities in 2010 had an ICD deactivation policy. The high prevalence of hospice care among older ICD recipients demonstrated in this study underscores the need for hospice providers to be prepared for dying patients who have ICDs. Broadly speaking, all providers, including cardiologists, should ensure that discussion regarding ICD therapies takes place when patients transition to hospice care.
Keywords: Arrhythmias, Cardiac, Defibrillators, Defibrillators, Implantable, Geriatrics, Heart Failure, Hospice Care, ICD Registry, Medicare, Outcome Assessment, Health Care, Secondary Prevention, Stroke Volume
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