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© 2003 American Society for Clinical Oncology Barriers to Hospice Care Among Older Patients Dying With Lung and Colorectal Cancer
From the Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, MA. Address reprint requests to Ellen P. McCarthy, Ph.D., Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rose-139, Boston, MA 02215; email: Ellen_Mccarthy{at}caregroup.harvard.edu.
Purpose: To identify factors associated with hospice enrollment and length of stay in hospice among patients dying with lung or colorectal cancer. Methods: We used the Linked Medicare-Tumor Registry Database to conduct a retrospective analysis of the last year of life among Medicare beneficiaries diagnosed with lung or colorectal cancer at age  66 years between January 1, 1973, and December 31, 1996, in the Surveillance, Epidemiology, and End Results Program who died between January 1, 1988, and December 31, 1998. Our outcomes of interest were time from cancer diagnosis to hospice enrollment and length of stay in hospice care. We used Cox proportional hazards regression to adjust for demographic and clinical information. Results: We studied elderly patients dying with lung cancer (n = 62,117) or colorectal cancer (n = 57,260). Overall, 27% of patients (n = 16,750) with lung cancer and 20% of patients (n = 11,332) with colorectal cancer received hospice care before death. Median length of stay for hospice patients with lung and colorectal cancer was 25 and 28 days, respectively. Overall, 20% of patients entered hospice within 1 week of death, whereas 6% entered more than 6 months before death. Factors associated with later hospice enrollment include being male; being of nonwhite, nonblack race; having fee-for-service insurance; and residing in a rural community. Many of these factors also were associated with shorter stays in hospice. Conclusion: Although use of hospice care has increased dramatically over time, specific patient groups, including men, patients residing in rural communities, and patients with fee-for-service insurance continue to experience delays in hospice enrollment.
CANCERS OF the lung and colon are leading causes of cancer morbidity and mortality among men and women in the United States. In 2002, an estimated 169,400 people will be diagnosed with lung cancer, and 154,900 will die from lung cancer. Another 148,300 people will be diagnosed with colorectal cancer, and 56,600 will die from the disease.1 Persons age 65 years and older account for more than two thirds of patients with these cancers, and nearly half are diagnosed with incurable metastatic disease.2 Therefore, most of the diagnosis, treatment, and end-of-life care for these patients is financed by the Medicare program.3 Death from cancer typically follows a course of progressive debility and rapid decline.4,5 Yet, little is known about the experience of patients dying with cancer. In recent years, a number of personal stories from physicians and patients’ family members have emerged in the clinical literature.6–8 These stories share common themes of patients who fear the process of dying more than death itself. Most often, patients fear losing control over how and when their death will occur, and that their preferences will not be respected. They fear a prolonged death causing substantial financial hardships on family members. Unfortunately, these fears were realized by patients dying with lung and colorectal cancer in a recent report from the Study to Understand Patient Prognoses and Preferences for Outcomes and Risks of Treatment.4 Severe pain and confusion were symptoms common in the last months of life despite preferences for comfort care. Patients’ families incurred substantial financial burdens to care for their loved ones, such as having to quit work, and losing their major source of income and their savings.4 Hospice provides an alternative, and perhaps an optimal, approach to caring for terminally ill patients.9–12 Under the hospice model of care, dying is affirmed as a natural part of life, and the emphasis shifts from curative and life-prolonging treatments to palliative care. Ideally, hospice patients die comfortably, often at home, and surrounded by loved ones. Family members are prepared for the patient’s death and assisted through the bereavement process.13 The Medicare Hospice Benefit was established in 1982.10,13 Since then, the number of hospices in the United States has increased from 500 to more than 3,000,13,14 and the number of patients receiving hospice care has increased from 25,000 to 700,000.14 Although Medicare spends an estimated $2 billion on hospice care annually, rates of hospice use remain low.14 Moreover, dying patients are often referred to hospice too late to benefit optimally from palliative care.11,12,15 Barriers to early hospice care are poorly understood. Therefore, we conducted a study to identify factors associated with time to hospice enrollment and length of stay in hospice for patients dying with cancers of the lung and colon.
Data Source We conducted a retrospective analysis of the last year of life using the Linked Medicare-Tumor Registry Database.16 The linked database contains cancer information on patients 65 years of age and older from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program and Medicare enrollment and utilization information from the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration). Medicare files are available for the years 1986 to 1998 for patients diagnosed with cancer between 1973 and 1996. Specific information describing the linkage between SEER and Medicare has been published elsewhere.16 Overall, the match rate for Medicare beneficiaries older than age 65 years is 93%. We used the Medicare denominator file and hospice file. The denominator file is generated annually and contains specific demographic and enrollment information, including date of death, for every Medicare beneficiary. The hospice file contains claims for every beneficiary who received hospice services under the Medicare Hospice Benefit, including services provided to beneficiaries enrolled in managed care.
Study Sample
Measures Stage at diagnosis is collected using two classification systems. The historic staging system, collected by SEER since its inception, classifies tumors as local, regional, distant, or unstaged. In 1988, SEER began to use a more specific staging system adopted by the American Joint Committee on Cancer (AJCC). Although SEER attempted to reclassify stage for patients diagnosed before 1988, only 8% of 7,146 patients with lung cancer and 51% of 22,254 patients with colorectal cancer had sufficient documentation to make an AJCC determination. Therefore, we performed our analyses using the historic staging system so that our findings would not be biased by excluding long-term survivors of cancer. We repeated our analyses using the AJCC system and found similar results. We present our analyses using the historic staging system because it was available for all patients. Our first outcome of interest, time to hospice enrollment, was measured from patients’ date of diagnosis. Patients who died without receiving hospice care (n = 45,367 lung cancer patients and n = 45,928 colorectal cancer patients) were treated as censored observations. Our second outcome of interest, length of stay in hospice, was measured from date of hospice enrollment until discharge or death, whichever came first. This analysis included the 16,750 patients with lung cancer and 11,332 with colorectal cancer who received hospice care during the last 6 months of life. We excluded patients (118 with lung cancer and 82 with colorectal cancer) who had a discrepancy between their date of death and date of last hospice service. Our final sample consisted of 16,632 hospice patients with lung cancer and 11,250 hospice patients with colorectal cancer. Patients who left hospice (n = 2,116 with lung cancer and 1,359 with colorectal cancer) before they died were treated as censored observations.
Statistical Analysis For hospice patients, we computed Kaplan-Meier estimates of median length of stay across the factors of interest. To better understand the distribution of length of stay, we determined the proportion of patients who enrolled in hospice care within 1 week of death, more than 1 week to 1 month, more than 1 month to 6 months, and more than 6 months before death. We fit multivariable Cox proportional hazards models for each outcome. Models were stratified by SEER area to account for any lack of proportionality among the tumor registries by allowing the underlying hazard to vary. We adjusted for factors identified in the literature12,15 to be associated with hospice use and factors associated with the outcome on bivariable analyses with P < .15. Factors common to both models were sex, race, and marital status at diagnosis, health insurance type, residence in urban or rural area, and median household income of zip code of residence. The time to hospice enrollment model also included age and year of diagnosis. The length of stay in hospice model also included age at hospice entry, year of hospice entry, and illness duration (measured as time from diagnosis until hospice entry). We estimated adjusted hazard ratios (aHR) and corresponding 95% confidence intervals (CI) from the beta coefficient and SE of the Cox model.18 aHRs less than 1.0 signify longer time to hospice enrollment and aHRs greater than 1.0 indicate shorter hospice stays.
Table 1  presents the demographic and clinical characteristics of patients with lung (n = 62,117) and colorectal (n = 57,260) cancers and the percentage who used hospice care by these characteristics. Mean age at diagnosis was 74 years for patients with lung cancer and 77 years for patients with colorectal cancer. Although the majority of patients with lung cancer were male, more than one half of patients with colorectal cancer were female. Most patients with lung or colorectal cancer were white, lived in urban communities, and had fee-for-service insurance. Almost two thirds of patients with lung cancer and one quarter of patients with colorectal cancer died within 1 year of their cancer diagnosis.
Overall, 27% of patients (n = 16,750) with lung cancer and 20% of patients (n = 11,332) with colorectal cancer received hospice care before death (Table 1  ). Many factors associated with hospice use were similar for both primary cancer sites. Hospice use has increased over time; for both cancer diagnoses only 15% of patients diagnosed between 1986 and 1989 used hospice services, whereas 41% of patients with lung cancer and 36% of patients with colorectal cancer diagnosed between 1994 and 1996 used hospice services. Patients who were married, resided in communities that were urban, or had higher median household incomes, and those diagnosed with distant metastases were more likely to use hospice. Patients with managed care insurance were substantially more likely to receive hospice care than were patients with fee-for-service insurance. Hospice use varied widely across the tumor registries; hospice use was lowest in Utah and highest in New Mexico. Of patients who died within 6 months of diagnosis, 22% of patients with lung cancer and 15% with colorectal cancer received hospice care.
There were a few notable differences across the primary cancer sites (Table 1
Table 2
Table 3 illustrates the bivariable distribution of length of stay in hospice by patient characteristics. Median length of stay in hospice for patients with lung and colorectal cancer was 25 and 28 days, respectively. Factors associated with shorter hospice stays were consistent across primary cancer sites. These factors were being male, being of white race, being married, having fee-for-service insurance, residing in communities that are urban or have high median household incomes, and having distant metastases at diagnosis. There was considerable variation in length of stay by geographic region; areas with the shortest hospice stays were Detroit and Connecticut, whereas areas with the longest stays were Iowa and San Francisco-Oakland.
As one potential indicator of poor quality of care, we examined hospice enrollment within 7 days of death. We found that 20% of patients with lung cancer and 21% of patients with colorectal cancer entered hospice within only 1 week of death. As one potential indicator of inappropriate hospice use, we examined hospice enrollment more than 180 days before death. Overall, 7% of patients with lung cancer and 6% of patients with colorectal cancer entered hospice more than 6 months before they died.
Table 4
Access to hospice services has improved over time. Rates of hospice use among Medicare beneficiaries dying with cancer remain low despite increased access and comprehensive coverage of services by the Medicare Hospice Benefit. One fifth of patients enrolled in hospice only a week before death, and 50% enrolled within a month of death. Patients dying with lung and colorectal cancers had several potential barriers to hospice services in common. Factors associated with later hospice enrollment included being male, being of a race other than white or black, having fee-for-service insurance, and residing in rural communities. Similarly, patient-related factors associated with shorter hospice stays included being male, of white race, being married at diagnosis, having fee-for-service insurance, residing in urban communities or in communities with high median household incomes, and having distant metastases at diagnosis. Our findings are consistent with studies of variation in end-of-life decision making by sex and race.19–22 We found that men were less likely to use hospice services, as were black patients with lung cancer. Other studies have found that patients who were male or black were more likely to undergo aggressive care, to prefer life-sustaining treatment, to want cardiopulmonary resuscitation, and to die in a hospital.21–28 Male sex and black race are also associated with attitudes less accepting of hospice, including wanting to be kept alive on life support under numerous scenarios.22,23 Black patients are less likely to have written do-not-resuscitate orders than are white patients.20 It is not entirely clear why black race was associated with decreased hospice use only among patients dying with lung cancer. Perhaps consistent with preferences for more aggressive care, patients with lung cancer often suffer from complications that may be controlled more effectively with hospital-based treatments. For example, pleural effusions in lung cancer patients cause shortness of breath that can be relieved by thoracentesis. Similarly, patients with lung cancer may be more likely to develop pneumonia that may be amenable to treatment with antibiotics and oxygen administered during hospitalization. We found that having Medicare fee-for-service insurance was an important barrier to hospice care. Patients with fee-for-service insurance were substantially less likely to use hospice and had considerably shorter hospice stays than were patients with managed care insurance. Our findings are consistent with those first described by Virnig et al.15,29,30 Different financial incentive structures between managed care and fee-for-service systems are one potential explanation for higher hospice rates among managed care beneficiaries.30 Once a beneficiary enrolls in hospice, the Medicare program assumes the costs of care, thus relieving managed care organizations of their responsibility for expensive end-of-life care. Because managed care organizations are more successful at getting patients into hospice care, it is possible that they have better systems in place to facilitate the transfer of a dying patient to hospice. We found significant geographic variability in hospice use and length of stay across the SEER registries. Patients residing in rural communities were at a distinct disadvantage to receipt of hospice services; however, once in hospice, residents of urban communities had shorter lengths of stay. Several factors are associated with geographic variations in hospice use, including hospice availability, number of inpatient beds, and managed care penetration.31–34 Of these factors, we could only examine the effect of managed care penetration. Tumor registries located in Hawaii, Northern California, and Seattle had the greatest Medicare managed care penetration and greater hospice use than registries in other regions. Hospice use increased dramatically during our study years. From 1988 to 1998, the annual number of hospice admissions increased from 151,000 to 540,000.35 Despite the substantial increase in hospice admissions, only 27% of patients dying with lung cancer and 20% with colorectal cancer used hospice care before death. Moreover, many patients entered too close to death to experience the full benefit of hospice care. Short hospice stays potentially limit the ability to implement a comprehensive patient-driven care plan and may also impede effective pain and symptom control.12 Adequate symptom management in dying patients may promote better quality of life and patient satisfaction.36,37 Our findings are consistent with previous studies demonstrating median hospice stays ranging from 19 days to 36 days.11,12,15,38,39 We found that although use of hospice increased from 1988 to 1998, length of stay remained relatively unchanged and may have even decreased between 1996 and 1998. This finding must be interpreted with caution because it could reflect an anomaly of the data. Because we only included patients diagnosed through 1996, there may be differences in the mix of patients who enrolled in hospice before 1996 and those who enrolled between 1996 and 1998. It is likely that the latter group excludes some patients with rapidly progressing disease. The United States General Accounting Office recently reported a decline in hospice length of stay during the same time period.39 One plausible explanation for decreased stays in hospice offered was that, in 1995, the Office of the Inspector General initiated an investigation into Medicare fraud and abuse. Hospice was one aspect of the Medicare program to come under scrutiny.39 Although the federal investigation ultimately found that only 7% of Medicare beneficiaries in hospice were ineligible, the trend toward shorter hospice stays persisted in 1998. An unfortunate consequence of the investigation was that the trend toward shorter stays was especially pronounced among noncancer patients, a group distinctly disadvantaged because they have the most uncertain prognoses.40–42 The Medicare eligibility criteria for hospice are commonly cited as a potential explanation for late enrollment among dying patients.11,12 One criterion, in particular, requires physicians to certify that a patient is terminally ill with a life expectancy of 6 months or less.43 Physicians are often reluctant to deem a patient terminal.44–46 Some physicians feel inadequately trained to make prognoses and to deliver bad news.46,47 Others believe they are giving up on the patient or that the patient will lose hope. More importantly, physicians commonly overestimate prognosis and often fail to recognize when death is imminent.48–54 To address this issue, Congress modified this rule in 1997 to permit physicians to recertify patients who do not die within the initial 6-month period.43 Although dying patients are eligible for an unlimited number of 60-day extensions if the physician continues to certify that the patient is terminal, there has been no effect on hospice length of stay. It is unlikely that uncertainty in physician prognoses’ fully explains the late hospice enrollment and short hospice stays observed in our study. To explore this possibility, we repeated our analyses on patients diagnosed with stage IV disease and found similar results (data available on request). Our study has several limitations. First, perhaps most importantly, we lacked information about patients’ preferences for care. Second, we lacked detailed clinical information about patients, including comorbid illnesses and functional impairments that may influence hospice use. Third, we lacked information about patients’ physicians, including their specialty, their experience caring for dying patients, or their practice patterns. Fourth, we lacked factors related to the healthcare system, including local availability of hospices. Finally, we studied only patients with lung and colorectal cancer. It is unclear whether our findings are generalizable to patients with diagnoses other than cancer. This is the first population-based comparative study to identify barriers to early hospice care and longer hospice stays among patients dying with lung and colorectal cancer in nine geographically diverse regions over an 11-year period. We also had the information necessary to explore the relationship between cancer stage at diagnosis and duration of cancer illness and receipt of hospice care. Finally, we examined the last 6 months of life among patients who died, focusing on a group for whom hospice is appropriate. Decisions to enter hospice care are complex. Over the last 20 years, the Medicare Hospice Benefit contributed to increased access to hospice care among older patients. Nevertheless, specific patient groups, including men, patients residing in rural communities, and patients with fee-for-service insurance, continue to experience barriers to earlier hospice care. Further research is required to determine whether these barriers affect patients with other diagnoses, and to establish how these barriers reduce access to hospice care. To what extent does reduced access reflect patient preferences, availability of services, or financial incentives? Increased efforts are needed to promote access to hospice, especially among patients at risk of experiencing barriers to such care.
This study used the Linked Medicare-Tumor Registry Database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of several groups responsible for the creation and dissemination of the Linked Database, including the Applied Research Branch, Division of Cancer Prevention and Population Science, National Cancer Institute; the Office of Information Services and the Office of Strategic Planning, Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration); Information Management Services, Inc.; and the SEER Program Tumor Registries.
Ellen P. McCarthy is the recipient of a First Independent Research Support & Transition (FIRST) Award No. 5-R29CA-79052 funded by the National Cancer Institute. Presented in part at the National Meeting of the Society of General Internal Medicine, San Diego, California, May 2001.
1. American Cancer Society: Cancer Facts and Figures 2002. Atlanta, Georgia, 2002 2. Ries LAG, Eisner MP, Kosary CL, et al: SEER Cancer Statistics Review, 1973–1999. Bethesda, MD, National Cancer Institute, 2002. Http://seer.cancer.gov/csr/1973_1999. Accessed May 15, 2002
3. Lubitz JD, Riley GF: Trends in Medicare payments in the last year of life. N Engl J Med 328:1092–1096, 1993 4. McCarthy EP, Phillips RS, Zhong Z, et al: Dying with cancer: Patients’ function, symptoms, and care preferences as death approaches. J Am Geriatr Soc 48:S110–S121, 2000 (suppl)[Medline] 5. Teno JM, Weitzen S, Fennell ML, et al: Dying trajectory in the last year of life: Does cancer trajectory fit other diseases? J Palliat Med 4:457–464, 2001[CrossRef][Medline] 6. Anonymous: It’s over Debbie. JAMA 259:272, 1988[CrossRef][Medline] 7. Quill TE: Death and dignity: A case of individualized decision making. N Engl J Med 324:691–694, 1991[Medline] 8. Angell M: The Supreme Court and physician-assisted suicide: The ultimate right. N Engl J Med 1:50–53, 1997 9. Bulkin W, Lukashok H: Rx for dying: The case of hospice. N Engl J Med 318:376–378, 1988[Medline] 10. Kidder D: The effects of hospice coverage on Medicare expenditures. Health Serv Res 27:195–217, 1992[Medline] 11. Christakis NA: Timing of referral of terminally ill patients to an outpatient hospice. J Gen Intern Med 9:314–320, 1994[Medline]
12. Christakis NA, Escarce JJ: Survival of Medicare patients after enrollment in hospice programs. N Engl J Med 335:172–178, 1996 13. Mahoney JJ: The Medicare Hospice Benefit: 15 years of success. J Palliat Med 1:139–146, 1998[CrossRef][Medline] 14. National Hospice and Palliative Care Organization (NHPCO): Delivering quality care and cost-effectiveness at the end of life. Building on the 20-year success of the Medicare Hospice Benefit, February 2002. Http://www.nhpco.org. Accessed May 15, 2002 15. Virnig BA, Persily NA, Morgan RO, et al: Do Medicare HMOs and Medicare FFS differ in their use of the Medicare Hospice Benefit? Hospice J 14:1–12, 1999 16. Potosky AL, Riley GF, Lubitz JD, et al: Potential for cancer related health services research using a Linked Medicare-Tumor Registry Database. Med Care 31:732–748, 1993[Medline] 17. SAS Institute: SAS/STAT User’s Guide, Version 6 (ed 4), Volumes 1 and 2. Cary, NC, SAS Institute, 1992 18. Lee ET: Statistical Methods for Survival Data Analysis (ed 2). New York, NY, Wiley & Sons, 1992 19. Krakauer EL, Crenner C, Fox K: Barriers to optimum end-of-life care for minority patients. J Am Geriatr Soc 50:182–190, 2002[CrossRef][Medline] 20. Shepardson LB, Gordon HS, Ibrahim SA, et al: Racial variation in the use of do-not-resuscitate orders. J Gen Intern Med 14:15–20, 1999[CrossRef][Medline] 21. McKinley ED, Garrett JM, Evans AT, et al: Differences in end-of-life decision making among black and white ambulatory cancer patients. J Gen Intern Med 11:651–656, 1996[Medline] 22. Blackhall LJ, Frank G, Murphy ST, et al: Ethnicity and attitudes toward life sustaining technology. Soc Sci Med 48:1779–1789, 1999[CrossRef][Medline] 23. Neubauer BJ, Hamilton CL: Racial differences in attitudes toward hospice care. Hospice J 6:37–48, 1990 24. Garrett JM, Harris RP, Norburn JK, et al: Life-sustaining treatments during terminal illness: Who wants what? J Gen Intern Med 8:361–368, 1993[Medline] 25. Gramelspacher GP, Zhou XH, Hanna MP, et al: Preferences of physicians and their patients for end-of-life care. J Gen Intern Med 12:346–351, 1997[CrossRef][Medline] 26. Phillips RS, Wenger NS, Teno J, et al: Choices of seriously ill patients about cardiopulmonary resuscitation: Correlates and outcomes. Am J Med 100:128–137, 1996[CrossRef][Medline]
27. Rosenfeld KE, Wenger NS, Phillips RS, et al: Factors associated with change in resuscitation preference of seriously ill patients. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Arch Intern Med 156:1558–1564, 1996
28. Goodlin SJ, Zhong Z, Lynn J, et al: Factors associated with use of cardiopulmonary resuscitation in seriously ill hospitalized adults. JAMA 282:2333–2339, 1999 29. Virnig BA, Morgan RO, Persily NA, et al: Racial and income differences in use of the hospice benefit between Medicare managed care and Medicare fee-for-service. J Palliat Med 2:23–31, 1999[CrossRef][Medline] 30. Virnig BA, Fisher ES, McBean AM, et al: Hospice use in Medicare managed care and fee-for-service systems. Am J Manag Care 7:777–786, 2001[Medline] 31. Virnig BA, Kind S, McBean M, et al: Geographic variation in hospice use prior to death. J Am Geriatr Soc 48:1117–1125, 2000[Medline] 32. Gallo WT, Baker MJ, Bradley EH: Factors associated with home versus institutional death among cancer patients in Connecticut. J Am Geriatr Soc 49:771–777, 2001[CrossRef][Medline] 33. Fried TR, Pollack DM, Drickamer MA, et al: Who dies at home? Determinants of site of death for community-based long-term care patients. J Am Geriatr Soc 47:25–29, 1999[Medline] 34. Pritchard RS, Fisher ES, Teno JM, et al: Influence of patient preferences and local health system characteristics on place of death. J Am Geriatr Soc 46:1242–1250, 1998[Medline] 35. National Hospice and Palliative Care Organization (NHPCO): Facts and Figures on Hospice Care in America, December 2001. Alexandria, VA, National Hospice and Palliative Care Organization, 2001 36. Kane RL, Wales J, Bernstein L, et al: A randomised controlled trial of hospice care. Lancet 1:890–894, 1984[Medline] 37. Greer DS, Mor V, Morris JN, et al: An alternative in terminal care: Results of the National Hospice Study. J Chronic Dis 39:9–26, 1986[CrossRef][Medline] 38. Virnig BA, McBean AM, Kind S, et al: Hospice use before death: Variability across cancer diagnoses. Med Care 40:73–78, 2002[CrossRef][Medline] 39. General Accounting Office. Medicare: More Beneficiaries Use Hospice but for Fewer Days. Washington, DC, U.S. General Accounting Office, September 2000, publication GAO/HEHS-00-182. Http://www.gao.gov. Accessed May 15, 2002 40. Lynn J, Ely EW, Zhong Z, et al: Living and dying with chronic obstructive pulmonary disease. J Am Geriatr Soc 48:S91–S100, 2000 (suppl)[Medline] 41. Levenson JW, McCarthy EP, Lynn J, et al: The last six months of life for patients with congestive heart failure. J Am Geriatr Soc 48:S101–S109, 2000 (suppl)[Medline] 42. Lynn J, Harrell FE, Cohn F, et al: Defining "terminally ill": Insights from SUPPORT. Duquesne Law Rev 35:311–336, 1996[Medline] 43. Health Care Financing Administration: The Medicare Hospice Benefit. Baltimore, MD, Health Care Financing Administration, publication HCFA 02154, March 2000. Http://www.medicare.gov/Publications/Pubs/pdf/02154.pdf. Accessed December 27, 2002
44. Morrison RS, Olson E, Mertz KR, et al: The inaccessibility of advanced directives on transfer from ambulatory to acute care settings. JAMA 274:478–482, 1995
45. Morrison RS, Morrison EW, Glickman DF: Physician reluctance to discuss advanced directives: An empirical investigation of potential barriers. Arch Intern Med 154:2311–2318, 1994
46. Christakis NA, Iwashyna TJ: Attitude and self-reported practice regarding prognostication in a national sample of internists. Arch Intern Med 158:2389–2395, 1998 47. Baile WF, Glober GA, Lenzi R, et al: Discussing disease progression and end-of-life decisions. Oncology 13:1021–1038, 1999[Medline]
48. Lamont EB, Christakis NA: Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med 134:1096–1105, 2001
49. Christakis NA, Lamont EB: Extent and determinants of error in doctors’ prognoses in terminally ill patients: Prospective cohort study. BMJ 320:469–472, 2000 50. Fischer GS, Tulsky JA, Rose MR, et al: Patient knowledge and physician predictions of treatment preferences after discussion of advanced directives. J Gen Intern Med 13:447–454, 1998[CrossRef][Medline] 51. Knaus WA, Harrell FE Jr., Lynn J, et al: The SUPPORT prognostic model: Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med 122:191–203, 1995 52. Christakis NA, Sachs GA: The role of prognosis in clinical decision making. J Gen Intern Med 11:422–425, 1996[Medline] 53. Lynn J, Teno JM, Harrell FE: Accurate prognostication of death: Opportunities and challenges for clinicians. West J Med 163:250–257, 1995[Medline]
54. Forster LE, Lynn J: Predicting life span for applicants to inpatient hospice. Arch Intern Med 148:2540–2543, 1988 Submitted June 24, 2002; accepted October 27, 2002.
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 statistics and Student’s t tests were used to identify factors that were significantly associated with hospice use. 
