New Research: Annals of Internal Medicine

Patients With Obesity Face Disparities in End-of-Life Care

February 09, 2017 03:46 pm Sheri Porter

Physicians know that patients with obesity face special health challenges. Obesity can, among other things, shorten a patient's lifespan, increase the risk of hospitalization and result in more use of hospital intensive care services.  

Authors of a new study(annals.org) published Feb. 6 in the Annals of Internal Medicine point out that obesity also "challenges the ability of health care providers and caregivers to conduct thorough physical assessments, assist with mobility and self-care, recognize frailty and malnutrition, and perform certain indicated procedures."

In an interview with AAFP News, the study's lead author, John Harris, M.D., assistant professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Pittsburgh School of Medicine in Pennsylvania said, "We know about obesity and serious illness, we know about obesity and disability, but there has basically been no research about obesity at the very end of life."

As reported in their article, titled "The Relationship of Obesity to Hospice Use and Expenditures: a Cohort Study," Harris and his research team found an association between obesity -- as measured by body mass index (BMI) -- and decreased hospice enrollment, shorter duration of hospice services, reduced incidence of in-home death and increased Medicare costs in the last six months of life.

Story Highlights
  • New research published in the Annals of Internal Medicine shows an association between obesity and decreased hospice enrollment, duration of hospice services and in-home death.
  • Researchers also found that during the last six months of life, total predicted Medicare expenditures increased as a patient's body mass index increased.
  • Lead author John Harris, M.D., said he understands from personal experience that the decision-making process regarding when to enroll a patient in hospice care can be skewed when patients with obesity exhibit fewer visual signs near the end of life, such as body wasting.

Hospice care is an important piece of end-of-life care, Harris explained.

"The goals of care at the end of life transition to more symptom management and less curative management. The management of symptoms at the end of life is closely related to better care and satisfaction for patients, as well as an increase in satisfaction for caregivers and family members," he said.

Study Methods, Highlights

Researchers analyzed 14 years of survey results and Medicare claims data pulled from the National Institute on Aging's Health and Retirement Study(hrsonline.isr.umich.edu) for 5,677 community-dwelling Medicare fee-for-service patients who died between 1998 and 2012.

Of those individuals, 7 percent were classified as underweight (BMI less than 18.5 kg/m2), 44 percent were normal weight (BMI of 18.5 to 24.9 kg/m2), 31 percent were overweight (BMI of 25 to 29.9 kg/m2), 15 percent were obese (BMI of 30 to 39.9 kg/m2) and 2 percent were morbidly obese (BMI of 40 kg/m2 or greater).

Authors found that participants identified as morbidly obese had a predicted probable hospice enrollment of 23.1 percent compared with an enrollment rate of 38.3 percent for patients of normal weight.

Furthermore, noted the authors, among patients enrolled in hospice care, "the predicted total hospice days decreased as BMI increased." In fact, they found that patients with a BMI greater than 40 kg/m2 spent 4.3 fewer days in hospice care than did patients with a BMI of 20 kg/m2.

The predicted probability of in-home death also was significantly lower for patients with a BMI of 40 kg/m2 when compared with that for patients with a BMI of 20 kg/m2 (55 percent versus 61.3 percent).

Lastly, the authors found that during the final six months of life, total predicted Medicare expenditures increased as a patient's BMI increased.

Harris focused on the difference in the quality of care for patients with obesity and called the small differences in cost of care "expected and not surprising."

The study authors noted that previous studies have shown how hospice care improves the quality of patient care and provides benefits to patients' families, "heightening concerns about the effect of underuse of hospice care in this population."

Hospice Enrollment

Authors hypothesized that hospice enrollment is affected by two factors: referral behaviors and varying hospice enrollment policies.

They noted that "prolonged cachexia" -- or body wasting -- experienced by some patients at the end of life can serve as a signal to family members and physicians.

Providers may be less likely to recognize patients who do not experience profound cachexia as appropriate referrals for palliative or hospice services when compared with more cachectic individuals, who may appear less physically robust, wrote the authors.

Harris explained that he has taken a special interest in patients with obesity during his career and has experienced the decision-making process of hospice enrollment first-hand. "Obesity may affect a physician's judgment as to when it's time for a patient to be transferred to symptomatic management. Patients with obesity may have fewer visual symptoms of that terminal phase of dying than a person who looks gaunt and frail," said Harris.

"One person you refer to hospice and the other you may delay hospice enrollment."

He added that hospice care provides important benefits to patients and their families but is limited in scope.

"Hospice provides some extra nursing and custodial help at the end of life, but it still requires a lot from informal caregivers -- that is, family members and close friends," said Harris.

"If the provider thinks that sort of informal care will be inadequate, he might be less likely to transfer the patient to hospice knowing that the care would not be the 24-hour-a-day nursing care the patient would receive in an inpatient setting."

Directing Future Research

Moving forward, the study authors suggested stakeholders look for ways to improve the disparities in hospice use. They suggested policy interventions that could include

  • increased reimbursement for home care services for patients with obesity who require multiple support personnel,
  • reimbursement for patient lifts and other special durable medical equipment in health care facilities, and
  • concurrent palliative care for patients with severe obesity.

"All people -- regardless of body size -- and their families should have equal opportunities to experience the benefits of high-quality end-of-life health care," wrote the authors.

Harris encouraged physicians, caregivers and policymakers to view patients with obesity as "at risk" for disparities in care.

"In this case, it's end-of-life care and hospice care, but I believe patients with obesity are at risk for disparities in a wide range of health care situations, and we should view them as vulnerable," he said.

Related AAFP News Coverage
Graham Center Research
More Primary Care Involvement Improves End-of-Life Care

(1/18/2017)

AAFP, Conversation Project Partner to Aid End-of-Life Care Conversations
(12/5/2016)

More From AAFP
Policy on Hospice Care

American Family Physician Curbside Consultation: The Hospice Referral
(5/1/2014)