The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study

Background: Obesity, defined as BMI > 30, has a prevalence of 37% among adults aged 60 and over.¹  Medical costs for adults with obesity in 2019 were $1861 higher than those of normal weight adults.²  Despite obesity being a risk factor for heart disease, stroke, diabetes type 2, and some cancers², obese patients receive inequitable care compared to normal weight individuals, including for immunizations, cancer screening, and intensive care.^3,4  The use of hospice services by obese adults has not been well studied but is hypothesized to be lower than that of normal weight adults due to similar barriers to care.

Design and Participants:  Review of the 5677 community-dwelling Health and Retirement Study participants who died between 1998 and 2012.  Participants’ survey results and Medicare fee-for-service claims were evaluated.  (The Health and Retirement Study surveys a representative sample of more than 20,000 U.S. adults > 50 years every 2 years about health and financial matters.  The longitudinal study is supported by the National Institute on Aging and the Social Security Administration.)

Results:  Of the 5677 decedents, 981 (17%) were obese or morbidly obese; median age at death was 81 years.  Overall hospice enrollment was 34.7% but declined with a higher BMI.  Enrollment in hospice was just 23% for those with BMI > 40 and hospice duration was 4.3 days fewer than those with BMI = 20.  Obese patients were less likely to die at home than non-obese and had higher overall Medicare expenditures in the last 6 months of life (~$3500 higher).

Commentary: Obese adults have decreased hospice enrollment, fewer days in hospice, less chance of in-home death, and higher healthcare costs in the last 6 months of life as compared to nonobese.  Similar to other health inequities experienced by the obese, end-of-life care may be of lesser quality for these individuals, perhaps related to diminished referral to hospice, different trajectories of dying, or more restrictive hospice enrollment policies which may not cover the added nursing assistance or durable equipment (e.g., Hoyer lifts) that these patients require.

Bottom Line: Obese patients utilize hospice less frequently than their normal weight counterparts and consume more Medicare dollars at end-of-life.  These patients require special focus from palliative care providers to determine their needs and potential to benefit from an at-home death.  Enhanced end-of-life care via hospice for these patients will likely require policy change to facilitate the additional needs of this patient population in the home or to provide specialized equipment for an inpatient hospice-home death.

References:

1. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. 2015.
2. Adult obesity facts. Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/data/adult.html.  Published May 17, 2022. Accessed October 22, 2022.
3. Harris JA, Byhoff E, Perumalswami CR, Langa KM, Wright AA, Griggs JJ. The relationship of obesity to hospice use and expenditures. Annals of Internal Medicine. 2017;166(6):381. doi:10.7326/m16-0749
4. Graham Y, Hayes C, Cox J, Mahawar K, Fox A, Yemm H. A systematic review of obesity as a barrier to accessing cancer screening services. Obesity Science & Practice. 2022. doi:10.1002/osp4.606

Source: Harris JA, Byhoff E, Perumalswami CR, Langa KM, Wright AA, Griggs JJ. The relationship of obesity to hospice use and expenditures. Annals of Internal Medicine. 2017;166(6):381. doi:10.7326/m16-0749