Background
Obesity complicates medical, surgical, nursing and informal caregiving in severe illness, but the impact of obesity on hospice utilization, location of death, and Medicare expenditures is unknown.
Objective
To describe the associations between body mass index (BMI) and hospice utilization and Medicare expenditures in the last six months of life.
Design
Retrospective cohort.
Setting
The Health and Retirement Study.
Participants
5,677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012.
Measures
Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures measured in the six months before death. Generalized linear models were used to examine the association of increasing BMI and mean predicted outcome in the four measures. BMI was modeled as a continuous variable with a quadratic functional form.
Results
For a decedent with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), the predicted hospice duration was 42.8 days (95% CI, 42.3 to 43.2 days), the predicted probability of in-home death was 61.3% (95% CI, 59.4% to 63.2%), and the predicted total Medicare expenditures was $42 803. As decedent BMI increased from 20 to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (95% CI, −9.3 to −4.0 percentage points), predicted hospice duration decreased by 3.8 days (95% CI, −4.4 to −3.1 days), predicted probability of in-home death decreased by 3.2 percentage points (95% CI, −6.0 to −0.4 percentage points), and predicted total Medicare expenditures increased by $3471 (95% CI, $955 to $5988). For decedents with morbid obesity (BMI ≥40 kg/m2), there were larger effects; the predicted probability of hospice enrollment decreased 15.2 percentage points (95% CI, −19.6 to −10.9 percentage points), hospice duration decreased 4.3 days (95% CI, −5.7 to −2.9 days), and in-home death decreased by 6.3 percentage points (95% CI, −11.2 to −1.5 percentage points) compared to decedents with BMI of 20 kg/m2.
Limitations
Baseline data was self-reported, and the interval of reported height and weight to time of death varied among participants.
Conclusion
Among community-dwelling decedents of the Health and Retirement Study, there was an independent association between obesity and reduced hospice service utilization, and in-home death, and higher Medicare expenditures in the last six months of life.
Primary Funding
Robert Wood Johnson Foundation Clinical Scholars Program