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Abstract 8: Hospice Use Following Implantable Cardioverter-Defibrillation Implantation in Older Patients: Results from the NCDR


 Background:
 ICDs are frequently inserted in older patients, who are at high risk for short-term mortality. Though hospice is the main provider of end-of-life care in the United States, its use in patients following ICD implantation is not known. We aimed to describe the incidence, timing, regional variation, and predictors of hospice use in a nationally-representative sample of older patients following ICD placement.
 
 
 Methods:
 ICD registry data for Medicare fee-for-service patients aged >65 was linked to Medicare Hospice Claims from January 1, 2006 - December 31, 2010 using indirect identifiers. Use of hospice services among decedents in the Health Referral Region (HRR) where the ICD was placed was evaluated using the Dartmouth Health Atlas. Cumulative incidence of hospice admission was calculated and multivariable Cox regression was used to identify factors associated with time-to-hospice enrollment with both analyses accounting for the competing risk of death.
 
 
 Results:
 A total of 194,969 eligible older ICD recipients were identified, whose mean age was 75.5 + 6.4 years, 25.7% were female, and 89.6% were white; 80.0% had CHF, 46.6% had CRT devices, and 79.0% had primary prevention ICDs. During the follow-up period (median 1.92 years, 25%-75% IQR, 1.13 - 2.97,) a total of 52,990 (27.1%) patients died and 22,336 (11.4%) were enrolled in hospice care. Among the subset of patients who died, 36.8% received hospice services. The cumulative incidence of hospice use, accounting for the competing risk of death, was 4.7% (95% CI, 4.6% - 4.8%) within 1 year and 21.3% (95% CI, 20.7% - 21.8%) at 5 years. The median time from ICD implantation to hospice enrollment was 1.3 years (25% - 75% IQR, 209 days - 2.3 years); median length of stay in hospice was only 10 days (25% - 75% IQR, 4 - 36 days). In multivariable analysis, the following factors were most strongly associated with shorter time to hospice enrollment: older age, Class IV HF, LVEF < 20, lung disease, and HRR (Table).
 
 
 Conclusions:
 After accounting for the competing risk of death, the cumulative incidence rate of hospice admission in the 5 years following ICD placement was 21%. This finding indicates a need for a greater understanding of the clinical experience, symptom management, treatment preferences, and end-of-life outcomes for these patients.
 
 
 
