Terminally ill Medicare recipients who are obese are less likely than their normal-weight peers to receive hospice care or to be given the chance to die at home, a new study has found.
Not only does that difference impose an emotional cost on the patient and his or her family, it also comes with a hefty price tag. For the study also found that Medicare expenditures during the last six months of life are significantly higher for people who are obese.
“Obesity is a complex disease, and this study has shown another side of its effect on patients and the healthcare system,” said the study’s lead author, Dr. John Harris, in a released statement. “Patients with obesity are less likely to receive high quality end-of-life care.”
The study was published earlier this month in the Annals of Internal Medicine. Harris led the study while a research fellow at the University of Michigan, but he is currently an assistant professor at the University of Pittsburgh School of Medicine.
Risks and biases
An estimated 37 percent of Americans aged 60 and older are obese, according to the Centers for Disease Control and Prevention. As background information in the new study points out, older people who are obese are at increased risk of hospitalization and of requiring intensive care services. They also have a shortened life expectancy.
For doctors and other health-care providers, providing medical services to patients who are obese often involves many special challenges, as the physical size of a patient can complicate even basic medical treatments and procedures, whether it be inserting an IV or determining the most effective dose of medicine.
Research has also shown that healthcare providers have, in general, negative attitudes toward patients with obesity — biases that may influence the care of such patients, including at the end of their lives.
For their study, Harris and his colleagues used 14 years of survey results and Medicare claims for 5,677 Medicare recipients who participated in the Health and Retirement Study, a longitudinal study of health, retirement and aging funded by the National Institute of Aging. All of the patients died between 1998 and 2012, at ages that ranged from 73 to 87 (average age at death: 81 years). None had been living long term in nursing homes before their death.
Of the people in the study, 7 percent were underweight (a body mass index, or BMI, of less than 18.5), 44 percent were normal weight (BMI of 18.5 to 24.9), 31 percent were overweight (BMI of 25 to 29.9), 15 percent were obese (BMI of 30 to 39.9) and 2 percent were severely obese (BMI of 40 or greater).
The researchers looked at how the participants’ BMI compared to the end-of-life care they received, particularly hospice services and whether the individuals died at home. (Both are considered positive measures of end-of-life care, and dying at home is one of the goals of hospice care.) They found that the higher someone’s BMI, the less likely they were to receive hospice care. Or, if they did receive such care, it was more likely to be delayed.
Specifically, the analysis revealed that 38 percent of all the study’s participants received hospice care. But people who were severely obese had only a 23 percent chance of receiving such care, compared with a 38 percent chance for someone with a “normal” weight BMI of 20.
And when obese patients did receive hospice care, they were likely to have it for fewer days. People in the study who were obese spent an average of 3.8 fewer days — and individuals who were severely obese spent an average of 4.3 fewer days — in hospice than those with lower BMIs.
The study also found an association between BMI and the likelihood of dying at home. Overall, 59.6 percent of the study’s participants died in their homes. Among people with normal body weight, that percentage climbed to 61.3, while it fell to 55.0 for those who were morbidly obese.
The researchers also examined the association between BMI and Medicare expenses during the last six months of life. They found that expenses were, on average, higher for people who were obese. For example, among people with a BMI of 20, the Medicare system spent about $43,000 for all types of care during the final six months of life. But for a person with a BMI of 30, the costs for that same period were about $3,500 higher.
Why are people who are obese less likely to receive hospice care or die at home than their non-obese peers?
Harris and his colleagues offer several possible explanations: Doctors may not immediately recognize that patients who are obese have “profound cachexia,” the weakening and wasting of the body that accompanies an end-of-life illness. Therefore, patients with obesity may be identified as candidates for hospice care later in their illness than less heavy patients. It may also be that people who are obese experience a more rapid decline in health and, thus, may die more suddenly — before they can be referred to hospice care.
Differences in hospice enrollment policies for obese and non-obese patients may also be at play. In-home hospice care for people who are obese tends to be more costly (such patients may need a mechanical lift, for example), a factor that may limit referrals.
This study comes with several caveats. Most notably, it included only fee-for-service Medicare patients. The study’s results might be different for people with managed care Medicare plans, Harris and his colleagues point out.
Still, the study’s findings raise some troubling questions regarding how our current medical system treats patients with obesity.
“Many policies focus on preventing or reducing obesity in the U.S., but we will also need policies to encourage the provision of high-quality care for people with obesity,” said Harris in the released statement. “More attention should be paid to payment structures that recognize the challenges involved with healthcare for men and women with obesity.”
FMI: You’ll find an abstract of the study on the Annals for Internal Medicine’s website, but, unfortunately, the full study is behind a paywall.