New Study Links Higher BMI to Lower-Quality End-of-Life Care

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A new study authored by a University of Pittsburgh researcher suggests that the heavier someone is, the less likely they are to receive quality end-of-life care, including hospice care and the chance to die at home.

The study was led by John Harris, M.D., M.Sc., who has recently been appointed as an assistant professor of obstetrics, gynecology and reproductive sciences at Pitt’s School of Medicine and Magee-Womens Hospital of UPMC. Dr. Harris conducted the research during his fellowship at the University of Michigan Institute for Healthcare Policy and Innovation (IHPI), and the findings are published today in the Annals of Internal Medicine.

Researchers analyzed records from more than 5,600 senior citizens who took part in the long-running national Health and Retirement Study (HRS), examining how their body mass index (BMI) related to end-of-life measures, such as their use of hospice services. Results indicated that people with higher BMIs were less likely to enter hospice care, and among those who did, seniors with obesity spent fewer days in hospice than those with lower BMIs.

The study also found that about 60 percent of the seniors in the study died at home—an experience that most Americans say they would choose for their own deaths. But that percentage dropped as BMI rose.

In all, Harris says, the findings point to a larger issue that will become more urgent as the increasingly overweight American population ages. “Obesity is a complex disease, and this study has shown another side of its effect on patients and the health care system. Patients with obesity may need extra help, but they deserve the best health care and better health outcomes.”

The researchers focused on Medicare claims in the last six months of the participants’ lives, looking at use of hospice services and controlling for gender, race, marital status, multiple medical conditions and household assets. They also had information from surveys of the participants’ loved ones about their end-of-life care in addition to all participants’ last measured BMI.

Fifteen percent of participants were obese, with BMIs over 30, and 2 percent were morbidly obese, with BMIs over 40. Another 31 percent were overweight, with BMIs between 25 and 29.9.

The differences in end-of-life care also translated into differences in cost. In the last six months of life for a person with a normal BMI, the Medicare system spent about $43,000 for all types of care. For an obese person, the costs for that same period were about $3,500 higher.

Although the study didn’t look at the reasons why people with obesity received less hospice care, senior author Jennifer Griggs, M.D., M.P.H., a professor at the University of Michigan Medical School, suspects that several factors may be involved.

One possibility is that obesity can mask the changes physicians typically use to determine when it is time for a person to enter hospice, which include more pronounced cheekbones, collarbones and pelvic bones due to end-of-life weight loss. These changes in body weight are more noticeable in leaner patients. “To refer a patient for hospice, you have to believe that they are in the dying process,” Griggs notes.

“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,” Dr. Harris said. “More attention should be paid to payment structures that recognize the challenges involved with health care for men and women with obesity.”

The study was funded by the Robert Wood Johnson FoundationU.S. Department of Veterans Affairs, and National Institutes of Health; the HRS is funded by the National Institute on Aging grant U01AG009740.

Harris is an assistant professor of obstetrics, gynecology and reproductive sciences at Pitt who participated in the Robert Wood Johnson Clinical Scholars Program at the University of Michigan. Griggs is a professor of hematology/oncology in the University of Michigan Medical School who also holds a joint appointment at the University of Michigan School of Public Health.

Other authors include current and former IHPI members Elena Byhoff, M.D., M.Sc., Chithra Perumalswami, M.D., M.Sc., and Kenneth Langa, M.D., Ph.D. Alexi Wright, M.D., M.P.H., of the Dana Farber Cancer Institute, is a co-author.