Clinical Standards Poor at Predicting 6 Month Survival for Seriously Ill

	November 4, 1999 - Standards used to predict 6 month survival of
seriously ill patients with lung, heart or liver disease improperly lowers
the number of these patients eligible for hospice, according to an article in
the November 3 issue of The Journal of the American Medical Association.
	Dr. Ellen Fox evaluated the accuracy of criteria in predicting death
within 6 months among 2,607 patients with serious advanced lung, heart or
liver disease. "For seriously ill hospitalized patients with advanced COPD,
CHF, or end-stage liver disease, current clinical prediction standards do not
accurately identify who really has 6 months or less to live," the authors say.
	The prognostic criteria used by the researchers were National Hospice
Organization guidelines.
	Hospice programs provide home medical support for the terminally ill.
The Medicare hospice benefit covers comprehensive services, including home
care, some in-patient care and medication costs, and has a daily cap of about
$100. Medicare beneficiaries are eligible for hospice coverage only if both
the patient's doctor and the hospice medical director certify a life
expectancy prognosis of 6 months or less "if the terminal illness runs its
normal course."
	According to the authors, "Only 15% of patients getting Medicare
hospice benefits survive longer than 6 months. Fraud and abuse auditors from
the Department of Health and Human Services are now sometimes requiring
repayment to Medicare for patients who survive more than 6 months."
	The authors found that all prognostic criteria used to predict 6
month survival had limited accuracy and drastically reduced the number of
patients eligible for hospice care. Even the most liberal criteria eliminated
65% of the study patients with advanced chronic disease, INCLUDING 58% of
patients who actually died within the 6 month period. The most conservative
criteria eliminated 99% of patients who did actually die within 6 months.
	"All the criteria we analyzed succeeded in excluding most patients who
lived longer than 6 months, but in doing so they also excluded the vast
majority of the group they were supposed to identify - patients who died in 6
months or less," the authors explain.
	"The goal of determining in advance - with a high degree of accuracy -
which patients with COPD, CHF or ESLD will die within 6 months is
unrealistic," conclude the researchers.

JAMA. 1999;282:1638-1645