Homes overtake hospitals as most common site of CV death

More heart patients are opting to spend their final days at home rather than in the hospital or at a nursing facility, researchers reported in the latest edition of the Journal of the American College of Cardiology.

Sarah H. Cross, MSW, MPH, of the Sanford School of Public Policy at Duke University in Durham, N.C., and colleagues undertook a study of mortality data in the U.S. to gain insight into an elusive question: where, exactly, do patients with CVD die? Centuries ago the answer was obvious—likely at home—but as time moved forward, so did medicine. And with better resources, tools and caregivers, it made more sense for people to pass their final moments in a hospital equipped to deal with any complications.

Still, the past few decades have seen an uptick in the prevalence of palliative care and a shift in the way physicians measure quality of life. Cross’ team analyzed the Mortality Multiple Cause-of-Death Public Use Record from 2003 to 2017, including natural deaths attributed to underlying CVD in their finalized study cohort.

The researchers recorded the place of death for each patient as either a hospital, home, nursing facility, inpatient hospice facility or “other” (outpatient medical facilities, emergency departments and dead-on-arrivals). They logged 12.3 million deaths attributed primarily to CVD between 2003 and 2017.

Nearly half of the study population—48.2%—reportedly died from ischemic heart disease. Cerebrovascular disease or stroke was the next-highest cause of death (16.7% of patients), followed by heart failure or cardiomyopathy (10.6% of patients). Just under one-third of patients died in their homes in 2017, the final year of study.

Between 2003 and 2017, CVD deaths occurring in the hospital decreased from 36.5% to 27.3%, Cross et al. wrote. Nursing facility deaths also fell, from 25.1% in 2003 to 20.6% in 2017, but the most dramatic change was in at-home deaths, which accounted for 21.3% of CVD fatalities in 2003 but rose to 30.9% by 2017. Deaths in hospice facilities had increased to 6% by 2017.

In the U.S., the Mountain census region saw the greatest proportion of home deaths (37%) and the lowest proportion of hospital deaths (23.6%) in 2017. The East South Central region had the highest number of hospital deaths in 2017 (32.1%), while New England saw the lowest percentage of home deaths in the country in the same year (27.2%).

Cross and co-authors said their research also confirmed underserved minorities were more likely than white patients to die in the hospital and more likely to die at home.

“A home death may be beneficial in situations where adequate resources and supports are available; CVD patients often have acute and intense needs at the end of life that are challenging to manage in the home and may strain the patient and caregivers,” the team wrote in JACC. “Higher education, often reflecting better socioeconomic status, was associated with higher odds of dying at home than in medical facilities, likely indicating greater access to resources.”

The disparities in place of death for CVD patients might also be driven by the nature of the illness, the authors said. Stroke patients, for example, are most likely to die in a nursing or hospice facility, which makes sense given the “sudden and debilitating” consequences of an infarction.

But Cross et al. said one of the biggest takeaways from their study should be the fact that the medical community needs to slow down and listen more—to minorities, to caregivers and to patients who may not want to spend their last days in a clinical environment.

“Home has become the most common place of death for CVD patients, reinforcing the need for more information about the experiences of these patients,” the authors wrote. “Even if home is the preferred location of death for many patients, concerns remain regarding potential limited access to resources and caregivers during acute exacerbations.”