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More U.S. heart disease patients may be choosing to die at home

(Reuters Health) – Fewer U.S. patients with cardiovascular disease are dying in hospitals and more of them are dying at home, a new analysis suggests.

Between 2003 and 2017, among the more than 12 million Americans who died of cardiovascular disease, the proportion dying at home rose from 23% to 31%, researchers report in the Journal of the American College of Cardiology.

“Being able to die at home is very important for a large number of people,” said coauthor Dr. Haider Warraich, associate director of the heart failure program at the Boston VA Healthcare System, and an instructor at the Harvard Medical School. “Historically all people died at home. The advent of modern medicine changed that.”

When investigating how to improve people’s last days and hours, researchers have focused on hospital care because most people died there, Warraich said. “Increasingly, researchers are trying to develop resources for patients dying at home so the experience can be as good as it can be,” he added.

Warraich allows that dying at home isn’t the best option for everyone. “It depends on their needs,” he said. “I think it’s important for us to study that as well.”

To take a closer look at how people die in the U.S., Warraich and colleagues merged data from the National Center for Health Statistics and the Centers for Disease Control and Prevention.

Focusing on natural deaths with cardiovascular disease as an underlying cause, the researchers broke down the list into categories such as heart attack, stroke and heart failure.

Ultimately, they determined that between 2003 and 2017, 12.3 million deaths were attributed primarily to cardiovascular disease. Nearly half, 48.2%, were attributed to coronary heart disease, while 16.7% were due to stroke and 10.6% to heart failure or cardiomyopathy.

In 2003, 36.5% of deaths occurred in a hospital, compared to 27.3% in 2017. Deaths at home rose from 21.1% in 2003 to 30.9% in 2017.

The pattern varied across the country, however. In 2017, patients were less likely to die in the hospital in the Mountain census region – 23% died in the hospital – than in the East South Central region, which had the greatest proportion of hospital deaths at 32.1%. New England had the lowest percentage of home deaths in the country with just 27.2% in 2017.

Race and ethnicity appeared to play a role in where people died. “Racial and ethnic minorities were more likely to die in the hospital than white people,” Warraich said. “Some data suggest that this might be related to whether or not there are resources at home to support someone who wishes to die at home.”

The new study provides “some good news,” said Dr. Albert Wu, an internist and professor of health policy and management at the Johns Hopkins School of Public Health. “Studies dating back to the 1990s document that most seriously ill people would rather die at home. The uptick in the proportion of people dying at home suggests that more people are having their preferences honored – and this is progress.”

Still, “it is distressing to see there are inequities with fewer black and lower income people dying at home,” Wu said in an email. While the authors suggest this might be related to a lack of services, “it seems to me this may also reflect having less power or less of a voice to have your final preferences honored.”

Through education and home support programs, “families have become more comfortable in providing end of life care at home,” said Dr. Gerald Beckham, a cardiologist at PIH Health Physicians.

“Newer programs such as home health, palliative care, and hospice can provide resources and assistance in ways that can ease the emotional, financial and physical stresses of caring for a loved one out-of-the hospital,” Beckham said in an email.

SOURCE: Journal of the American College of Cardiology, online October 7, 2019.

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