Accuracy of Medicare Hospice Local Coverage Determination Guidelines for End-Stage Kidney Disease

Background: Patients with end-stage kidney disease (ESKD) face significant barriers to accessing hospice services in the United States, where Medicare Local Coverage Determination (LCD) guidelines significantly contribute to establishing hospice eligibility, ostensibly by identifying patients with an estimated life expectancy of six months or less. Objective: Researchers sought to determine whether LCD guidelines for ESKD accurately identified patients with a six-month prognosis. Design: This study utilized a retrospective cohort design. Setting/Subjects: Medicare beneficiary data from a large midwestern Accountable Care Organization, collected between October 2017 and May 2024, were included in study analyses. Data were included for decedent patients who had chronic kidney disease at the time of death, met LCD guidelines for ESKD at the time of death, and had laboratory testing completed in the 180 days prior to death. Data Analysis: Data were analyzed via nonparametric maximum likelihood survival analyses to assess the length of time the patients had met LCD guidelines for ESKD prior to death. Results: Among 769 patients who met LCD guidelines for ESKD at the time of death, the probability of a patient meeting LCD guidelines for ESKD for at least one month prior to death was 0.28 (95% confidence interval [CI]: 0.24, 0.32), the probability of meeting these guidelines for at least six months prior to death was 0.05 (95% CI: 0.03, 0.09), and the median time of meeting these guidelines was nine days prior to death. Conclusions: Results indicated that hospice LCD guidelines inaccurately predicted six-month life expectancy for patients with ESKD, suggesting they may be inappropriate for use in determining hospice eligibility.