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May P, Garrido MM, Aldridge MD, Cassel JB, Kelley AS, Meier DE, Normand C, Penrod JD, Smith TJ, Morrison RS. Prospective Cohort Study of Hospitalized Adults With Advanced Cancer: Associations Between Complications, Comorbidity, and Utilization. J Hosp Med 2017; 12:407-413. [PMID: 28574529 DOI: 10.12788/jhm.2745] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Inpatient hospital stays account for more than a third of direct medical cancer care costs. Evidence on factors driving these costs can inform planning of services, as well as consideration of equity in access. OBJECTIVE To measure the association between hospital costs, and demographic, clinical, and system factors, for a cohort of adults with advanced cancer. DESIGN Prospective multisite cohort study. SETTING Four medical and cancer centers. PATIENTS Adults with advanced cancer admitted to a participating hospital between 2007 and 2011, excluding those with dementia. Final analytic sample included 1020 patients. METHODS With receipt of palliative care controlled for, the associations between hospital cost and patient factors were estimated. Factors covered the domains of demographics (age, sex, race), socioeconomics and systems (education, insurance, living will, proxy), clinical care (diagnoses, complications deemed to pose a threat to life or bodily functions, comorbidities, symptom burden, activities of daily living), and prior healthcare utilization (home help, analgesic prescribing). OUTCOME MEASURE Direct hospital costs. RESULTS A major (markedly abnormal) complication (+$8267; P < 0.01), a minor but not a major complication (+$5289; P < 0.01), and number of comorbidities (+$852; P < 0.01) were associated with higher cost, and admitting diagnosis of electrolyte disorders (-$4759; P = 0.01) and increased age (-$53; P = 0.03) were associated with lower cost. CONCLUSIONS Complications and comorbidity burden drive inhospital utilization for adults with advanced cancer. There is little evidence of sociodemographic associations and no apparent impact of advance directives. Attempts to control growth of hospital cancer costs require consideration of how the most resource-intensive patients are identified promptly and prioritized for cost-effective care. Journal of Hospital Medicine 2017;12:407-413.
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Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland; Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa M Garrido
- Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters VA Medical Center, New York, New York
| | | | | | - Amy S Kelley
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Diane E Meier
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Joan D Penrod
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters VA Medical Center, New York, New York
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Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data. Med Care 2017; 55:155-163. [PMID: 27579912 PMCID: PMC5266421 DOI: 10.1097/mlr.0000000000000634] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Health care spending increases sharply at the end of life. Little is known about variation of cost of end of life care between regions and the drivers of such variation. We studied small-area patterns of cost of care in the last year of life in Switzerland. Methods: We used mandatory health insurance claims data of individuals who died between 2008 and 2010 to derive cost of care. We used multilevel regression models to estimate differences in costs across 564 regions of place of residence, nested within 71 hospital service areas. We examined to what extent variation was explained by characteristics of individuals and regions, including measures of health care supply. Results: The study population consisted of 113,277 individuals. The mean cost of care during last year of life was 32.5k (thousand) Swiss Francs per person (SD=33.2k). Cost differed substantially between regions after adjustment for patient age, sex, and cause of death. Variance was reduced by 52%–95% when we added individual and regional characteristics, with a strong effect of language region. Measures of supply of care did not show associations with costs. Remaining between and within hospital service area variations were most pronounced for older females and least for younger individuals. Conclusions: In Switzerland, small-area analysis revealed variation of cost of care during the last year of life according to linguistic regions and unexplained regional differences for older women. Cultural factors contribute to the delivery and utilization of health care during the last months of life and should be considered by policy makers.
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Rochigneux P, Raoul JL, Beaussant Y, Aubry R, Goldwasser F, Tournigand C, Morin L. Use of chemotherapy near the end of life: what factors matter? Ann Oncol 2017; 28:809-817. [PMID: 27993817 DOI: 10.1093/annonc/mdw654] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Use of chemotherapy near the end of life in patients with metastatic cancer is often ineffective and toxic. Data about the factors associated with its use remain scarce, especially in Europe. Methods Nationwide, register-based study including all hospitalized patients aged ≥20 years who died from metastatic solid tumors in France between 2010 and 2013. Results A total of 279 846 hospitalized patients who died from metastatic cancer were included. During the last month before death, 19.5% received chemotherapy (including 11.3% during the last 2 weeks). Female sex (OR= 0.96, 95% CI= 0.93-0.98), older age (OR= 0.70, 95% CI= 0.69-0.71 for each 10-year increase) and higher number of chronic comorbidities (OR= 0.83, 95% CI= 0.82-0.84) were independently associated with lower rates of chemotherapy. Although patients with chemosensitive tumors were statistically more likely to receive chemotherapy during the last month before death (OR= 1.21, 1.18-1.25), this association was mostly fueled by testis and ovary tumors and we found no obvious pattern between the expected chemosensitivity of different cancers and the rates of chemotherapy use close to death. Compared with university hospitals, patients who died in for-profit clinics/hospital (OR= 1.40, 95% CI= 1.34-1.45), or comprehensive cancer centers (OR= 1.43, 95% CI= 1.36-1.50) were more likely to receive chemotherapy. Finally, high-volume centers and hospitals without palliative care units reported greater-than-average rates of chemotherapy near the end of life. Conclusion among hospitalized patients with cancer, young individuals, treated in comprehensive cancer centers or in high-volume centers without palliative care units were the most likely to receive chemotherapy near the end of life. We found no evident pattern between the expected chemosensitivity of different cancers and the probability for patients to receive chemotherapy close to death.
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Affiliation(s)
- P Rochigneux
- Department of Medical Oncology, Paoli-Calmettes Institute, Marseille, France
| | - J L Raoul
- Department of Medical Oncology, Paoli-Calmettes Institute, Marseille, France
| | - Y Beaussant
- Department of Palliative Care, Besancon University Hospital, Besancon, France.,Inserm CIT808, Besancon University Hospital, Besançon, France
| | - R Aubry
- Department of Palliative Care, Besancon University Hospital, Besancon, France.,Inserm CIT808, Besancon University Hospital, Besançon, France
| | - F Goldwasser
- Department of Medical Oncology, Cochin University Hospital (AP-HP) Paris, France
| | - C Tournigand
- Department of Medical Oncology, Henri Mondor University Hospital (AP-HP), Créteil, France.,Department of Oncology, Paris-Est University, Créteil, France
| | - L Morin
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
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Dingfield LE, Kayser JB. Integrating Advance Care Planning Into Practice. Chest 2017; 151:1387-1393. [PMID: 28283409 DOI: 10.1016/j.chest.2017.02.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 02/27/2017] [Accepted: 02/27/2017] [Indexed: 11/19/2022] Open
Abstract
Advanced respiratory diseases progress over time and often lead to death. As the condition worsens, patients may lose medical decision-making ability. Advance care planning (ACP) is a process in which patients receive information about their diagnosis and prognosis; discuss values, goals, and fears; articulate preferences about life-sustaining treatments and end-of-life care; and appoint a surrogate medical decision maker. This process may result in written documentation of patient preferences or the appointment of a health-care power of attorney (HCPOA). ACP discussions have multiple benefits for patients and their surrogate decision makers, including ensuring that the care provided is aligned with the patient's goals and preferences and decreasing stress, anxiety, and burden in surrogates. Time and provider comfort are often cited barriers to ACP, so it may be necessary for clinicians to gain experience in conversations and identify the patients most likely to benefit from ACP discussions. Two new Current Procedural Terminology (CPT) codes, 99497 and 99498, have been recognized by the Centers for Medicare and Medicaid Services (CMS) as of January 1, 2016 and are intended to incentivize clinicians to engage in ACP discussions with their patients earlier and with more frequency. This manuscript reviews the benefits and barriers to ACP in patients with advanced respiratory disease and provides guidance on the use of the new CPT codes for reimbursement of these conversations.
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Affiliation(s)
- Laura E Dingfield
- Palliative Care Service, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joshua B Kayser
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, and Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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55
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Carr D, Luth EA. Advance Care Planning: Contemporary Issues and Future Directions. Innov Aging 2017; 1:igx012. [PMID: 30480109 PMCID: PMC6177019 DOI: 10.1093/geroni/igx012] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 11/30/2022] Open
Abstract
Advance care planning (ACP) is widely considered an essential step toward achieving end-of-life care that is consistent with the preferences of dying patients and their families. ACP comprises a living will and a durable power of attorney for health care (DPAHC); these tools enable patients to articulate and convey their treatment preferences when they are still cognitively intact. In this article, we describe the strengths, weaknesses, and correlates of ACP in the United States, with attention to race and socioeconomic disparities therein. We then discuss other public policies and community programs designed to increase both the number of older adults who articulate their preferences for end-of-life care, and efficacy of ACP for ensuring that patients' end-of-life treatment preferences are met. We describe the characteristics, strengths, and limitations of Physician Orders for Life Sustaining Treatment (POLSTs), and describe community programs, educational interventions, and public policies aimed toward increasing the prevalence and efficacy of end-of-life preparations. A key policy advance in the early 2010s has been Medicare coverage of one doctor-patient consultation session regarding end-of-life issues; we highlight the potentials and possible pitfalls of this policy. We conclude by identifying areas for future research, and highlighting practices from other nations that may help improve quality of end-of-life care in the United States.
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Affiliation(s)
- Deborah Carr
- Department of Sociology, Boston University, Massachusetts
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56
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Hung YN, Liu TW, Wen FH, Chou WC, Tang ST. Escalating Health Care Expenditures in Cancer Decedents' Last Year of Life: A Decade of Evidence from a Retrospective Population-Based Cohort Study in Taiwan. Oncologist 2017; 22:460-469. [PMID: 28232596 DOI: 10.1634/theoncologist.2016-0283] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/02/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND No population-based longitudinal studies on end-of-life (EOL) expenditures were found for cancer decedents. METHODS This population-based, retrospective cohort study examined health care expenditures from 2001 to 2010 among 339,546 Taiwanese cancer decedents' last year of life. Individual patient-level data were linked from administrative datasets. Health care expenditures were converted from Taiwan dollars to U.S. dollars by health-specific purchasing power parity conversions to account for different health-purchasing powers. Associations of patient, physician, hospital, and regional factors with EOL care expenditures were evaluated by multilevel linear regression model by generalized estimating equation method. RESULTS Mean annual EOL care expenditures for Taiwanese cancer decedents increased from 2000 to 2010 from U.S. $49,591 to U.S. $68,773, respectively, with one third of spending occurring in the patients' last month. Increased EOL care expenditures were associated with male gender, younger age, being married, diagnosed with hematological malignancies and cancers other than lung, gastric, and hepatic-pancreatic cancers, and dying within 7-24 months of diagnosis. Patients spent less at EOL when they had higher comorbidities and metastatic disease, died within 6 months of diagnosis, were under care of oncologists, gastroenterologists, and intensivists, and received care at a teaching hospital with more terminally ill cancer patients. Higher EOL care expenditures were associated with greater EOL care intensity at the primary hospital and regional levels. CONCLUSION Taiwanese cancer decedents consumed considerable National Health Insurance disbursements at EOL, totaling more than was consumed in six developed non-U.S. countries surveyed in 2010. To slow increasing cost and improve EOL cancer care quality, interventions to ensure appropriate EOL care provision should target hospitals and clinicians less experienced in providing EOL care and those who tend to provide aggressive EOL care to high-risk patients. The Oncologist 2017;22:460-469Implications for Practice: Cancer-care costs are highest during the end-of-life (EOL) period for cancer decedents. This population-based study longitudinally examined EOL expenditures for cancer decedents. Mean annual EOL-care expenditures for Taiwanese cancer decedents increased from U.S. $49,591 to U.S. $68,773 from the year 2000 to 2010, with one third of spending in patients' last month and more than for six developed non-U.S. countries surveyed in 2010. To slow the increasing cost of EOL-cancer care, interventions should target hospitals/clinicians less experienced in providing EOL care, who tend to provide aggressive EOL care to high-risk patients, to avoid the physical suffering, emotional burden, and financial costs of aggressive EOL care.
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Affiliation(s)
- Yen-Ni Hung
- School of Gerontology Health Management and Master Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan, Republic of China
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, Republic of China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
- Graduate School of Nursing, Chang Gung University, Tao-Yuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung City, Taiwan, Republic of China
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Dillon E, Chuang J, Gupta A, Tapper S, Lai S, Yu P, Ritchie C, Tai-Seale M. Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health-Care Directives and Physician Orders for Life-Sustaining Treatment. Am J Hosp Palliat Care 2017; 34:918-924. [PMID: 28196448 DOI: 10.1177/1049909117693578] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Advance care planning (ACP) is valued by patients and clinicians, yet documenting ACP in an accessible manner is problematic. OBJECTIVES In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice, we interviewed providers in primary care and specialty departments about ACP practices (n = 13) and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice. METHODS Structured interviews were conducted with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments. The EHR problem list data on Advance Health Care Directives (AHCDs) and Physician Orders for Life-Sustaining Treatment (POLST) were used to calculate ACP documentation rates. RESULTS Examining seriously ill patients ≥65 years with no preexisting ACP documentation seen by providers during 2013 to 2014, 88.6% (AHCD) and 91.1% (POLST) of 79 specialists had zero ACP documentations. Of 358 PCPs, 29.1% (AHCD) and 62.3% (POLST) had zero ACP documentations. Interviewed PCPs often believed ACP documentation was beneficial and accessible, while specialists more often did not. Specialists expressed more confusion about documenting ACP, whereas PCPs reported standard clinic workflows. Problems with interoperability between outpatient and inpatient EHR systems and lack of consensus about who should document ACP were sources of variations in practices. CONCLUSION Results suggest that providers desire standardized workflows for ACP discussion and documentation. New Medicare reimbursement for ACP and an increasing number of quality metrics for ACP are incentives for health-care systems to address barriers to ACP documentation.
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Affiliation(s)
- Ellis Dillon
- 1 Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | - Judith Chuang
- 1 Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
| | - Atul Gupta
- 2 Department of Economics, Stanford University, Stanford, CA, USA
| | - Sharon Tapper
- 3 Palo Alto Medical Foundation, Department of Palliative Care, Santa Cruz, CA, USA
| | - Steve Lai
- 4 Palo Alto Medical Foundation, Department of Palliative Care, Palo Alto, CA, USA
| | - Peter Yu
- 5 Hartford Health Care Cancer Institute, Memorial Sloan Kettering Cancer Alliance, Hartford, CT, USA
| | - Christine Ritchie
- 6 Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Ming Tai-Seale
- 1 Palo Alto Medical Foundation Research Institute, Mountain View, CA, USA
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Kelley AS, Covinsky KE, Gorges RJ, McKendrick K, Bollens‐Lund E, Morrison RS, Ritchie CS. Identifying Older Adults with Serious Illness: A Critical Step toward Improving the Value of Health Care. Health Serv Res 2017; 52:113-131. [PMID: 26990009 PMCID: PMC5264106 DOI: 10.1111/1475-6773.12479] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To create and test three prospective, increasingly restrictive definitions of serious illness. DATA SOURCES Health and Retirement Study, 2000-2012. STUDY DESIGN We evaluated subjects' 1-year outcomes from the interview date when they first met each definition: (A) one or more severe medical conditions (Condition) and/or receiving assistance with activities of daily living (Functional Limitation); (B) Condition and/or Functional Limitation and hospital admission in the last 12 months and/or residing in a nursing home (Utilization); and (C) Condition and Functional Limitation and Utilization. Definitions are increasingly restrictive, but not mutually exclusive. DATA COLLECTION Of 11,577 eligible subjects, 5,297 met definition A; 3,151 definition B; and 1,447 definition C. PRINCIPAL FINDINGS One-year outcomes were as follows: hospitalization 33 percent (A), 44 percent (B), 47 percent (C); total average Medicare costs $20,566 (A), $26,349 (B), and $30,828 (C); and mortality 13 percent (A), 19 percent (B), 28 percent (C). In comparison, among those meeting no definition, 12 percent had hospitalizations, total Medicare costs averaged $7,789, and 2 percent died. CONCLUSIONS Prospective identification of older adults with serious illness is feasible using clinically accessible criteria and may be a critical step toward improving health care value. These definitions may aid clinicians and health systems in targeting patients who could benefit from additional services.
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Affiliation(s)
- Amy S. Kelley
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
- Geriatric Research Education and Clinical CentersJames J Peters VA Medical CenterBronxNY
| | - Kenneth E. Covinsky
- Division of GeriatricsDepartment of MedicineUniversity of CaliforniaSan FranciscoCA
| | | | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Evan Bollens‐Lund
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
- Geriatric Research Education and Clinical CentersJames J Peters VA Medical CenterBronxNY
| | - Christine S. Ritchie
- Division of GeriatricsDepartment of MedicineUniversity of CaliforniaSan FranciscoCA
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Chen B, Fan VY, Chou YJ, Kuo CC. Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study. BMC Nephrol 2017; 18:36. [PMID: 28122500 PMCID: PMC5267416 DOI: 10.1186/s12882-017-0456-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/19/2017] [Indexed: 11/25/2022] Open
Abstract
Background Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD. Methods We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients. Results During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care. Conclusions Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.
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Affiliation(s)
- Bradley Chen
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Victoria Y Fan
- Department of Public Health Sciences & Epidemiology, University of Hawaii at Manoa, 1960 East-West Road, Biomed D204, Honolulu, HI, USA.,François-Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, USA.,Center for Global Development, Washington, D.C., USA
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Chi Kuo
- Big Data Center, China Medical University Hospital, Taichung, Taiwan. .,Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, 13F.-2, No.101, Kaixuan Rd., East Dist, Tainan City, Taiwan.
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Kumar P, Wright AA, Hatfield LA, Temel JS, Keating NL. Family Perspectives on Hospice Care Experiences of Patients with Cancer. J Clin Oncol 2016; 35:432-439. [PMID: 27992271 DOI: 10.1200/jco.2016.68.9257] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To determine whether hospice use by patients with cancer is associated with their families' perceptions of patients' symptoms, goal attainment, and quality of end-of-life (EOL) care. Methods We interviewed 2,307 families of deceased patients with advanced lung or colorectal cancer who were enrolled in the Cancer Care Outcomes Research and Surveillance study (a multiregional, prospective, observational study) and died by 2011. We used propensity-score matching to compare family-reported outcomes for patients who did and did not receive hospice care, including the presence and relief of common symptoms (ie, pain, dyspnea), concordance with patients' wishes for EOL care and place of death, and quality of EOL care. We also examined associations between hospice length of stay and these outcomes among hospice enrollees. Results In a propensity-score-matched sample of 1,970 individuals, families of patients enrolled in hospice reported more pain in their patient compared with those not enrolled in hospice. However, families of patients enrolled in hospice more often reported that patients received "just the right amount" of pain medicine (80% v 73%; adjusted difference, 7 percentage points; 95% confidence interval [CI], 1 to 12 percentage points) and help with dyspnea (78% v 70%; adjusted difference, 8 percentage points; 95% CI, 2 to 13 percentage points). Families of patients enrolled in hospice also more often reported that patients' EOL wishes were followed (80% v 74%; adjusted difference, 6 percentage points; 95% CI, 2 to 11 percentage points) and "excellent" quality EOL care (57% v 42%; adjusted difference, 15 percentage points; 95% CI, 11 to 20). Families of patients who received > 30 days of hospice care reported the highest quality EOL outcomes. Conclusion Hospice care is associated with better symptom relief, patient-goal attainment, and quality of EOL care. Encouraging earlier and increased hospice enrollment may improve EOL experiences for patients with cancer and their families.
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Affiliation(s)
- Pallavi Kumar
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
| | - Alexi A Wright
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
| | - Laura A Hatfield
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
| | - Jennifer S Temel
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
| | - Nancy L Keating
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
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Obermeyer Z, Powers BW, Makar M, Keating NL, Cutler DM. Physician Characteristics Strongly Predict Patient Enrollment In Hospice. Health Aff (Millwood) 2016; 34:993-1000. [PMID: 26056205 DOI: 10.1377/hlthaff.2014.1055] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Individual physicians are widely believed to play a large role in patients' decisions about end-of-life care, but little empirical evidence supports this view. We developed a novel method for measuring the relationship between physician characteristics and hospice enrollment, in a nationally representative sample of Medicare patients. We focused on patients who died with a diagnosis of poor-prognosis cancer in the period 2006-11, for whom palliative treatment and hospice would be considered the standard of care. We found that the proportion of a physician's patients who were enrolled in hospice was a strong predictor of whether or not that physician's other patients would enroll in hospice. The magnitude of this association was larger than that of other known predictors of hospice enrollment that we examined, including patients' medical comorbidity, age, race, and sex. Patients cared for by medical oncologists and those cared for in not-for-profit hospitals were significantly more likely than other patients to enroll in hospice. These findings suggest that physician characteristics are among the strongest predictors of whether a patient receives hospice care-which mounting evidence indicates can improve care quality and reduce costs. Interventions geared toward physicians, both by specialty and by previous history of patients' hospice enrollment, may help optimize appropriate hospice use.
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Affiliation(s)
- Ziad Obermeyer
- Ziad Obermeyer is an assistant professor of emergency medicine and health care policy at Harvard Medical School and an emergency physician at Brigham and Women's Hospital, in Boston, Massachusetts
| | - Brian W Powers
- Brian W. Powers is an MD candidate at Harvard Medical School
| | - Maggie Makar
- Maggie Makar is a research assistant in the Department of Emergency Medicine at Brigham and Women's Hospital
| | - Nancy L Keating
- Nancy L. Keating is a professor of health care policy and medicine at Harvard Medical School and an internist at Brigham and Women's Hospital
| | - David M Cutler
- David M. Cutler is the Otto Eckstein Professor of Applied Economics at Harvard University and a research associate at the National Bureau of Economic Research, both in Cambridge, Massachusetts
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Johnson KJ, Hong M, Inoue M, Adamek ME. Social Work Should Be More Proactive in Addressing the Need to Plan for End of Life. HEALTH & SOCIAL WORK 2016; 41:271-274. [PMID: 29206973 DOI: 10.1093/hsw/hlw021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/09/2015] [Indexed: 06/07/2023]
Affiliation(s)
- Kimberly J Johnson
- School of Social Work, Indiana University-Purdue University Indianapolis
| | - Michin Hong
- School of Social Work, Indiana University-Purdue University Indianapolis
| | - Megumi Inoue
- Social Work, George Mason University, Fairfax, VA
| | - Margaret E Adamek
- School of Social Work, Indiana University-Purdue University Indianapolis
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Eneanya ND, Hailpern SM, O'Hare AM, Kurella Tamura M, Katz R, Kreuter W, Montez-Rath ME, Hebert PL, Hall YN. Trends in Receipt of Intensive Procedures at the End of Life Among Patients Treated With Maintenance Dialysis. Am J Kidney Dis 2016; 69:60-68. [PMID: 27693262 DOI: 10.1053/j.ajkd.2016.07.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 07/18/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Many dialysis patients receive intensive procedures intended to prolong life at the very end of life. However, little is known about trends over time in the use of these procedures. We describe temporal trends in receipt of inpatient intensive procedures during the last 6 months of life among patients treated with maintenance dialysis. STUDY DESIGN Mortality follow-back study. SETTING & PARTICIPANTS 649,607 adult Medicare beneficiaries on maintenance dialysis therapy who died in 2000 to 2012. PREDICTORS Period of death (2000-2003, 2004-2008, or 2009-2012), age at time of death (18-59, 60-64, 65-69, 70-74, 75-79, 80-84, and ≥85 years), and race/ethnicity (Hispanic, non-Hispanic black, or non-Hispanic white). OUTCOME Receipt of an inpatient intensive procedure (defined as invasive mechanical ventilation/intubation, tracheostomy, gastrostomy/jejunostomy tube insertion, enteral or parenteral nutrition, or cardiopulmonary resuscitation) during the last 6 months of life. RESULTS Overall, 34% of cohort patients received an intensive procedure in the last 6 months of life, increasing from 29% in 2000 to 36% in 2012 (with 2000-2003 as the referent category; adjusted risk ratios [RRs] were 1.06 [95% CI, 1.05-1.07] and 1.10 [95% CI, 1.09-1.12] for 2004-2008 and 2009-2012, respectively). Use of intensive procedures increased more markedly over time in younger versus older patients (comparing 2009-2012 to 2000-2003, adjusted RR was 1.18 [95% CI, 1.15-1.20] for the youngest age group as opposed to 1.00 [95% CI, 0.96-1.04] for the oldest group). Comparing 2009 to 2012 to 2000 to 2003, the use of intensive procedures increased more dramatically for Hispanic patients than for non-Hispanic black or non-Hispanic white patients (adjusted RRs of 1.18 [95% CI, 1.14-1.22], 1.09 [95% CI, 1.07-1.11], and 1.10 [95% CI, 1.08-1.12], respectively). LIMITATIONS Data sources do not provide insight into reasons for observed trends in the use of intensive procedures. CONCLUSIONS Among patients treated with maintenance dialysis, there is a trend toward more frequent use of intensive procedures at the end of life, especially in younger patients and those of Hispanic ethnicity.
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Affiliation(s)
- Nwamaka D Eneanya
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Susan M Hailpern
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Ann M O'Hare
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA; Hospital and Specialty Medicine, Veteran Affairs Puget Sound Health Care System, Seattle, WA; Group Health Research Institute, Seattle, WA
| | - Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Ronit Katz
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA
| | - William Kreuter
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Paul L Hebert
- Seattle-Denver Center of Innovation, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Yoshio N Hall
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA
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Harris ML, Dolja-Gore X, Kendig H, Byles JE. End of life hospitalisations differ for older Australian women according to death trajectory: a longitudinal data linkage study. BMC Health Serv Res 2016; 16:484. [PMID: 27613597 PMCID: PMC5017050 DOI: 10.1186/s12913-016-1729-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 08/30/2016] [Indexed: 11/12/2022] Open
Abstract
Background Hospitalisations are the prime contributor to healthcare expenditure, with older adults often identified as high hospital users. Despite the apparent high use of hospitals at the end of life, limited evidence currently exists regarding reasons for hospitalisation. Understanding complex end of life care needs is required for future health care planning as the global population ages. This study aimed to investigate patterns of hospitalisation in the last year of life by cause of death (COD) as well as reasons for admission and short-term predictors of hospital use. Methods Survey data from 1,205 decedents from the 1921–1926 cohort of the Australian Longitudinal Study on Women’s Health were matched with the state-based hospital records and the National Death Index. Hospital patterns based on COD were graphically summarised and multivariate logistic regression models examined the impact of short-term predictors of length of stay (LOS). Results 85 % of women had at least one admission in the last year of life; and 8 % had their first observed admission during this time. Reasons for hospitalisation, timing of admissions and LOS differed by COD. Women who died of cancer, diabetes and ‘other’ causes were admitted earlier than women who died of organ failure, dementia and influenza. Women who died of organ failure overall spent the longest time in hospital, and women with cancer had the highest median LOS. Longer LOS was associated with previous short- and medium-term- hospitalisations and type of hospital separation. Conclusions Reducing acute care admissions and LOS at the end of life is complex and requires a shift in perceptions and treatment regarding end of life care and chronic disease management. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1729-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Melissa L Harris
- Research Centre for Generational Health and Ageing, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Xenia Dolja-Gore
- Research Centre for Generational Health and Ageing, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Hal Kendig
- Centre for Research on Ageing, Health and Wellbeing, College of Medicine, Biology and Environment, Australian National University, Mills Road, Acton, ACT, Australia.,ARC Centre of Excellence in Population Ageing Research, Sydney, NSW, 2033, Australia
| | - Julie E Byles
- Research Centre for Generational Health and Ageing, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,ARC Centre of Excellence in Population Ageing Research, Sydney, NSW, 2033, Australia
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65
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Byhoff E, Harris JA, Langa KM, Iwashyna TJ. Racial and Ethnic Differences in End-of-Life Medicare Expenditures. J Am Geriatr Soc 2016; 64:1789-97. [PMID: 27588580 PMCID: PMC5237584 DOI: 10.1111/jgs.14263] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life. DESIGN Retrospective cohort study. SETTING Health and Retirement Study (HRS). PARTICIPANTS Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105). MEASUREMENTS Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected. RESULTS The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models. CONCLUSION Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.
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Affiliation(s)
- Elena Byhoff
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Center for Clinical Management and Research, Ann Arbor, MI, USA
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - John A. Harris
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Kenneth M. Langa
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Center for Clinical Management and Research, Ann Arbor, MI, USA
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Theodore J. Iwashyna
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Center for Clinical Management and Research, Ann Arbor, MI, USA
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Abrashkin KA, Washko J, Zhang J, Poku A, Kim H, Smith KL. Providing Acute Care at Home: Community Paramedics Enhance an Advanced Illness Management Program-Preliminary Data. J Am Geriatr Soc 2016; 64:2572-2576. [DOI: 10.1111/jgs.14484] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Karen A. Abrashkin
- Department of Internal Medicine; Hoftstra-Northwell School of Medicine; New Hyde Park New York
| | - Jonathan Washko
- Center for Emergency Medical Services; Northwell Health; New Hyde Park New York
| | - Jenny Zhang
- Department of Internal Medicine; Hoftstra-Northwell School of Medicine; New Hyde Park New York
| | - Asantewaa Poku
- Department of Internal Medicine; Hoftstra-Northwell School of Medicine; New Hyde Park New York
| | - Hyun Kim
- Division of Environmental Health Sciences; University of Minnesota; Minneapolis Minnesota
| | - Kristofer L. Smith
- Department of Internal Medicine; Hoftstra-Northwell School of Medicine; New Hyde Park New York
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Characteristics and Correlates of Increasing Use of Surgery in Taiwanese Cancer Patients’ Last Month of Life, 2001–2010. Ann Surg 2016; 264:283-90. [DOI: 10.1097/sla.0000000000001373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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68
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Klingler C, in der Schmitten J, Marckmann G. Does facilitated Advance Care Planning reduce the costs of care near the end of life? Systematic review and ethical considerations. Palliat Med 2016; 30:423-33. [PMID: 26294218 PMCID: PMC4838173 DOI: 10.1177/0269216315601346] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While there is increasing evidence that Advance Care Planning has the potential to strengthen patient autonomy and improve quality of care near the end of life, it remains unclear whether it could also reduce net costs of care. AIM This study aims to describe the cost implications of Advance Care Planning programmes and discusses ethical conflicts arising in this context. DESIGN We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA SOURCES We systematically searched the databases PubMed, NHS EED, EURONHEED, Cochrane Library and EconLit. We included empirical studies (no limitation to study type) that investigated the cost implications of Advance Care Planning programmes involving professionally facilitated end-of-life discussions. RESULTS AND DISCUSSION Seven studies met our inclusion criteria. Four of them used a randomised controlled design, one used a before-after design and two were observational studies. Six studies found reductions in costs of care ranging from USD1041 to USD64,827 per patient, depending on the study period and the cost measurement. One study detected no differences in costs. Studies varied considerably regarding the Advance Care Planning intervention, patient selection and costs measured which may explain some of the variations in findings. NORMATIVE APPRAISAL Looking at the impact of Advance Care Planning on costs raises delicate ethical issues. Given the increasing pressure to reduce expenditures, there may be concerns that cost considerations could unduly influence the sensitive communication process, thus jeopardising patient autonomy. Safeguards are proposed to reduce these risks. CONCLUSION The limited data indicate net cost savings may be realised with Advance Care Planning. Methodologically robust trials with clearly defined Advance Care Planning interventions are needed to make the costs and returns of Advance Care Planning transparent.
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Affiliation(s)
- Corinna Klingler
- Institute for Ethics, History and Theory of Medicine, Ludwig Maximilian University, Munich, Germany
| | - Jürgen in der Schmitten
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Marckmann
- Institute for Ethics, History and Theory of Medicine, Ludwig Maximilian University, Munich, Germany
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Curtis JR, Engelberg RA, Teno JM. Understanding variability of end-of-life care in the ICU for the elderly. Intensive Care Med 2016; 43:94-96. [PMID: 27033890 DOI: 10.1007/s00134-016-4340-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 03/21/2016] [Indexed: 11/26/2022]
Affiliation(s)
- J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
- Cambia Palliative Care Center of Excellence at the University of Washington, Seattle, WA, USA.
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence at the University of Washington, Seattle, WA, USA
| | - Joan M Teno
- Cambia Palliative Care Center of Excellence at the University of Washington, Seattle, WA, USA
- Division of Gerontology and Geriatrics, Department of Medicine, University of Washington, Seattle, WA, USA
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Abstract
OBJECTIVES To provide an overview of key elements of the Affordable Care Act. To evaluate ways in which the Affordable Care Act will likely impact the practice of critical care medicine. To describe strategies that may help health systems and providers effectively adapt to changes brought about by the Affordable Care Act. DATA SOURCES AND SYNTHESIS Data sources for this concise review include search results from the PubMed and Embase databases, as well as sources relevant to public policy such as the text of the Patient Protection and Affordable Care Act and reports of the Congressional Budget Office. As all of the Affordable Care Act's provisions will not be fully implemented until 2019, we also drew upon cost, population, and utilization projections, as well as the experience of existing state-based healthcare reforms. CONCLUSIONS The Affordable Care Act represents the furthest reaching regulatory changes in the U.S. healthcare system since the 1965 Medicare and Medicaid provisions of the Social Security Act. The Affordable Care Act aims to expand health insurance coverage to millions of Americans and place an emphasis on quality and cost-effectiveness of care. From models which link pay and performance to those which center on episodic care, the Affordable Care Act outlines sweeping changes to health systems, reimbursement structures, and the delivery of critical care. Staffing models that include daily rounding by an intensivist, palliative care integration, and expansion of the role of telemedicine in areas where intensivists are inaccessible are potential strategies that may improve quality and profitability of ICU care in the post-Affordable Care Act era.
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Affiliation(s)
- Anjali P Dogra
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD
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71
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Pataky R, Cheung W, de Oliveira C, Bremner K, Chan K, Hoch J, Krahn M, Peacock S. Population-based trends in systemic therapy use and cost for cancer patients in the last year of life. Curr Oncol 2016; 23:S32-41. [PMID: 26985144 PMCID: PMC4780587 DOI: 10.3747/co.23.2946] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The use of systemic therapy near the end of life can expose cancer patients to severe toxicity for minimal survival gain and comes with a high cost. Early palliative care is recommended, but there is evidence that aggressive care remains common. To better understand those patterns, the present study set out to describe trends in systemic therapy use and cost for cancer patients in the last year of life. METHODS Using the BC Cancer Registry, a retrospective population-based cohort of cancer decedents (2002-2007) was identified and linked to systemic therapy records. The outcomes of interest were any systemic therapy use and total systemic therapy costs during the last year of life. Multiple logistic regression (systemic therapy use) and generalized linear regression (costs) were conducted, adjusting for age, sex, and survival. Subgroup analyses were performed for patients with primary colorectal, lung, prostate, or breast cancer. RESULTS From 2002 to 2007, use of systemic therapy in the last 12-4 months of life increased by 21% (95% ci: 10% to 33%); no significant change in use in the last 3 months of life was observed. Costs for both periods increased over time, by 48% (95% ci: 36% to 63%) and by 33% (95% ci: 19% to 49%) respectively. The trends varied across cancer sites, with the greatest increases being observed for lung and colorectal cancer patients. CONCLUSIONS The use and costs of systemic therapy have generally been increasing, putting pressure on health care providers and payers, but the quality-of-life implications for patients must be better understood.
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Affiliation(s)
- R.E. Pataky
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
- BC Cancer Agency, Vancouver, BC
| | | | - C. de Oliveira
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
- Centre for Addiction and Mental Health, Toronto, ON
| | - K.E. Bremner
- Toronto General Research Institute and The Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON
| | - K.K.W. Chan
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
- Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON
| | - J.S. Hoch
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
| | - M.D. Krahn
- Toronto General Research Institute and The Toronto Health Economics and Technology Assessment Collaborative, University Health Network, Toronto, ON
- Faculty of Pharmacy, University of Toronto, University Health Network, Toronto, ON
| | - S.J. Peacock
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, and Vancouver, BC
- BC Cancer Agency, Vancouver, BC
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC
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Kaambwa B, Ratcliffe J, Bradley SL, Masters S, Davies O, Whitehead C, Milte C, Cameron ID, Young T, Gordon J, Crotty M. Costs and advance directives at the end of life: a case of the 'Coaching Older Adults and Carers to have their preferences Heard (COACH)' trial. BMC Health Serv Res 2015; 15:545. [PMID: 26645745 PMCID: PMC4673742 DOI: 10.1186/s12913-015-1201-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 11/30/2015] [Indexed: 12/31/2022] Open
Abstract
Background Total costs associated with care for older people nearing the end of life and the cost variations related with end of life care decisions are not well documented in the literature. Healthcare utilisation and associated health care costs for a group of older Australians who entered Transition Care following an acute hospital admission were calculated. Costs were differentiated according to a number of health care decisions and outcomes including advance directives (ADs). Methods Study participants were drawn from the Coaching Older Adults and Carers to have their preferences Heard (COACH) trial funded by the Australian National Health and Medical Research Council. Data collected included total health care costs, the type of (and when) ADs were completed and the place of death. Two-step endogenous treatment-regression models were employed to test the relationship between costs and a number of variables including completion of ADs. Results The trial recruited 230 older adults with mean age 84 years. At the end of the trial, 53 had died and 80 had completed ADs. Total healthcare costs were higher for younger participants and those who had died. No statistically significant association was found between costs and completion of ADs. Conclusion For our frail study population, the completion of ADs did not have an effect on health care utilisation and costs. Further research is needed to substantiate these findings in larger and more diverse clinical cohorts of older people. Trial registration This study was registered on 13/12/2007 with the Australian New Zealand Clinical Trial Registry (ACTRN12607000638437).
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Affiliation(s)
- Billingsley Kaambwa
- Flinders Health Economics group, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia. .,Billingsley Kaambwa, Flinders Health Economics Group, School of Medicine, Flinders University, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Australia.
| | - Julie Ratcliffe
- Flinders Health Economics group, Flinders University, A Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia.
| | - Sandra L Bradley
- CareSearch, Palliative care knowledge network, Palliative and Supportive Services, Flinders University, PO Box 2100, Adelaide, SA, 5001, Australia.
| | - Stacey Masters
- The Discipline of General Practice, Health Sciences Building, Flinders University, GPO Box 2100, SA, 5001, Adelaide, Australia.
| | - Owen Davies
- Department of Rehabilitation and Aged Care, Flinders University, C Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia.
| | - Craig Whitehead
- Department of Rehabilitation and Aged Care, Flinders University, C Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia.
| | - Catherine Milte
- School of Exercise and Nutrition Sciences, Deakin University, Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC, 3125, Melbourne, Australia.
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, University of Sydney, Level 13, Kolling Institute of Medical Research, Corner Reserve Road and Westbourne Avenue, Royal North Shore Hospital, St Leonards, NSW, 2065, Sydney, Australia.
| | - Tracey Young
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Jason Gordon
- Discipline of Public Health, University of Adelaide, 178 North Terrace, Terrace Towers, SA, 5005, Adelaide, Australia.
| | - Maria Crotty
- Department of Rehabilitation and Aged Care, Flinders University, C Block, Repatriation General Hospital, 202-16 Daws Road, Daw Park, SA, 5041, Adelaide, Australia.
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Dixon J, Matosevic T, Knapp M. The economic evidence for advance care planning: Systematic review of evidence. Palliat Med 2015; 29:869-84. [PMID: 26060176 DOI: 10.1177/0269216315586659] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Advance care planning is a process of discussion and review concerning future care in the event of losing capacity. Aimed at improving the appropriateness and quality of care, it is also often considered a means of making better use of healthcare resources at the end of life. AIM To review and summarise economic evidence on advance care planning. DESIGN A systematic review of the academic literature. DATA SOURCES We searched for English language, peer-reviewed journal articles, 1990-2014, using relevant research databases: PubMed, ProQuest, CINAHL Plus with Full Text; EconLit, PsycINFO, SocINDEX with Full Text and International Bibliography of the Social Sciences. Empirical studies using statistical methods in which advance care planning and costs are variables were included. RESULTS There are no published cost-effectiveness studies. Included studies focus on healthcare savings, usually associated with reduced demand for hospital care. Advance care planning appears to be associated with healthcare savings for some people in some circumstances, such as people living with dementia in the community, people in nursing homes or in areas with high end-of-life care spending. There is no evidence that advance care planning is likely to be more expensive. CONCLUSION There is need for clearer articulation of the likely mechanisms by which advance care planning can lead to reduced care costs or improved cost-effectiveness, particularly for people who retain capacity. There is also a need to consider wider costs, including the costs of advance care planning facilitation or interventions and the costs of substitute health, social and informal care. Economic outcomes need to be considered in the context of quality benefits.
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Affiliation(s)
- Josie Dixon
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
| | - Tihana Matosevic
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
| | - Martin Knapp
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
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Aldridge MD, Kelley AS. The Myth Regarding the High Cost of End-of-Life Care. Am J Public Health 2015; 105:2411-5. [PMID: 26469646 PMCID: PMC4638261 DOI: 10.2105/ajph.2015.302889] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 11/04/2022]
Abstract
Health care reform debate in the United States is largely focused on the highly concentrated health care costs among a small proportion of the population and policy proposals to identify and target this "high-cost" group. To better understand this population, we conducted an analysis for the Institute of Medicine Committee on Approaching Death using existing national data sets, peer-reviewed literature, and published reports. We estimated that in 2011, among those with the highest costs, only 11% were in their last year of life, and approximately 13% of the $1.6 trillion spent on personal health care costs in the United States was devoted to care of individuals in their last year of life. Public health interventions to reduce health care costs should target those with long-term chronic conditions and functional limitations.
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Affiliation(s)
- Melissa D Aldridge
- The authors are with the Department of Geriatrics and Palliative Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, and the James J. Peters VA Medical Center, Bronx, NY
| | - Amy S Kelley
- The authors are with the Department of Geriatrics and Palliative Medicine, Ichan School of Medicine at Mount Sinai, New York, NY, and the James J. Peters VA Medical Center, Bronx, NY
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Kelley AS, McGarry K, Gorges R, Skinner JS. The burden of health care costs for patients with dementia in the last 5 years of life. Ann Intern Med 2015; 163:729-36. [PMID: 26502320 PMCID: PMC4809412 DOI: 10.7326/m15-0381] [Citation(s) in RCA: 263] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Common diseases, particularly dementia, have large social costs for the U.S. population. However, less is known about the end-of-life costs of specific diseases and the associated financial risk for individual households. OBJECTIVE To examine social costs and financial risks faced by Medicare beneficiaries 5 years before death. DESIGN Retrospective cohort. SETTING The HRS (Health and Retirement Study). PARTICIPANTS Medicare fee-for-service beneficiaries, aged 70 years or older, who died between 2005 and 2010 (n = 1702), stratified into 4 groups: persons with a high probability of dementia or those who died because of heart disease, cancer, or other causes. MEASUREMENTS Total social costs and their components, including Medicare, Medicaid, private insurance, out-of-pocket spending, and informal care, measured over the last 5 years of life; and out-of-pocket spending as a proportion of household wealth. RESULTS Average total cost per decedent with dementia ($287 038) was significantly greater than that of those who died of heart disease ($175 136), cancer ($173 383), or other causes ($197 286) (P < 0.001). Although Medicare expenditures were similar across groups, average out-of-pocket spending for patients with dementia ($61 522) was 81% higher than that for patients without dementia ($34 068); a similar pattern held for informal care. Out-of-pocket spending for the dementia group (median, $36 919) represented 32% of wealth measured 5 years before death compared with 11% for the nondementia group (P < 0.001). This proportion was greater for black persons (84%), persons with less than a high school education (48%), and unmarried or widowed women (58%). LIMITATION Imputed Medicaid, private insurance, and informal care costs. CONCLUSION Health care expenditures among persons with dementia were substantially larger than those for other diseases, and many of the expenses were uncovered (uninsured). This places a large financial burden on families, and these burdens are particularly pronounced among the demographic groups that are least prepared for financial risk. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Amy S. Kelley
- From Icahn School of Medicine at Mount Sinai, New York, New York; University of California, Los Angeles, Los Angeles, California; and Dartmouth College, Hanover, New Hampshire
| | - Kathleen McGarry
- From Icahn School of Medicine at Mount Sinai, New York, New York; University of California, Los Angeles, Los Angeles, California; and Dartmouth College, Hanover, New Hampshire
| | - Rebecca Gorges
- From Icahn School of Medicine at Mount Sinai, New York, New York; University of California, Los Angeles, Los Angeles, California; and Dartmouth College, Hanover, New Hampshire
| | - Jonathan S. Skinner
- From Icahn School of Medicine at Mount Sinai, New York, New York; University of California, Los Angeles, Los Angeles, California; and Dartmouth College, Hanover, New Hampshire
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Ananth P, Melvin P, Feudtner C, Wolfe J, Berry JG. Hospital Use in the Last Year of Life for Children With Life-Threatening Complex Chronic Conditions. Pediatrics 2015; 136:938-46. [PMID: 26438707 PMCID: PMC4621793 DOI: 10.1542/peds.2015-0260] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although many adults experience resource-intensive and costly health care in the last year of life, less is known about these health care experiences in children with life-threatening complex chronic conditions (LT-CCCs). We assessed hospital resource use in children by type and number of LT-CCCs. METHODS A retrospective analysis of 1252 children with LT-CCCs, ages 1 to 18 years, who died in 2012 within 40 US children's hospitals of the Pediatric Health Information System database. LT-CCCs were identified with International Classification of Diseases, 9th Revision, Clinical Modification codes. Using generalized linear models, we assessed hospital admissions, days, costs, and interventions (mechanical ventilation and surgeries) in the last year of life by type and number of LT-CCCs. RESULTS In the last year of life, children with LT-CCCs experienced a median of 2 admissions (interquartile range [IQR] 1-5), 27 hospital days (IQR 7-84), and $142 562 (IQR $45 270-$410 087) in hospital costs. During the terminal admission, 76% (n = 946) were mechanically ventilated; 36% (n = 453) underwent surgery. Hospital use was greatest (P < .001) among children with hematologic/immunologic conditions (99 hospital days [IQR 51-146]; cost = $504 145 [IQR $250 147-$879 331]) and children with ≥3 LT-CCCs (75 hospital days [IQR 28-132]; cost = $341 222 [IQR $146 698-$686 585]). CONCLUSIONS Hospital use for children with LT-CCCs in the last year of life varies significantly across the type and number of conditions. Children with hematologic/immunologic or multiple conditions have the greatest hospital use. This information may be useful for clinicians striving to improve care for children with LT-CCCs nearing the end of life.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center,
| | - Patrice Melvin
- Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joanne Wolfe
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center,,Division of Pediatric Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and
| | - Jay G. Berry
- Division of General Pediatrics, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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von Wyl V, Telser H, Weber A, Fischer B, Beck K. Cost trajectories from the final life year reveal intensity of end-of-life care and can help to guide palliative care interventions. BMJ Support Palliat Care 2015; 8:325-334. [DOI: 10.1136/bmjspcare-2014-000784] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 06/24/2015] [Accepted: 09/16/2015] [Indexed: 11/04/2022]
Abstract
ObjectiveExploration of healthcare utilisation patterns in the final life year to assess palliative care potential.MethodsRetrospective cluster analyses (k-means) of anonymised healthcare expenditure (HCE) trajectories, derived from health insurance claims of a representative sample of Swiss decedents who died between 2008 and 2010 (2 age classes: 4818 <66 years, 22 691 elderly).Results3 (<66 years) and 5 (elderly) trajectory groups were identified, whose shapes were dominated by HCE from inpatient care in hospitals and at nursing homes. In each age class, the most expensive group (average cumulative HCE for <66 years: SFr 84 295; elderly: SFr 84 941) also had the largest abundance of cancers (<66 years: 55%; elderly: 32%) and showed signs of continued treatment intensification until shortly before death. Although sizes of these high-cost groups were comparatively small (26% in younger; 6% in elderly), they contributed substantially to the end-of-life HCE in each age class (62% and 18%, respectively).As age increased, these potential target groups for palliative care gained in share among <66-year olds (from 9% in children to 28% in 60–65-year olds), but decreased from 17% (66–70-year olds) to 1% (>90-year olds) among elderly.ConclusionsCost trajectory clustering is well suited for first-pass population screenings of groups that warrant closer inspection to improve end-of-life healthcare allocation. The Swiss data suggest that many decedents undergo intensive medical treatment until shortly before death. Investigations into the clinical circumstances and motives of patients and physicians may help to guide palliative care.
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78
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Nicholas LH, Bynum JPW, Iwashyna TJ, Weir DR, Langa KM. Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia. Health Aff (Millwood) 2015; 33:667-74. [PMID: 24711329 DOI: 10.1377/hlthaff.2013.1258] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The number of older adults with cognitive impairment is increasing, and such adults often require a surrogate to make decisions about health care. However, little is known about the aggressiveness of end-of-life care for these people, especially those who reside in the community. We found that cognitive impairment is common among older adults approaching the end of life, whether they live in the community or in a nursing home, and that nearly 30 percent of patients with severe dementia remained in the community until death. Among those patients, having an advance directive in the form of a living will was associated with significantly less aggressive care at the end of life, compared to similar patients without an advance directive-as measured by Medicare spending ($11,461 less per patient), likelihood of in-hospital death (17.9 percentage points lower), and use of the intensive care unit (9.4 percentage points lower). In contrast, advance directives were not associated with differences in care for people with normal cognition or mild dementia, whether they resided in the community or in a nursing home. Timely advance care planning after a diagnosis of cognitive impairment may be particularly important for older adults who reside in the community.
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79
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Garrido MM, Balboni TA, Maciejewski PK, Bao Y, Prigerson HG. Quality of Life and Cost of Care at the End of Life: The Role of Advance Directives. J Pain Symptom Manage 2015; 49:828-35. [PMID: 25498855 PMCID: PMC4441858 DOI: 10.1016/j.jpainsymman.2014.09.015] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 09/22/2014] [Accepted: 10/17/2014] [Indexed: 12/21/2022]
Abstract
CONTEXT Advance directives (ADs) are expected to improve patients' end-of-life outcomes, but retrospective analyses, surrogate recall of patients' preferences, and selection bias have hampered efforts to determine ADs' effects on patient outcomes. OBJECTIVES The aim was to examine associations among ADs, quality of life, and estimated costs of care in the week before death. METHODS We used prospective data from interviews of 336 patients with advanced cancer and their caregivers and analyzed patient baseline interview and caregiver and provider post-mortem evaluation data from the Coping with Cancer study. Cost estimates were from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and published Medicare payment rates and cost estimates. Outcomes were quality of life (range 0-10) and estimated costs of care received in the week before death. Because patient end-of-life care preferences influence both AD completion and care use, analyses were stratified by preferences regarding heroic end-of-life measures (everything possible to remain alive). RESULTS Most patients did not want heroic measures (76%). Do-not-resuscitate (DNR) orders were associated with higher quality of life (β = 0.75, standard error = 0.30, P = 0.01) across the entire sample. There were no statistically significant relationships between DNR orders and outcomes among patients when we stratified by patient preference or between living wills/durable powers of attorney and outcomes in any of the patient groups. CONCLUSION The associations between DNR orders and better quality of life in the week before death indicate that documenting preferences against resuscitation in medical orders may be beneficial to many patients.
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Affiliation(s)
- Melissa M Garrido
- James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tracy A Balboni
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Yuhua Bao
- Weill Cornell Medical College, New York, New York, USA
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80
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Webb JA, Horton JR, Johnson K. Update in hospice and palliative care. J Palliat Med 2015; 18:545-51. [PMID: 25856765 DOI: 10.1089/jpm.2015.0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jason A Webb
- 1Duke Palliative Care, Duke University School of Medicine, Durham, North Carolina
- 2Division of General Psychiatry, Duke University School of Medicine, Durham, North Carolina
- 3Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
- 4Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
- 5Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- 6Duke University School of Medicine, Durham, North Carolina
- 7Mental Health Services, Durham Veterans Administration Medical Center, Durham, North Carolina
| | - Jay R Horton
- 8Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kimberly Johnson
- 1Duke Palliative Care, Duke University School of Medicine, Durham, North Carolina
- 5Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- 6Duke University School of Medicine, Durham, North Carolina
- 9Division of Geriatrics, Durham Veterans Administration Medical Center, Durham, North Carolina
- 10Geriatrics Research Education and Clinical Center, Durham Veterans Administration Medical Center, Durham, North Carolina
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The health care cost of dying: a population-based retrospective cohort study of the last year of life in Ontario, Canada. PLoS One 2015; 10:e0121759. [PMID: 25811195 PMCID: PMC4374686 DOI: 10.1371/journal.pone.0121759] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 02/04/2015] [Indexed: 11/23/2022] Open
Abstract
Background Coordinated and appropriate health care across sectors is an ongoing challenge, especially at the end-of-life. Population-level data on end-of-life health care use and cost, however, are seldom reported across a comprehensive array of sectors. Such data will identify the level of care being provided and areas where care can be optimized. Methods This retrospective cohort study identified all deaths in Ontario from April 1, 2010 to March 31, 2013. Using population-based health administrative databases, we examined health care use and cost in the last year of life. Results Among 264,755 decedents, the average health care cost in the last year of life was $53,661 (Quartile 1-Quartile 3: $19,568-$66,875). The total captured annual cost of $4.7 billion represents approximately 10% of all government-funded health care. Inpatient care, incurred by 75% of decedents, contributed 42.9% of total costs ($30,872 per user). Physician services, medications/devices, laboratories, and emergency rooms combined to less than 20% of total cost. About one-quarter used long-term-care and 60% used home care ($34,381 and $7,347 per user, respectively). Total cost did not vary by sex or neighborhood income quintile, but were less among rural residents. Costs rose sharply in the last 120 days prior to death, predominantly for inpatient care. Interpretation This analysis adds new information about the breadth of end-of-life health care, which consumes a large proportion of Ontario’s health care budget. The cost of inpatient care and long-term care are substantial. Introducing interventions that reduce or delay institutional care will likely reduce costs incurred at the end of life.
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82
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Musich S, Wang SS, Hawkins K, Yeh CS. Disparities Among Those With Advance Directives in a Medicare Supplement Population. Am J Hosp Palliat Care 2015; 33:463-70. [PMID: 25735807 DOI: 10.1177/1049909115574837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Advance directives (ADs) detail patients' end-of-life (EOL) care preferences. We estimated AD prevalence rates among a Medicare Supplement population and determined characteristics associated with having ADs. We also estimated the impact of having an AD on EOL Medicare expenditures among respondents who later died. Survey respondents with an AD (72%) were significantly more likely to be female, older, nonminority, higher income and education, and have more comorbid conditions. Following regression adjustments, EOL expenditures were significantly lower for those with ADs in the last 3 months (-US$11 189) and 1 month (-US$6092) prior to death. Patients with ADs specifying their wishes for EOL care had significantly lower medical expenditures during the last few months of life. However, disparities exist among those with ADs that may warrant interventions.
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83
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Abstract
Due to the unprecedented increase in the United States aging demographics, many more people are living longer and reaching older ages than ever before. However, a longer life is not necessarily a better life, as the vast majority will face a period of prolonged deteriorating health prior to death. Although notable efforts have been underway that are designed to improve the end-of-life experience, increasing numbers of individuals express a desire and/or act upon an intent to end their lives precipitously. Though still limited, the options to actively participate in their own deaths are growing. Requests for a hastened death can occur among people of all ages and includes those with advanced illness as well as others wanting to die due to unbearable suffering. This article provides an overview of the ongoing discourse about the experience of dying faced by many older adults, including aspects frequently associated with "a good death." The limitations of established practices which seek to provide a "better" dying experience are identified followed by discussion of the growing availability of alternative options. Reflective considerations are presented to guide practice vis-à-vis the changing landscape surrounding options in dying.
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Affiliation(s)
- Kathy Black
- a College of Arts and Sciences , University of South Florida, Sarasota-Manatee , Sarasota , Florida , USA
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84
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Sudore RL, Casarett D, Smith D, Richardson DM, Ersek M. Family involvement at the end-of-life and receipt of quality care. J Pain Symptom Manage 2014; 48:1108-16. [PMID: 24793077 DOI: 10.1016/j.jpainsymman.2014.04.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 03/24/2014] [Accepted: 04/23/2014] [Indexed: 11/18/2022]
Abstract
CONTEXT Most patients will lose decision-making capacity at the end of life. Little is known about the quality of care received by patients who have family involved in their care. OBJECTIVES To evaluate differences in the receipt of quality end-of-life care for patients who died with and without family involvement. METHODS We retrospectively reviewed the charts of 34,290 decedents from 146 acute and long-term care Veterans Affairs facilities between 2010 and 2011. Outcomes included: (1) palliative care consult, (2) chaplain visit, and 3) death in an inpatient hospice or palliative care unit. We also assessed "do not resuscitate" (DNR) orders. Family involvement was defined as documented discussions with the health care team in the last month of life. We used logistic regression adjusted for demographics, comorbidity, and clustered by facility. For chaplain visit, hospice or palliative care unit death, and DNR, we additionally adjusted for palliative care consults. RESULTS Mean (SD) age was 74 (±12) years, 98% were men, and 19% were nonwhite. Most decedents (94.2%) had involved family. Veterans with involved family were more likely to have had a palliative care consult, adjusted odds ratio (AOR) 4.31 (95% CI 3.90-4.76); a chaplain visit, AOR 1.18 (95% CI 1.07-1.31); and a DNR order, AOR 4.59 (95% CI 4.08-5.16) but not more likely to die in a hospice or palliative care unit. CONCLUSION Family involvement at the end of life is associated with receipt of palliative care consultation and a chaplain visit and a higher likelihood of a DNR order. Clinicians should support early advance care planning for vulnerable patients who may lack family or friends.
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Affiliation(s)
- Rebecca L Sudore
- San Francisco VA Medical Center, University of California, San Francisco, California, USA; Division of Geriatrics, University of California, San Francisco, California, USA.
| | - David Casarett
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dawn Smith
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Diane M Richardson
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Mary Ersek
- School of Nursing, Philadelphia, Pennsylvania, USA; Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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85
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Hedinger D, Braun J, Zellweger U, Kaplan V, Bopp M. Moving to and dying in a nursing home depends not only on health - an analysis of socio-demographic determinants of place of death in Switzerland. PLoS One 2014; 9:e113236. [PMID: 25409344 PMCID: PMC4237376 DOI: 10.1371/journal.pone.0113236] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 10/22/2014] [Indexed: 11/18/2022] Open
Abstract
Background In developed countries generally about 7 out of 10 deaths occur in institutions such as acute care hospitals or nursing homes. However, less is known about the influence of non-medical determinants of place of death. This study examines the influence of socio-demographic and regional factors on place of death in Switzerland. Data and Methods We linked individual data from hospitals and nursing homes with census and mortality records of the Swiss general population. We differentiated between those who died in a hospital after a length of stay ≤2 days or ≥3 days, those who died in nursing homes, and those who died at home. In gender-specific multinomial logistic regression models we analysed N = 85,129 individuals, born before 1942 (i.e., ≥65 years old) and deceased in 2007 or 2008. Results Almost 70% of all men and 80% of all women died in a hospital or nursing home. Regional density of nursing home beds, being single, divorced or widowed, or living in a single-person household were predictive of death in an institution, especially among women. Conversely, homeownership, high educational level and having children were associated with dying at home. Conclusion Place of death substantially depends on socio-demographic determinants such as household characteristics and living conditions as well as on regional factors. Individuals with a lower socio-economic position, living alone or having no children are more prone to die in a nursing home. Health policy should empower these vulnerable groups to choose their place of death in accordance to needs and wishes.
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Affiliation(s)
- Damian Hedinger
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Julia Braun
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Ueli Zellweger
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | | | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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86
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Tschirhart EC, Du Q, Kelley AS. Factors influencing the use of intensive procedures at the end of life. J Am Geriatr Soc 2014; 62:2088-94. [PMID: 25376084 DOI: 10.1111/jgs.13104] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To examine individual and regional factors associated with the use of intensive medical procedures in the last 6 months of life. DESIGN Retrospective cohort study. SETTING The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of older adults. PARTICIPANTS HRS decedents aged 66 and older (N = 3,069). MEASUREMENTS Multivariable logistic regression was used to evaluate associations between individual and regional factors and receipt of five intensive procedures: intubation and mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral and parenteral nutrition, or cardiopulmonary resuscitation in the last 6 months of life. RESULTS Approximately 18% of subjects (n = 546) underwent at least one intensive procedure in the last 6 months of life. Characteristics significantly associated with lower odds of an intensive procedure included aged 85-94 (vs 65-74, adjusted odds ratio (AOR) = 0.67, 95% confidence interval (CI) = 0.51-0.90), Alzheimer's disease (AOR = 0.71, 95% CI = 0.54-0.94), cancer (AOR = 0.60, 95% CI = 0.43-0.85), nursing home residence (AOR = 0.70, 95% CI = 0.50-0.97), and having an advance directive (AOR = 0.71, 95% CI = 0.57-0.89). In contrast, living in a region with higher hospital care intensity (AOR = 2.16, 95% CI = 1.48-3.13) and black race (AOR = 2.02, 95% CI = 1.52-2.69) each doubled one's odds of undergoing an intensive procedure. CONCLUSION Individual characteristics and regional practice patterns are important determinants of intensive procedure use in the last 6 months of life. The effect of nonclinical factors highlights the need to better align treatments with individual preferences.
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Affiliation(s)
- Evan C Tschirhart
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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87
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Tucker-Seeley RD, Abel GA, Uno H, Prigerson H. Financial hardship and the intensity of medical care received near death. Psychooncology 2014; 24:572-8. [PMID: 25052138 DOI: 10.1002/pon.3624] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/26/2014] [Accepted: 06/30/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although end-of-life (EOL) care can present a substantial financial burden for the household, the influence of this burden on the intensity of care received at the EOL remains unknown. The goal of this study was to determine the association between financial hardship and intensive care in the last week of life. METHODS The Coping with Cancer (CwC) Study is a longitudinal, multisite cohort study of terminally ill cancer patients and their informal caregivers, September 2002-February 2008. Patients (N = 281) were followed from baseline to death, a median of 4.4 months after baseline assessment. Intensive care was defined as the use of resuscitation and/or ventilation in the patient's last week of life. Financial hardship was measured at study baseline as a positive response to whether the household had to use all or most of their savings because of the family member's illness. RESULTS Twenty-nine percent reported financial hardship, and 9% received intensive EOL care. Patients reporting financial hardship had a 3.22 (95% CI: 1.38, 7.53) higher likelihood of receiving intensive EOL care compared with patients not reporting financial hardship. After adjusting for sociodemographic characteristics and patient preferences, patients reporting financial hardship had a 3.05 (95% CI: 1.22, 7.62) higher likelihood of receiving intensive EOL care. CONCLUSION The depletion of a family's financial resources is a significant predictor of intensive EOL care, over and above the influence of sociodemographic characteristics and patient preferences.
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88
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May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med 2014; 17:1054-63. [PMID: 24984168 DOI: 10.1089/jpm.2013.0594] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Maintaining the recent expansion of palliative care access in the United States is a recognized public health concern. Economic evaluation is essential to validate current provision and assess the case for new programs. Previous economic reviews in palliative care reported on programs across settings and systems; none has examined specifically the hospital consultative model, the dominant model of provision in the United States. OBJECTIVES To review systematically the economic evidence on specialist palliative care consultation teams in the hospital setting, to appraise this evidence critically, and to identify areas for future research in this field. DATA SOURCES A meta-review ("a review of existing reviews") was conducted of eight published systematic reviews and one relevant nonsystematic review. To identify articles published outside of the timeframe of these reviews, systematic searches were performed on the PubMed, CINAHL, and EconLit databases. STUDY SELECTION Articles were included if they compared the costs and/or cost effectiveness of a specialist hospital inpatient palliative care consultation for adult patients with those of a comparator. RESULTS Ten studies were included and these demonstrate a clear pattern of cost-saving impact from inpatient consultation programs. Nevertheless, knowledge gaps still exist regarding the economic effects of these programs. Current evidence has been generated from the hospital perspective; health system costs, patient and caregiver costs, and health outcomes are typically not included. CONCLUSIONS Inpatient palliative care consultation programs have been shown to save hospitals money and to provide improved care to patients with serious illness. With a clear pattern of cost-saving using current methodology, it is timely to begin expanding the scope of economic evaluation in this field. Future research must address the measurement of both costs and outcomes to understand more fully the role that palliative care plays in enhancing value in health care. Relevant domains for such research are identified.
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Affiliation(s)
- Peter May
- 1 Centre for Health Policy and Management, Trinity College Dublin , Ireland
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89
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Meeker MA, Waldrop DP, Schneider J, Case AA. Contending with advanced illness: patient and caregiver perspectives. J Pain Symptom Manage 2014; 47:887-95. [PMID: 24035069 DOI: 10.1016/j.jpainsymman.2013.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 06/07/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Despite improvements in end-of-life care, some unrelieved suffering persists for patients with advanced illness and their family members. Hospice and palliative care services can reduce suffering, but these services remain under-used. OBJECTIVES To investigate how patients with advanced illness and their primary caregivers experienced and responded to health care needs and decision making and how some dyads moved toward comfort-focused care. METHODS This was a qualitative study using the grounded theory method for sample selection, data collection, and analysis. Dyadic semi-structured interviews were audio-recorded and transcribed for analysis. Twenty-two participants, 12 patients and 10 family surrogates, provided 16 interviews for this study. RESULTS Participants engaged in a process of contending with advanced illness. The major phases comprising this process were suffering, struggling, and settling. Struggling included enduring the experience and fighting the illness. During the phase of settling, the focus shifted away from curative efforts and toward supportive care. Conditions that facilitated the movement into this phase included receiving clear and consistent information about the patient's health status, trusting health care providers, having attended to advance care planning in some form, and being aware of and able to acknowledge the terminal nature of the illness. CONCLUSION Findings from this pilot study offer a preliminary theoretical model to enhance the understanding of patient and family caregiver needs during advanced illness. Awareness of their perspective can inform the timing and content of clinicians' communication and interventions.
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Affiliation(s)
- Mary Ann Meeker
- University at Buffalo, The State University of New York, Buffalo, New York, USA.
| | - Deborah P Waldrop
- University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Jaclyn Schneider
- University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Amy A Case
- University at Buffalo, The State University of New York, Buffalo, New York, USA; VA Western New York Healthcare System, Buffalo, New York, USA
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90
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Kelley AS, Langa KM, Smith AK, Cagle J, Ornstein K, Silveira MJ, Nicholas L, Covinsky KE, Ritchie CS. Leveraging the health and retirement study to advance palliative care research. J Palliat Med 2014; 17:506-11. [PMID: 24694096 DOI: 10.1089/jpm.2013.0648] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The critical need to expand and develop the palliative care evidence base was recently highlighted by the Journal of Palliative Medicine's series of articles describing the Research Priorities in Geriatric Palliative Care. The Health and Retirement Study (HRS) is uniquely positioned to address many priority areas of palliative care research. This nationally representative, ongoing, longitudinal study collects detailed survey data every 2 years, including demographics, health and functional characteristics, information on family and caregivers, and personal finances, and also conducts a proxy interview after each subject's death. The HRS can also be linked with Medicare claims data and many other data sources, e.g., U.S. Census, Dartmouth Atlas of Health Care. SETTING While the HRS offers innumerable research opportunities, these data are complex and limitations do exist. Therefore, we assembled an interdisciplinary group of investigators using the HRS for palliative care research to identify the key palliative care research gaps that may be amenable to study within the HRS and the strengths and weaknesses of the HRS for each of these topic areas. CONCLUSION In this article we present the work of this group as a potential roadmap for investigators contemplating the use of HRS data for palliative care research.
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Affiliation(s)
- Amy S Kelley
- 1 Brookdale Depratment of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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91
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Gómez-Batiste X, Martínez-Muñoz M, Blay C, Amblàs J, Vila L, Costa X, Espaulella J, Espinosa J, Constante C, Mitchell GK. Prevalence and characteristics of patients with advanced chronic conditions in need of palliative care in the general population: a cross-sectional study. Palliat Med 2014; 28:302-11. [PMID: 24403380 DOI: 10.1177/0269216313518266] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Of deaths in high-income countries, 75% are caused by progressive advanced chronic conditions. Palliative care needs to be extended from terminal cancer to these patients. However, direct measurement of the prevalence of people in need of palliative care in the population has not been attempted. AIM Determine, by direct measurement, the prevalence of people in need of palliative care among advanced chronically ill patients in a whole geographic population. DESIGN Cross-sectional, population-based study. MAIN OUTCOME MEASURE prevalence of advanced chronically ill patients in need of palliative care according to the NECPAL CCOMS-ICO(©) tool. NECPAL+ patients were considered as in need of palliative care. SETTING/PARTICIPANTS County of Osona, Catalonia, Spain (156,807 inhabitants, 21.4% > 65 years). Three randomly selected primary care centres (51,595 inhabitants, 32.9% of County's population) and one district general hospital, one social-health centre and four nursing homes serving the patients. Subjects were all patients attending participating settings between November 2010 and October 2011. RESULTS A total of 785 patients (1.5% of study population) were NECPAL+: mean age = 81.4 years; 61.4% female. Main disease/condition: 31.3% advanced frailty, 23.4% dementia, 12.9% cancer (ratio of cancer/non-cancer = 1/7), 66.8% living at home and 19.7% in nursing home; only 15.5% previously identified as requiring palliative care; general clinical indicators of severity and progression present in 94% of cases. CONCLUSIONS Direct measurement of prevalence of palliative care needs on a population basis is feasible. Early identification and prevalence determination of these patients is likely to be the cornerstone of palliative care public health policies.
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Affiliation(s)
- Xavier Gómez-Batiste
- 1The Qualy Observatory/WHO Collaborating Centre for Palliative Care Public Health Programmes (WHOCC), Institut Català d'Oncologia (ICO), Barcelona, Spain
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92
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Schousboe JT, Paudel ML, Taylor BC, Mau LW, Virnig BA, Ensrud KE, Dowd BE. Estimation of standardized hospital costs from Medicare claims that reflect resource requirements for care: impact for cohort studies linked to Medicare claims. Health Serv Res 2014; 49:929-49. [PMID: 24461126 DOI: 10.1111/1475-6773.12151] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To compare cost estimates for hospital stays calculated using diagnosis-related group (DRG) weights to actual Medicare payments. DATA SOURCES/STUDY SETTING Medicare MedPAR files and DRG tables linked to participant data from the Study of Osteoporotic Fractures (SOF) from 1992 through 2010. Participants were women age 65 and older recruited in three metropolitan and one rural area of the United States. STUDY DESIGN Costs were estimated using DRG payment weights for 1,397 hospital stays for 795 SOF participants for 1 year following a hip fracture. Medicare cost estimates included Medicare and secondary insurer payments, and copay and deductible amounts. PRINCIPAL FINDINGS The mean (SD) of inpatient DRG-based cost estimates per person-year were $16,268 ($10,058) compared with $19,937 ($15,531) for MedPAR payments. The correlation between DRG-based estimates and MedPAR payments was 0.71, and 51 percent of hospital stays were in different quintiles when costs were calculated based on DRG weights compared with MedPAR payments. CONCLUSIONS DRG-based cost estimates of hospital stays differ significantly from Medicare payments, which are adjusted by Medicare for facility and local geographic characteristics. DRG-based cost estimates may be preferable for analyses when facility and local geographic variation could bias assessment of associations between patient characteristics and costs.
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Affiliation(s)
- John T Schousboe
- Park Nicollet Institute for Research and Education, Division of Health Policy and Management, University of Minnesota, Minneapolis, MN
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93
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Kelley AS, Deb P, Du Q, Aldridge Carlson MD, Morrison RS. Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff (Millwood) 2014; 32:552-61. [PMID: 23459735 DOI: 10.1377/hlthaff.2012.0851] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53-105 days before death. Using data from the Health and Retirement Study, 2002-08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53-105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1-7, 8-14, and 15-30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.
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Affiliation(s)
- Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, USA.
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94
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Bern-Klug M. A conceptual model of family surrogate end-of-life decision-making process in the nursing home setting: goals of care as guiding stars. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2014; 10:59-79. [PMID: 24628142 DOI: 10.1080/15524256.2013.877863] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
An increasing proportion of dying is occurring in America's nursing homes (NH). Family members are involved in (and affected by) medical decision-making on behalf of NH residents approaching the end of life, especially when the resident is cognitively impaired. This article proposes an empirically derived conceptual model of the key factors NH family surrogate decision-makers consider when establishing or changing goals of care and the iterative process as applied to the NH setting. This model also establishes the importance of family social role expectations toward their loved one as well as the concept, "stance toward dying," as key in establishing or changing the main goal of care. NH staff and physicians can use the model as a framework for providing information and support to family members. Research is needed to better understand how to prepare staff and settings to support family surrogate decision-makers, in particular around setting goals of care. The model can be generalized beyond nursing homes.
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95
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Rosenkrantz AB. Regional Variation in Medicare Imaging Utilization and Expenditures: 2007-2011 Trends and Comparison with Other Health Services. J Am Coll Radiol 2014; 11:45-50. [DOI: 10.1016/j.jacr.2013.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 05/17/2013] [Indexed: 11/29/2022]
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96
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Mohan AV, Fazel R, Huang PH, Shen YC, Howard D. Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial. Circ Cardiovasc Qual Outcomes 2014; 7:125-30. [DOI: 10.1161/circoutcomes.113.000282] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Clinical uncertainty is cited as a cause of geographic variation. However, little is known about the effect of comparative effectiveness research on variation. We examined whether geographic variation in the use of percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) declined after publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial.
Methods and Results—
We examined changes in utilization and geographic variation in 67 hospital referral regions using the State Inpatient Databases. We compared age- and sex-adjusted rates of PCI for SIHD before (2006) and after (2008) publication of the COURAGE trial and compared those with contemporaneous changes in PCI volume for acute coronary syndrome. A total of 272 659 PCIs for SIHD from 526 hospitals were included in the analysis. After the publication of the COURAGE trial, PCI volume for SIHD declined by 25% (
P
<0.001) and decreased by 12% for acute coronary syndrome (
P
<0.001). This was predominantly attributable to changes in hospital referral regions with the highest levels of utilization pre-COURAGE trial (35% decline in the highest tertile versus 18% in the lowest). As measured by the systematic component of variation, there was substantial geographic variation in the use of PCI for SIHD preceding the publication of the COURAGE trial. Variation declined by 28% (0.53 versus 0.40) after publication, but geographic variation remained higher for SIHD than acute coronary syndrome (0.40 versus 0.17).
Conclusions—
There was a substantial decline in the use of and geographic variation in PCI for SIHD after the publication of the COURAGE trial. However, geographic variation in the use of PCI for SIHD remained high.
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Affiliation(s)
- Arun V. Mohan
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Reza Fazel
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Pei-Hsiu Huang
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Yu-Chu Shen
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - David Howard
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
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Abstract
AIM Ageism in health care delivery and nursing poses a fundamental threat to health and society. In this commentary, implications of age discrimination are presented to generate an agenda for action in nursing management. BACKGROUND In nations like the United States and the United Kingdom, nursing is an ageing profession caring for an ageing society where age discrimination takes many forms and has broad impact. EVALUATION This commentary critically synthesizes the literature on ageism and relevant data on ageing societies for nurse managers and other leaders. KEY ISSUES Investigations of ageism suggest that discrimination negatively affects health and results in poor health care experiences. Age discrimination is present in nursing, exacerbating workforce shortages and limiting the use of expertise within the profession. CONCLUSION Nursing faces a future for which understanding ageing societies and ageism is essential. An agenda for the future is proposed. IMPLICATIONS FOR NURSING MANAGEMENT Nurse managers possess the power to enact an agenda for combating ageism in health care and nursing.
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Affiliation(s)
- Sarah H Kagan
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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98
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Morishima T, Lee J, Otsubo T, Imanaka Y. Association of healthcare expenditures with aggressive versus palliative care for cancer patients at the end of life: a cross-sectional study using claims data in Japan. Int J Qual Health Care 2013; 26:79-86. [PMID: 24225269 DOI: 10.1093/intqhc/mzt081] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND End-of-life (EOL) care imposes heavy economic burdens on patients and health insurers. Little is known about the association between the types of EOL care and healthcare costs for cancer patients across various providers. OBJECTIVE To explore the association of healthcare expenditures with benchmarking indicators of aggressive versus palliative care among terminally ill cancer patients, from the perspective of health insurers. DESIGN Cross-sectional retrospective study using health insurance claims data. SETTING participants Cancer patients who had died in Kyoto prefecture, Japan, between April 2009 and May 2010. Main outcome measure Claims data were analyzed using multilevel generalized linear models to examine whether aggressive care and palliative care were associated with expenditures during the last 3 months of life, after adjusting for patient characteristics, hospital characteristics and other non-indicator procedures. RESULTS We analyzed 3143 decedents from 54 hospitals. Median expenditure per patient during the last 3 months was US$13 030. Higher expenditures were associated with the aggressive care indicators of higher mortality at acute-care hospitals and use of chemotherapy in the last month of life, as well as with the palliative care indicators of increased hospice care and opioid use in the last 3 months of life. However, increased physician home care in the last 3 months was associated with lower expenditure. CONCLUSIONS Indicators of both aggressive and palliative EOL care were associated with higher healthcare expenditures. These results may support the coherent development of measures to optimize aggressive care and reduce the financial burdens of terminal cancer care.
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Affiliation(s)
- Toshitaka Morishima
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.
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99
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Abstract
The U.S. health care system is struggling to improve the quality of health care while containing costs. The rapidly expanding population of older adults with serious illness presents both the greatest challenge and potentially the greatest opportunity to achieving this goal. In order to capitalize on this opportunity, we must first examine the epidemiology of the care of older adults with serious illness, that is, a full description of the characteristics and quality of care from the time of diagnosis through the full course of illness, including measurement of all factors that may influence or impact that care. Several methodological challenges exist in this area of study, including but not limited to, defining the onset of serious illness, avoiding bias in sample selection, and measuring the full breadth of personal, social, local, regional and provider factors that may influence care. Yet, this work is possible through a combination of targeted primary research and efficient leveraging of ongoing studies and existing data sources. Through these studies, we may identify those factors and services associated with high value health care, and learn to develop and refine policies and health care delivery models that yield the greatest improvements in care for seriously ill older patients and their families.
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Affiliation(s)
- Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York 10029-6574, USA.
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100
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Gessert CE, Haller IV, Johnson BP. Regional variation in care at the end of life: discontinuation of dialysis. BMC Geriatr 2013; 13:39. [PMID: 23635315 PMCID: PMC3649921 DOI: 10.1186/1471-2318-13-39] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 04/22/2013] [Indexed: 11/10/2022] Open
Abstract
Background Regional variation in the intensity of end-of-life care contributes significantly to the overall cost of health care. The interpretation of patterns of regional variation hinges, in part, on appropriate adjustment for regional variation in demographic variables such as age, race, sex, and rural vs. urban residence. This study examined regional variation in discontinuation of dialysis prior to death in the US, after adjustment for key demographic variables. Methods In this retrospective cohort study of the 2009 United States Renal Data System (USRDS) database we examined discontinuation of dialysis prior to death among deceased adult patients with end-stage renal disease (ESRD) from the 50 states and the District of Columbia. The discontinuation of dialysis prior to death was ascertained from the Centers for Medicare & Medicaid Services form 2746 (ESRD Death Notification form). We used logistic regression to estimate the log-odds of discontinuation of dialysis with ESRD network as independent variable adjusted for urban–rural status, demographic and treatment variables. Results The study cohort included 715,605 deceased ESRD patients; for 176,021 of whom (24.6%) dialysis was discontinued prior to death. Dialysis was discontinued at higher rates for women than for men (26.3% vs. 23.0%, p < 0.001) and for whites than for blacks (29.5% vs. 14.7%, p < 0.001). Significant regional variation in dialysis discontinuation prior to death was noted after adjustment for age, race and rural–urban status: rates of discontinuation in the Upper Midwest and Mountain regions were more than double the rates in Southern and Coastal regions. This pattern parallels the regional pattern of end-of-life health service utilization documented in the Dartmouth Atlas and other studies. Conclusions Discontinuation of dialysis prior to death was common in the US between 1995 and 2009. The deaths of nearly one quarter of chronic dialysis patients followed a decision to discontinue dialysis. Significant regional variation in discontinuation rates exists after adjusting for age, race, sex, and rural–urban status. Further research and analysis is needed on the cultural and economic factors that affect regional variation in health services utilization, especially in regard to the use of expensive medical services near the end of life.
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Affiliation(s)
- Charles E Gessert
- Division of Research, Essentia Institute of Rural Health, Duluth, MN, USA.
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