Medicare Cost at End of Life

Procedural Interventions for Terminally Ill Children - Are We Aiding Palliation?

Objectives: Many children undergo surgery or an invasive procedure during their terminal hospital admission.1 The types of procedures, patients, and the intent of the procedures has not been well defined. Understanding these details may help pediatric surgeons better determine the clinical settings in which certain procedures will not enhance palliation or survival. Methods: A retrospective single institution chart review was performed for patients age 14 days to 18 years with chronic conditions who died while inpatient from 2013-2017. Data was gathered on demographics, primary diagnosis, intubation status, palliative care involvement, duration of hospital stay, length of palliative care involvement, and total number of procedures. Negative binomial regression was used to assess association with number of procedures. Results: 132 children met inclusion criteria. Most children were White and less than one year old. The most common type of diagnosis was cardiac in nature. Children underwent an average of three procedures. 75% were intubated and 77.5% had palliative care involved. Patients who were less than one year old at death were more likely to have been intubated, had longer terminal hospital stays, and had more procedures. Those who were intubated underwent more procedures and had longer hospital stays. Those with longer palliative care involvement had fewer procedures. Conclusions: Children undergo a significant number of surgical procedures during their terminal hospitalization. This may be influenced by age, intubation status, and length of stay. Ongoing study may help refine which procedures may have limited impact on survival in the chronically ill pediatric population.

Paying for advance care planning in medicare: Impacts on care and spending near end of life

Spending at end of life (EOL) accounts for a large and growing share of healthcare expenditures in the US, and often reflects aggressive care with questionable value for dying patients. Using a novel instrumental variables approach, we conduct the first study on the causal effect of Medicare reimbursement for advance care planning (ACP)-the process of discussing and recording patient preferences for goals of care-on care utilization, spending, and mortality outcomes for critically ill Medicare patients. We find that billed ACP services substantially increase hospice use and hospice spending within a year, accompanied by corresponding increase in one-year mortality. The impacts of ACP services on hospice use and spending are especially prominent among patients with dementia and those of lower socioeconomic status. Among decedents, death is significantly less likely to occur in the hospital, and total and inpatient spending within the last 30 days of life fall significantly. Our findings suggest that paying for ACP services can be effective in improving hospice use for critically ill Medicare patients, with the (possibly intended) consequence of increased one-year mortality.

Economic Evaluation of 'Watch and Wait' Following Neoadjuvant Therapy in Locally Advanced Rectal Cancer: A Systematic Review

BACKGROUND

Owing to multimodal treatment and complex surgery, locally advanced rectal cancer (LARC) exerts a large healthcare burden. Watch and wait (W&W) may be cost saving by removing the need for surgery and inpatient care. This systematic review seeks to identify the economic impact of W&W, compared with standard care, in patients achieving a complete clinical response (cCR) following neoadjuvant therapy for LARC.

METHODS

The PubMed, OVID Medline, OVID Embase, and Cochrane CENTRAL databases were systematically searched from inception to 26 April 2024. All economic evaluations (EEs) that compared W&W with standard care were included. Reporting and methodological quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), BMJ and Philips checklists. Narrative synthesis was performed. Primary and secondary outcomes were (incremental) cost-effectiveness ratios and the net financial cost.

RESULTS

Of 1548 studies identified, 27 were assessed for full-text eligibility and 12 studies from eight countries (2016-2024) were included. Seven cost-effectiveness analyses (complete EEs) and five cost analyses (partial EEs) utilized model-based (n = 7) or trial-based (n = 5) analytics with significant variations in methodological design and reporting quality. W&W showed consistent cost effectiveness (n = 7) and cost saving (n = 12) compared with surgery from third-party payer and patient perspectives. Critical parameters identified by uncertainty analysis were rates of local and distant recurrence in W&W, salvage surgery, perioperative mortality and utilities assigned to W&W and surgery.

CONCLUSION

Despite heterogenous methodological design and reporting quality, W&W is likely to be cost effective and cost saving compared with standard care following cCR in LARC. Clinical Trials Registration PROSPERO CRD42024513874.

Cost Offset of Dapagliflozin in the US Medicare Population with Cardio-Kidney Metabolic Syndrome

INTRODUCTION

Cardiovascular-kidney-metabolic (CKM) syndrome is highly prevalent in the US Medicare population and is projected to increase further. Sodium-glucose co-transporter 2 inhibitors have indications in chronic kidney disease (CKD), heart failure (HF), and type 2 diabetes (T2D), providing protective efficacy across conditions within CKM syndrome. The objective of this study was to develop a model to extrapolate key outcomes observed in pivotal clinical trials to the US Medicare population, and to assess the potential direct cost offsets associated with dapagliflozin therapy.

METHODS

All US 2022 Medicare beneficiaries (≥ 65 years of age) eligible to receive dapagliflozin were estimated according to drug label indication and Medicare enrollment and claims data. Incidence of key outcomes from the dapagliflozin clinical program were modelled over a 4-year time horizon based on patient-level data with CKD, HF, and T2D. Published cost data of relevant clinical outcomes were used to calculate direct medical care cost-offset associated with treatment with dapagliflozin.

RESULTS

In a population of 13.1 million patients with CKM syndrome, treatment with dapagliflozin in addition to historical standard of care (hSoC) versus hSoC alone led to fewer incidents of HF-related events (hospitalization for HF, 613,545; urgent HF visit, 98,896), renal events (kidney failure, 285,041; ≥ 50% sustained decline in kidney function, 375,137), and 450,355 fewer deaths (of which 225,346 and 13,206 incidences of cardiovascular and renal death were avoided). In total this led to medical care cost offsets of $99.3 billion versus treatment with hSoC only (dapagliflozin plus hSoC, $310.3 billion; hSoC, $211.0 billion).

CONCLUSION

By extrapolating data from trials across multiple indications within CKM syndrome, this broader perspective shows that considerable medical care cost offsets may result through attenuated incidence of clinical events in CKD, T2D, and HF populations if treated with dapagliflozin in addition to hSoC over a 4-year time horizon. Graphical abstract available for this article.

Diverging Patterns of Cognitive Decline by Sex and Race-Ethnicity in Seriously Ill Older Americans

Objectives

Differences in Cognitive decline are common in older adults in the last years of life, but differences across sex and race-ethnicity are poorly understood. This study investigated if sex and/or race-ethnicity moderated changes in cognitive function in older adults in the last years of life.

Methods

Data from the Health and Retirement Study (HRS) from 1993 to 2016 were used to analyze imputed cognition summary scores for total word recall and mental status of older adults aged 60-99. Loss of cognitive function was estimated using a multilevel mixed-effects model and accelerated cognitive decline was approximated by incorporating a change-point model using a restricted sample of decedent respondents who died aged 65-99.

Results

Notable disparities were seen in the rates of cognitive decline across sex and race-ethnic groups in the last years of life. Women consistently scored lower than men in word recall but higher in mental status, regardless of race-ethnicity. Non-Hispanic White respondents, men and women, consistently outperformed Hispanic and Black respondents in word recall tasks and mental status.

Conclusions

Our study shows that sex and race-ethnicity moderate cognitive decline in older adults during the last years of life. Older adults from underserved communities are at higher risk of cognitive decline. Our study could inform clinical practice and policy focused on mitigating the adverse impact of cognitive decline experienced by marginalized populations of older adults in the last years of life.

The Structure of Clinical Ethical Decision-Making: A Hospital System Needs Assessment

Bioethical dilemmas can emerge in research and clinical settings, from end-of-life decision-making to experimental therapies. The COVID-19 pandemic raised serious ethical challenges for healthcare organizations, highlighting the need to conduct needs assessments of the bioethics infrastructures of healthcare organizations. Clinical ethics committees (CECs) also create equitable policies, train staff on ethics issues, and play a consultative role in resolving the difficulty of complex individual cases. The main objective of this project was to conduct a needs assessment of the bioethics infrastructure within a comprehensive hospital system. A cross-sectional anonymous online survey, including quantitative and qualitative formatted questions. The survey was sent to five key leaders from the organization's hospitals. Survey questions focused on the composition, structure, function, and effectiveness of their facilities' bioethics infrastructure and ethics-related training and resources. Positive findings included that most facilities have active CECs with multidisciplinary membership; CECs address critical issues and encourage team members to express clinical ethics concerns. Areas of concern included uncertainty about how CECs function and the process for resolving clinical ethics dilemmas. Most reported no formal orientation process for CEC members, and many said there was no ongoing ethics education process. The authors conclude that if CECs are a critical institutional resource where the practice of medicine and mission intersect, having well-functioning ethics committees with trained and oriented members demonstrates an essential commitment to the mission. The survey revealed that more needs to be done to bolster the bioethics infrastructure of this institution.

Challenges of palliative care identified by stakeholders in resource-limited settings: A multi-regional study in Kazakhstan

INTRODUCTION

In Kazakhstan, a country of 19 million residents, more than 100,000 patients need palliative care. Since at least one family member is usually involved in the care of a terminal patient, more than 200,000 people would benefit from high-quality palliative care services in the country. However, with only 45 physicians and 101 nurses attending to 1925 palliative beds, Kazakhstan seeks to develop palliative services that meet the national needs in resource-limited settings and international standards. The objectives of this study are to explore the challenges faced by stakeholders involved in palliative care in Kazakhstan and to subsequently provide recommendations that can guide policymakers towards further developing palliative care services in the country.

METHODS

This cross-sectional descriptive study collected narrative data with in-depth interviews from n= 29 palliative stakeholders (family caregivers n= 12, healthcare professionals =12, administrators n= 5) across five regions of Kazakhstan. Verbatim transcripts of interviews were analyzed using content analysis to identify needs and challenges of stakeholders involved in palliative care.

RESULTS

Our analysis identified seven main challenges of palliative care stakeholders: high out-of-pocket expenditures; lack of mobile palliative care services for home-based care; severe shortages of opioids to prevent pain suffering; poor formal palliative care education; absence of practical skills training for family caregivers; lack of awareness about palliative care in the society, and lack of state support.

CONCLUSION

Implementation of national palliative care strategies and policies require a large-scale coordinated involvement of all stakeholders. Our recommendations are based on the idea that coordinated, targeted, and tailored stakeholder engagement is preferred to a one-size-fits-all strategy.

Integrating Palliative Care Screening in the Intensive Care Unit: A Quality Improvement Project

BACKGROUND

Patients admitted to the intensive care unit have complex medical problems and increased rates of mortality and recurrent hospitalization for the following 10 years compared with patients without a history of critical illness. Delayed access to palliative care can result in untreated symptoms, lack of understanding of care preferences, and preventable admissions. Despite studies supporting palliative care screening, there is no standardized method to assess palliative care needs of patients admitted to critical care units.

LOCAL PROBLEM

A community hospital critical care team identified a need for an improved palliative care process for patients admitted to the intensive care unit.

METHODS

The aim of this quality improvement project was to improve patient access to timely palliative care consultation while increasing the reach of the palliative care team. Guided by the Institute for Healthcare Improvement model of plan-do-study-act cycles, the team created a palliative care screening tool with clinical indicators for nurses to use upon patient admission. Patients with numeric scores indicating positive screening tool results could be automatically referred for palliative care consultation.

RESULTS

Of 267 patients, 59 (22%) had positive screening tool results, compared with 31 (11.6%) identified with the traditional consultative method. Descriptive analysis revealed that patients identified for referral without use of the screening tool were hospitalized a mean of 6 days until consultation was requested.

CONCLUSION

The screening process can maximize the benefit of palliative care services with early patient identification, improved consultation efficiency, decreased critical care resource use, and reduced readmission rates.

End-of-life expenditure on health care for the older population: a scoping review

BACKGROUND

The existing evidence shows that the pattern of health expenditure differs considerably between people at the end-of-life and people in other periods of their lives. The awareness of these differences, combined with a detailed analysis of future mortality rates is one of the key pieces of information needed for health spending prognoses. The general objective of this review was to identify and map the existing empirical evidence on end-of-life expenditure related to health care for the older population.

METHODS

To achieve the objective of the study a systematic scoping review was performed. There were 61 studies included in the analysis. The project has been registered through the Open Science Framework.

RESULTS

The included studies cover different kinds of expenditure in terms of payers, providers and types of services, although most of them include analyses of hospital spending and nearly 60% of analyses were conducted for insurance expenditure. The studies provide very different results, which are difficult to compare. However, all of the studies analyzing expenditure by survivorship status indicate that expenditure on decedents is higher than on survivors. Many studies indicate a strong relationship between health expenditure and proximity to death and indicate that proximity to death is a more important determinant of health expenditure than age per se. Drawing conclusions on the relationship between end-of-life expenditure and socio-economic status would be possible only by placing the analysis in a broader context, including the rules of a health system's organization and financing. This review showed that a lot of studies are focused on limited types of care, settings, and payers, showing only a partial picture of health and social care systems in the context of end-of-life expenditure for the older population.

CONCLUSION

The results of studies on end-of-life expenditure for the older population conducted so far are largely inconsistent. The review showed a great variety of problems appearing in the area of end-of-life expenditure analysis, related to methodology, data availability, and the comparability of results. Further research is needed to improve the methods of analyses, as well as to develop some analysis standards to enhance research quality and comparability.

Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services

Accountable care organizations (ACOs) are often tasked with helping providers to deliver care efficiently and with higher quality outcomes. For an ACO to succeed in delivering efficient care, it is important to direct resources toward patients who exhibit the greatest levels of opportunity while focusing attention toward mitigating their needs. Home-based palliative care (HBPC) services are known to address patient needs for those with serious illness while decreasing the total cost of care (TCC). In this retrospective review, ACO researchers reviewed cost, quality, and utilization patterns for 3418 beneficiaries within a Medicare Shared Saving Program approaching the end of life comparing decedents who received HBPC versus those who did not receive the service. Those individuals who received HBPC services were significantly less likely to be hospitalized (51% reduction in the HBPC group), more likely to use hospice (70% vs. 43%; P = 0.001), and their TCC was less than that of those who did not receive the service ($27,203 vs. $36,089: P = 0.0163). Although more research needs to be done to understand the specific components of care delivery that are helpful in decreasing unnecessary utilization, in this retrospective review in an accountable care population, HBPC is associated with a significant decrease in cost and utilization in a population approaching end of life.

Longitudinal varying coefficient single-index model with censored covariates

It is of interest to health policy research to estimate the population-averaged longitudinal medical cost trajectory from initial cancer diagnosis to death, and understand how the trajectory curve is affected by patient characteristics. This research question leads to a number of statistical challenges because the longitudinal cost data are often non-normally distributed with skewness, zero-inflation, and heteroscedasticity. The trajectory is nonlinear, and its length and shape depend on survival, which are subject to censoring. Modeling the association between multiple patient characteristics and nonlinear cost trajectory curves of varying lengths should take into consideration parsimony, flexibility, and interpretation. We propose a novel longitudinal varying coefficient single-index model. Multiple patient characteristics are summarized in a single-index, representing a patient's overall propensity for healthcare use. The effects of this index on various segments of the cost trajectory depend on both time and survival, which is flexibly modeled by a bivariate varying coefficient function. The model is estimated by generalized estimating equations with an extended marginal mean structure to accommodate censored survival time as a covariate. We established the pointwise confidence interval of the varying coefficient and a test for the covariate effect. The numerical performance was extensively studied in simulations. We applied the proposed methodology to medical cost data of prostate cancer patients from the Surveillance, Epidemiology, and End Results-Medicare-Linked Database.

Estimating the Costs of End-of-Life Care in Patients With Advanced Cancer From the Perspective of an Insurance Organization: A Cross-Sectional Study in Iran

OBJECTIVES

Cancers are significant medical conditions that contribute to the rising costs of healthcare systems and chronic diseases. This study aimed to estimate the average costs of medical services provided to patients with advanced cancers at the end of life (EOL).

METHODS

We analyzed data from the Sata insurance claim database and the Health Information System of Baqiyatallah hospital in Iran. The study included all adult decedents who had advanced cancer without comorbidities, died between March 2020 and September 2020, and had a history of hospitalization in the hospital. We calculated the average total cost of healthcare services per patient during the EOL period, including both cancer-related and noncancer-related costs.

RESULTS

A total of 220 patients met the inclusion criteria. The average duration of the EOL period for these patients was 178 days, with an average total cost of $8278 (SD $5698) for men and $9396 (SD $6593) for women. Cancer-related costs accounted for 64.42% of the total costs, including inpatient and outpatient services. Among these costs, hospitalization was the primary cost driver and had the greatest impact on EOL costs. This observation was supported by the multiple linear regression model, which suggested that hospitalization in the final days of life could potentially drive costs in these patients. Notably, no specialized palliative care was provided to the patients included in this study.

CONCLUSIONS

The results demonstrate that there is a significant rise in costs of care in patients receiving routine cancer care rather than optimized EOL care.

Improving Policy and Practices of Hospice Live Discharge: A Historical Exploration of the Medicare Hospice Benefit

Hospice care in the US is heavily regulated to ensure access to the Medicare Hospice Benefit (MHB) for individuals with serious illness. Policy changes to the MHB, many of which intended to minimize potential fraud (e.g. focused medical reviews; documentation requirements for certifications, recertifications, and discharges; requirements of physician narratives and face-to-face visits), directly impact current hospice discharge practices and experiences. When patients revoke hospice or are unable to be recertified due to a stabilized condition, they lose access to the holistic philosophy of care and experience additional stressors with increased potential for burdensome transitions. Patients with chronic conditions, such as Alzheimer's disease or related dementias, Chronic Obstructive Pulmonary Disease, or heart failure are more likely to have longer length of stays and are more often discharged alive from hospice. Few policy changes have been made to account for growing incidents of patients dying of chronic illness though the policy was originally created primarily for cancer patients, reflecting a time when most patients were dying of cancer. This manuscript describes the uniquely American phenomenon of a hospice live discharge, reviews relevant and historical policies, and provides recommendations for future research, policy, and practice to better support patients and families during this critical healthcare transition.

Navigating parental requests: considering the relational potential standard in paediatric end-of-life care in the paediatric intensive care unit

Families and clinicians approaching a child's death in the paediatric intensive care unit (PICU) frequently encounter questions surrounding medical decision-making at the end of life (EOL), including defining what is in the child's best interest, finding an optimal balance of benefit over harm, and sometimes addressing potential futility and moral distress. The best interest standard (BIS) is often marshalled by clinicians to help navigate these dilemmas and focuses on a clinician's primary ethical duty to the paediatric patient. This approach does not consider a clinician's potential duty to the patient's family. This paper argues that when a child is dying in the PICU, the physician has a duty to serve both the patient and the family, and that in some circumstances, the duty to serve the family becomes as important as that owed to the child. We detail the limitations of the BIS in paediatric EOL care and propose the relational potential standard as an additional ethical framework to guide our decisions.

Unique characteristics of end-of-life hospitalizations in Parkinson disease

Introduction

Persons with Parkinson disease (PD) are hospitalized at higher rates, have longer lengths of stay, and are more likely to die in the hospital than age-matched peers. Although prior studies have compared inpatient outcomes between persons with and without PD, little is known about inpatient outcomes across the PD trajectory, or whether hospitalizations occurring in the last 6 months of life differ from earlier hospitalizations.

Methods

This cross-sectional study compared Medicare Part A and B beneficiaries aged 65 and older with a qualifying PD diagnosis who were hospitalized in 2017: decedents who died between 7/1/2017 and 12/31/2017 from all causes and were hospitalized at least once in their last 6 months of life, and non-decedents who were hospitalized between 1/1/2017 and 6/30/2017 and lived 6 or more months after discharge. End-of-life (EoL) hospitalizations were defined as those occurring in the last 6 months of life. Descriptive analyses compared patient-level variables (e.g., demographics, comorbidities, treatment intensity) and encounter-level variables (e.g., length of stay, total charges) between groups. Multivariable logistic regression models also compared rates of intensive care unit (ICU) admission and 30-day readmission between hospitalized decedents and hospitalized non-decedents, adjusting for age, sex, race/ethnicity, rural residence, and Charlson Comorbidity Index Score.

Results

Of 26,492 Medicare decedents with PD, 16,187 (61.1%) were hospitalized in their last 6 months of life. Of 347,512 non-decedents with PD, 62,851 (18.1%) were hospitalized in a 6-month period. Hospitalized decedents were slightly older than hospitalized non-decedents (82.3 [SD 7.40] vs. 79.5 [SD 7.54] years) and had significantly more comorbidities. Compared to non-EoL hospitalizations, EoL hospitalizations were slightly longer (5 [IQR 3-9] vs. 4 [IQR 3-7] days) and more expensive based on total charges per admission ($36,323 [IQR 20,091-69,048] vs. $32,309 [IQR 18,789-57,756]). In covariate-adjusted regression models using hospitalized non-decedents as the reference group, hospitalized decedents were more likely to experience an ICU admission (AOR 2.36; CI 2.28-2.45) and 30-day readmission (AOR 2.43; CI 2.34-2.54).

Discussion

Hospitalizations occurring in the last 6 months of life among persons with PD in the United States are longer, more costly, and more resource intensive than earlier hospitalizations and may stem from medical comorbidities. Once hospitalized, ICU admission and 30-day readmission may aid in prognostication and serve as markers of transition to the EoL period.

End-of life medical spending and care pathways in the last 12 months of life: A comprehensive analysis of the national claims database in France

BACKGROUND

To inform policy makers on efficient provision of end-of-life care, we estimated the 12-month medical expenditures of French decedents in 2015.

METHODS

We estimated total medical expenditures by service type and diagnosis category, and analyzed care pathways for breast cancer, dementia, chronic obstructive lung disease.

RESULTS

501,121 individuals died in 2015, 59% of whom were in a hospital at the time of death. The aggregated spending totaled 9% of total health expenditures, a mean of €28,085 per capita, 44% of which was spent during the last 3 months of life. Hospital admissions represented over 70% of total expenditures; 21.3% of the population used hospital palliative care services in their last year of life. Analyses performed on breast cancer, dementia and lung disease found that differences in care pathways markedly influenced spending and were not simply explained by patients characteristics.

CONCLUSION

Diagnoses and care trajectories, including repeated hospital stays, are the main drivers of the last year of life expenditures. Our data suggests that early identification of patients requiring palliative care and community-based end-of-life service delivery is feasible and could better support patients, families and caregivers with constant or reduced costs.

Healthcare utilization and direct medical costs of Huntington's disease among Medicaid beneficiaries in the United States

AIMS

To provide more recent estimates of healthcare utilization and costs in Huntington's disease (HD) in the Medicaid population.

MATERIALS AND METHODS

This retrospective analysis used administrative claims data for HD beneficiaries (≥1 HD claim; ICD-9-CM 333.4) from Medicaid Analytic eXtract data files from 01/01/2010-12/31/2014. The date of the first HD claim during the identification period (01/01/2011-12/31/13) was assigned as the index date. If a beneficiary had multiple HD claims during the identification period, one was randomly chosen as the index date. Beneficiaries were required to be continuously enrolled in fee-for-service plans during the one-year pre-index and post-index periods. Medicaid beneficiaries without HD were drawn from a 100% random sample and matched (3:1) to those with HD. Beneficiaries were classified by disease stage (early/middle/late). All-cause and HD-related (any utilization related to HD diagnosis or symptoms associated with HD) healthcare utilization and costs were reported.

RESULTS

A total of 1,785 beneficiaries without HD were matched to 595 beneficiaries with HD (139 early-, 78 middle-, and 378 late-stage). The mean (SD) annual total costs were higher for beneficiaries with HD than beneficiaries without HD ($73,087 [$75,140] vs. $26,834 [$47,659], p < 0.001) and driven by inpatient costs ($45,190 [$48,185] vs. $13,808 [$39,596], p < 0.001). Total healthcare costs were highest among beneficiaries with late-stage HD (mean [SD] cost: $22,797 [$31,683] for early-stage HD vs. $55,294 [$129,290] for middle-stage HD vs. $95,251 [$60,197] for late-stage HD; p < 0.001).

LIMITATIONS

Administrative claims are intended for billing purposes and subject to coding errors. This study did not address functional status, which may provide further insight to late-stage and end-of-life burden of HD, and indirect costs.

CONCLUSIONS

Medicaid beneficiaries with HD have higher acute healthcare utilization and costs compared to beneficiaries without HD, which tend to increase with disease progression, indicating that HD beneficiaries at later disease stages have greater burden.

Rethinking Medical Aid in Dying: What Does It Mean to 'Do No Harm?'

Medical aid in dying is the act of prescribing lethal medications to a consenting patient who can self-ingest them with the intent of hastening their death. A majority of patients who utilize medical aid in dying are patients with terminal cancer. As oncology patients continue to choose deaths most suitable to them, it is critical that advanced practitioners in oncology be knowledgeable regarding this end-of-life decision. With 40 states denying patients access to medical aid in dying, the purpose of this end-of-life care review is not to persuade for or against medical aid in dying, active euthanasia, or other forms of dying with dignity, but rather to shed light on patient decisions and available end-of-life options for patients where medical aid in dying is not honored. One author has succinctly named this era as "Dying in the Age of Choice," and therefore the purpose of this article is to present the current state of medical aid in dying. The article presents case studies for the reader, as well as a comparison of California's statistics with the national average. Much like other controversial subjects that intersect morality, religion, and Hippocratic medical ethics, practitioners in the healing arts must remain unbiased and honor the wishes of patients even when they differ from their own. In serving the population with the highest utilization of medical aid in dying, advanced practitioners in oncology should be familiar with the legal specifications in their state or be abreast of solutions for guiding patients through end of life in the states where medical aid in dying remains illegal.

Elevated end-of-life spending: A new measure of potentially wasteful health care spending at the end of life

OBJECTIVE

To construct a new measure of end-of-life (EoL) spending-the elevated EoL spending-and examine its associations with measures of quality of care and patient and physician preferences in comparison with the commonly used total Medicare EoL spending measures.

DATA SOURCES AND STUDY SETTING

Medicare claims data for a 20% random sample of Medicare fee-for-service (FFS) patients, from the health care quality data for 2015-2016, from the Hospital Compare and the Medicare Geographic Variation public use file, and survey data about patient and physician preferences.

STUDY DESIGN

We constructed the elevated EoL spending measure as the differential monthly spending between decedents and survivors with the same one-year mortality risk, where the risk was predicted using machine learning models. We then examined the associations of the hospital referral region (HRR)-level elevated EoL spending with various health care quality measures and with the survey-elicited patient and provider preferences. We also examined analogous associations for monthly total EoL spending on decedents.

DATA EXTRACTION METHODS

Medicare FFS patients who were continuously enrolled in Medicare Parts A & B in 2015 and were alive as of January 1, 2016.

PRINCIPAL FINDINGS

We found a large variation in the elevated EoL spending across HRRs in the United States. There was no evidence of an association between HRR-level elevated EoL spending and established health care quality measures, including those specific to EoL care, whereas total EoL spending was positively associated with certain quality of care measures. We also found no evidence that elevated EoL spending was associated with patient preferences for EoL care. However, elevated EoL spending was positively and significantly associated with physician preferences for treatment intensity.

CONCLUSIONS

Our findings suggested that elevated EoL spending captures different resource use from conventional measures of EoL spending and may be more valuable in identifying potentially wasteful spending.

Trends in and predictors of multiple readmissions following heart failure hospitalization: A National wide analysis from the United States

BACKGROUND

Readmission following Heart failure (HF) hospitalization is common: 25% are readmitted within a month of discharge and ≈50% within 6 months. A small proportion of these patients can have multiple readmissions within this period, adding disproportionately to the health care costs. In this study, we assessed the trends, predictors and costs associated with multiple readmissions using National readmissions database (NRD).

METHODS

We queried NRD for HF hospitalizations from 2010 to 2018 using ICD-9/10-CM codes. Multinomial logistic regression was used to compare readmission cohorts, with the multivariable model adjusting for other factors. All analyses accounted for the NRD sampling design were conducted using SAS v. 9.4 with p < 0.05 used to indicate statistical significance.

RESULTS

Within the study period, an estimated 6,763,201 HF hospitalizations were identified. Of these, 58% had no readmission; 26% had 1 readmission; and 16% had ≥2 readmissions within 90 days of index hospitalization. There was no statistically significant change in readmission rates during the observation period. Multiple readmissions which accounted for 37% of all readmissions contributed to 57% of readmission costs. Younger age was identified as a predictor of multiple readmissions while sex, comorbidities and the type of insurance were not significantly different from those with single readmission.

CONCLUSIONS

Multiple readmissions in HF are common (16%), have remained unchanged between 2010 and 2018 and impose a significant health care cost burden. Future research should focus on identifying these patients for targeted intervention that may minimize excessive readmissions particularly in those patients who are in the palliation phase of HF.

The High Cost of Death After Acute Myocardial Infarctions: Results from a National US Hospital Database

Introduction

This study described the differences in costs and length of stay (LOS) among patients with AMI who died versus survived using a large, nationally representative cohort of AMI patients.

Methods

The 2019 HCUP NIS was used to analyze costs, and LOS among all patients with a principal diagnosis of AMI. A propensity-score matched analysis and multivariable regression were used to adjust for patient and hospital characteristics.

Results

There were 4559 visits in each of the cohorts (total 9118). The adjusted mean hospital cost was $18,970 (95% CI $16,453 - $21,871) for those that survived and $23,173 (95% CI $20,167 - $26,626; p <0.001) for those that died. The LOS was 3.95 (95% CI 3.41-4.57) in survivors and 4.24 (95% CI 3.67-4.89; p <0.001) in those who died.

Conclusion

Survivors of AMI incurred lower costs and length of stay than those who died. Higher costs were attributed to greater LOS and higher-level care. The results suggest that economic evaluations of cardiovascular interventions that do not include the cost of dying may underestimate the benefits of the intervention.

The affordable care act and do-not-resuscitate orders: Differences by race and ethnicity

BACKGROUND

The Affordable Care Act (ACA) created new payment rules that provided reimbursement for physicians to engage in advance care planning (ACP) conversations with patients. This reimbursement policy has the potential to increase ACP participation, including among racial and ethnic minority groups that have had lower ACP participation.

OBJECTIVES

To examine whether the ACP payment rules were associated with an increase in use of do-not-resuscitate (DNR) orders, particularly among racial and ethnic minority groups, among patients diagnosed with heart failure (HF) in California.

METHODS

The California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data Set was used to identify a cohort of elderly patients with a principal diagnosis of HF. This study included 432,520 hospital admissions of patients over the age of 65 with a primary diagnosis of HF between 2012 and 2018. DNR status was identified using International Classification of Diseases, Clinical Modification Ninth and Tenth Revision, codes.

RESULTS

There was a small increase in the utilization of DNR orders overall after the ACA reimbursement policy, but the change was not significantly different for all racial and ethnic groups when compared to white non-Hispanic patients.

CONCLUSIONS

ACP payment rules provided in the ACA were associated with increased utilization of DNR, but the effect was not significantly different for racial and ethnic minorities hospitalized with HF in CA. Additional efforts are needed to increase ACP participation among racial and ethnic minorities.

The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs

BACKGROUND

Medicare cancer expenditures in the last month of life have increased. Aggressive cancer care at the end-of-life (ACEOL) is considered poor quality care. We used Geisinger Health Plan (GHP) last month's costs for cancer patients who died in 2018 and 2019 to determine the costs of and influence of Palliative Care (PC) on ACEOL.

METHOD

Patients with GHP ages 18-99 who died in 2018 and 2019 were included. Demographic, clinical characteristics, and Charlson Comorbid Index were compared across care groups defined as no ACEOL indicator, 1 or more than 1 indicator. Differences between groups were compared with Kruskal-Wallis tests and one-way ANOVA for 3 groups. Median two-sample tests and independent t-tests compared groups of 2. A P-value </= .05 indicated statistical significance.

RESULTS

Of 608 eligible patients; 261 had no indicator, 133 had 1 and 214 > 1. There were incremental cost increases with each additional ACEOL indicator (p = < .0001). Palliative Care <90 days before death was associated with increased costs while consultations >90 days before death lowered cost (P < .0001) due to reduced chemotherapy in the last month. Completed ADs reduced cost by $4000.

DISCUSSION

ACEOL indicators multiply costs during the last month of life. Palliative care instituted >90 days before death reduces chemotherapy in the last month of life and AD reduces health care costs.

CONCLUSION

Cancer health care costs increase with indicators of ACEOL. Palliative care consultations >90 days before death; ADs reduce cancer health care costs.

Factors Potential Patients Deem Important for Decision-Making in High-Risk Surgical Scenarios

BACKGROUND

Surgical futility and shared decision-making to proceed with high-risk surgery are challenging for patients and surgeons alike. It is unknown which factors contribute to a patient's decision to undergo high-risk and potentially futile surgery. The clinical perspective, founded in statistical probabilities of survival, could be misaligned with a patient's determination of worthwhile surgery. This study assesses factors most important to patients in pursuing high-risk surgery.

STUDY DESIGN

Via anonymous survey, lay participants recruited through Amazon's Mturk were presented high-risk scenarios necessitating emergency surgery. They rated factors (objective risk and quality-of-life domains) in surgical decision-making (0 = not at all, 4 = extremely) and made the decision to pursue surgery based on clinical scenarios. Repeated observations were accounted for via a generalized mixed-effects model and estimated effects of respondent characteristics, scenario factors, and likelihood to recommend surgery.

RESULTS

Two hundred thirty-six participants completed the survey. Chance of survival to justify surgery averaged 69.3% (SD = 21.3), ranking as the highest determining factor in electing for surgery. Other factors were also considered important in electing for surgery, including the average number of days the patient lived if surgery were and were not completed, functional and pain status after surgery, family member approval, and surgery cost. Postoperative independence was associated with proceeding with surgery (p < 0.001). Recommendations by patient age was moderated by respondent age (p = 0.002).

CONCLUSION

Patients highly value likelihood of survival and postoperative independence in shared decision-making for high-risk surgery. It is important to improve the understanding of surgical futility from a patient's perspective.

A Retrospective Evaluation of the Impacts of a Multidisciplinary Care Model for Managing Patients with Advanced Illness on Acute Care Utilization and Quality of Care at End of Life

Background: A home-based goal-concordant care model targeting patients with advanced illnesses may reduce acute care utilization and improve quality outcomes at end of life. Aim: Study aim was to determine impact of the Advanced Illness Management (AIM) program on end-of-life utilization and quality of care. Design: A retrospective observational study design using propensity score fine stratum weighting methodologies was applied to decedent patients identified for AIM enrollment/eligibility in 2018 to 2019. Setting/Participants: A total of 3859 decedents, 216 of whom were AIM enrollees, were identified from a metropolitan health system's electronic medical records (EMR) and met study eligibility criteria. Results: Compared with usual care, AIM enrollees spent more days away from acute care in the last 30, 90, and 180 days of life. Furthermore, AIM enrollees were less likely to expire in an acute care hospital. Conclusions: Enrollment in programs such as AIM should be considered for patients with advanced illnesses approaching end of life.

Cost-effectiveness of management strategies for patients with recurrent ovarian cancer and inoperable malignant bowel obstruction

OBJECTIVES

Patients with recurrent platinum-resistant ovarian cancer often present with inoperable malignant bowel obstruction (MBO) from a large burden of abdominal disease. Interventions such as total parenteral nutrition (TPN) and chemotherapy may be used in this setting. We aim to describe the relative cost-effectiveness of these interventions to inform clinical decision making.

METHODS

Four strategies for management of platinum-resistant recurrent ovarian cancer with inoperable MBO were compared from a societal perspective using a Monte Carlo simulation: (1) hospice, (2) TPN, (3) chemotherapy, and (4) TPN + chemotherapy. Survival, hospitalization rates, end-of-life (EOL) setting, and MBO-related utilities were obtained from literature review: hospice (survival 38 days, 6% hospitalization), chemotherapy (42 days, 29%), TPN (55 days, 25%), TPN + chemotherapy (74 days, 47%). Outcomes were the average cost per strategy and incremental cost-effectiveness ratios (ICERs) in US dollars per quality-adjusted life year (QALY) gained.

RESULTS

In the base case scenario, TPN + chemotherapy was the most costly strategy (mean; 95% CI) ($49,741; $49,329-$50,162) and provided the highest QALYs (0.089; 0.089-0.090). The lowest cost strategy was hospice ($14,591; $14,527-$14,654). The TPN alone and chemotherapy alone strategies were dominated by a combination of hospice and TPN + chemotherapy. The ICER of TPN + chemotherapy was $918,538/QALY compared to hospice. With a societal willingness to pay threshold of $150,000/QALY, hospice was the strategy of choice in 71.6% of cases, chemotherapy alone in 28.4%, and TPN-containing strategies in 0%.

CONCLUSIONS

TPN with or without chemotherapy is not cost-effective in management of inoperable malignant bowel obstruction and platinum-resistant ovarian cancer.

End of life decisions and preference of place of death among geriatric and chronic disease patients: A scoping review

Background

Geriatric and chronic disease patients and families consider the nature, time, and place of death because issues related to the end of life are rarely discussed. This study assessed the end of life decisions and preferences among geriatric and chronic disease patients.

Methods

There was an in-depth search in five electronic databases (PubMed Central, CINAHL, Embase, Web of Science, and Scopus) using the population, concept, and context, framework. A matrix was developed, discussed, accepted, and used for data extraction. Convergent synthesis and thematic data analysis technique were adopted for the analysis. The reporting of findings was done in accordance with the JBI and PRISMA guidelines for reviews.

Results

From the data analysis, home-based end of life care was intuitive and included home visits, telephone follow-up, and patient-initiated services. The key themes that emerged from our analysis that sought to influence end end of life decisions were 1) approach to home-based end of life care, 2) patient and family characteristics, 3) clinical characteristics of the patient, 4) health care provider factors, 5) satisfaction and care rendered to the patient and family, 6) family preference of the place of death, 7) collaboration between multidisciplinary teams of care, and 8) challenges associated with the home-based end of life care. The personal characteristics of the nurse (age, personal and work experience, nursing perspective, and competence) and conducting a home visit influenced patient and family end of life decision. Multidisciplinary care teams (nurses and palliative care specialists) were important in delivering effective end-of-life services.

Conclusion

To support patients in making informed decisions, they must be educated on expected outcomes and implications, adverse impacts of decisions, and the emotional influence on the bereaved family. It is important that divergent technological methods are leveraged to provide essential care to patients nearing the end of life at home. Advancing the quality of end of life care techniques through home visiting will improve the feeling of patients and families about the dying process.

Tweetable abstracts

End-of-life preferences warrants that, divergent technological methods are leveraged to provide care to patients nearing the end of life.

End-of-Life Costs of Cancer Patients With Alzheimer's Disease and Related Dementias in the U.S

CONTEXT

End-of-Life (EOL) care consumes a substantial amount of healthcare resources, especially among older persons with cancer. Having Alzheimer's Disease and Related Dementias (ADRD) brings additional complexities to these patients' EOL care.

OBJECTIVES

To examine the Medicare expenditures at the EOL (last 12 months of life) among beneficiaries having cancer and ADRD vs. those without ADRD.

METHODS

A retrospective cohort study used 2004-2016 Surveillance, Epidemiology, and End Results-Medicare data. Patient populations were deceased Medicare beneficiaries with cancer (breast, lung, colorectal, and prostate) and continuously enrolled for 12 months before death. Beneficiaries with ADRD were propensity score matched with non-ADRD counterparts. Generalized Estimating Equation Model was deployed to estimate monthly Medicare expenditures. Generalized Linear Models were constructed to assess total EOL expenditures.

RESULTS

Eighty six thousand three hundred ninety-six beneficiaries were included (43,198 beneficiaries with ADRD and 43,198 beneficiaries without ADRD). Beneficiaries with ADRD utilized $64,901 at the EOL, which was roughly $407 more than those without ADRD ($64,901 vs. $64,494, P = 0.31). Compared to beneficiaries without ADRD, those with ADRD had 11% higher monthly expenditure and 7% higher in total expenditures. Greater expenditure was incurred on inpatient (5%), skilled nursing facility (SNF) (119%), home health (42%), and hospice (44%) care.

CONCLUSION

Medicare spending at the EOL per beneficiary was not statistically different between cohorts. However, specific types of service (i.e., inpatient, SNF, home health, and hospice) were significantly higher in the ADRD group compared to their non-ADRD counterparts. This study underscored the potential financial burden and informed Medicare about allocation of resources at the EOL.

Early Integration of Palliative Care in Frail Patients with Hip Fracture

Frailty is a condition of vulnerability characterized by instability and inconsistency after a stressor event. It is associated with a range of adverse outcomes including delirium, falls, disability, mortality, and increased healthcare utilization. A subset of frail patients who are increasingly high risk for poor outcomes are older adults with hip fracture. Palliative care is a philosophy of care focused on maximizing the quality of life for seriously ill patients and their families. For frail patients with hip fracture, timely referrals to palliative care are essential to have a meaningful impact on quality of life. Recommendations for frailty screening have been offered by professional organizations; however, multiple barriers to routine preoperative frailty assessment exist. This quality improvement project evaluated the feasibility of utilizing a frailty screening tool on patients (age > 65) with hip fracture to readily identify patients with palliative care needs at the time of admission. Although nurses' compliance with the screening tool was less than expected, having a standardized process to accurately identify this high risk population resulted in a higher percentage of appropriate palliative care referrals when compared to usual practice. Improvement in quality of life was reported in patients who received a palliative care consultation.

The cost-effectiveness of brigatinib in adult patients with ALK inhibitor–naive ALK-positive non–small cell lung cancer from a US perspective

BACKGROUND: The discovery of specific oncogenic drivers in non-small cell lung cancer (NSCLC) has led to the development of highly targeted anaplastic lymphoma kinase tyrosine kinase inhibitors (ALKis). Brigatinib is a next-generation ALKi associated with prolonged progression-free survival in patients with ALKi-naive ALK+ NSCLC. OBJECTIVE: To estimate the cost-effectiveness of brigatinib compared with crizotinib and alectinib in patients with ALKi-naive ALK+ NSCLC, from a US payer perspective. METHODS: A lifetime area under the curve-partitioned survival model with 4 health states was used to evaluate the relative cost-effectiveness of brigatinib in the ALKi-naive ALK+ NSCLC setting. Brigatinib was compared with crizotinib within a cost-effectiveness framework and compared with alectinib in a cost-comparison framework, where all efficacy outcomes were assumed equal. The efficacy of brigatinib and crizotinib was informed by the ALTA-1L trial, and an indirect treatment comparison was performed to inform the efficacy of brigatinib vs alectinib owing to a lack of head-to-head data. Costs were derived from public sources. The main outcomes of the model were total costs, quality-adjusted life-years (QALYs), life-years, and incremental cost-effectiveness ratios. Univariate and probabilistic sensitivity analyses, in addition to multiple scenario analyses, were conducted to assess the robustness of the model outcomes. RESULTS: The improved outcomes observed in ALTA-1L translated into QALY gains (+0.97) in the comparison of brigatinib vs crizotinib. The superior efficacy profile was associated with increased time on treatment with brigatinib, which drove the increase in costs vs crizotinib (+$210,519). The resulting base-case incremental cost-effectiveness ratio was $217,607/QALY gained. Compared with alectinib, brigatinib was associated with a cost difference of -$8,546. Sensitivity analysis suggested that extrapolation of overall survival, the assumptions relating to time on treatment, and subsequent therapy costs were the most influential determinants of results. Probabilistic sensitivity analysis suggested brigatinib had the highest probability of being cost-effective beyond willingness-to-pay thresholds of $236,000 per QALY vs crizotinib and alectinib. CONCLUSIONS: At list prices and under base-case assumptions in the current analysis, brigatinib was associated with cost-savings vs alectinib, and QALY gains but at higher costs vs crizotinib. Additional research into the real-world efficacy of ALKis is warranted to further understand the comparative cost-effectiveness of these therapies. DISCLOSURES: Ms Cranmer and Ms Kearns are employees of Takeda UK Ltd. Dr Young is a former employee of Takeda Pharmaceuticals America, Inc. Dr Humphries is an employee of Takeda Pharmaceuticals U.S.A., Inc. Mr Trueman is an employee of Source Health Economics, the consultancy company that provided health economic and writing services. This work was funded by ARIAD Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited. Work by Source Health Economics was funded by ARIAD Pharmaceuticals, Inc. Professional medical writing assistance was provided by Phillipa White, of Source Health Economics, and funded by ARIAD Pharmaceuticals, Inc.

Societal Cost of Opioid Use in Symptomatic Knee Osteoarthritis Patients in the United States

OBJECTIVE

Symptomatic knee osteoarthritis (SKOA) is a chronic, disabling condition, requiring long-term pain management; over 800,000 SKOA patients in the US use opioids on a prolonged basis. We aimed to characterize the societal economic burden of opioid use in this population.

METHODS

We used the Osteoarthritis Policy Model, a validated computer simulation of SKOA, to estimate the opioid-related lifetime and annual cost generated by the US SKOA population. We included direct medical, lost productivity, criminal justice, and diversion costs. We modeled the SKOA cohort with a mean ± SD age of 54 ± 14 years and Western Ontario and McMaster Universities Osteoarthritis Index pain score of 29 ± 17 (0-100, 100 = worst). We estimated annual costs of strong ($1,381) and weak ($671) opioid regimens using Medicare fee schedules, Red Book, the Federal Supply Schedule, and published literature. The annual lost productivity and criminal justice costs of opioid use disorder (OUD), obtained from published literature, were $11,387 and $4,264, per-person, respectively. The 2015-2016 Medicare Current Beneficiary Survey provided OUD prevalence. We conducted sensitivity analyses to examine the robustness of our estimates to uncertainty in input parameters.

RESULTS

Assuming 5.1% prevalence of prolonged strong opioid use, the total lifetime opioid-related cost generated by the US SKOA population was estimated at $14.0 billion, of which only $7.45 billion (53%) were direct medical costs.

CONCLUSION

Lost productivity, diversion, and criminal justice costs comprise approximately half of opioid-related costs generated by the US SKOA population. Reducing prolonged opioid use may lead to a meaningful reduction in societal costs that can be used for other public health causes.

Mapping the future for research in emergency medicine palliative care: A research roadmap

BACKGROUND

The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation.

OBJECTIVE

The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research.

METHODS

Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics.

RESULTS

Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC.

CONCLUSIONS

There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.

Racial and Ethnic Differences in Hospice Use and Hospitalizations at End-of-Life Among Medicare Beneficiaries With Dementia

IMPORTANCE

The pool of studies examining ethnic and racial differences in hospice use and end-of-life hospitalizations among patients with dementia is limited and results are conflicting, making it difficult to assess health care needs of underresourced racial and ethnic groups.

OBJECTIVE

To explore differences in end-of-life utilization of hospice and hospital services among patients with dementia by race and ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used national survey data from the Health and Retirement Study linked with Medicare and Medicaid claims that reflected a range of socioeconomic, health, and psychosocial characteristics. Eligible participants were Medicare fee-for-service beneficiaries aged 65 years or older diagnosed with dementia who died between 2000 and 2016. Analyses were performed from June to December 2021.

EXPOSURES

Race and ethnicity.

MAIN OUTCOMES AND MEASURES

We examined the frequency and costs of hospice care, emergency department (ED) visits, and hospitalizations during the last 180 days of life among Medicare decedents with dementia. We analyzed the proportion of dementia decedents with advance care planning and their end-of-life care preferences.

RESULTS

The cohort sample included 5058 beneficiaries with dementia (mean [SD] age, 85.5 [8.0] years; 3038 women [60.1%]; 809 [16.0%] non-Hispanic Black, 357 [7.1%] Hispanic, and 3892 non-Hispanic White respondents [76.9%]). In adjusted analysis, non-Hispanic Black decedents (odds ratio [OR], 0.65; 95% CI, 0.55-0.78), nursing home residents (OR, 0.81; 95% CI, 0.71-0.93), and survey respondents represented by a proxy (OR, 0.84; 95% CI, 0.71-0.99) were less likely to use hospice, whereas older decedents (age 75-84 vs 65-74 years: OR, 1.39; 95% CI, 1.12-1.72; age ≥85 vs 65-74 years: OR, 1.39; 95% CI, 1.13-1.71), women (OR, 1.19; 95% CI, 1.05-1.35), and decedents with higher education (high school vs less than high school: OR, 1.17; 95% CI, 1.01-1.36; more than high school vs less than high school: OR, 1.32; 95% CI, 1.13-1.54), more severe cognitive impairment (OR, 1.51; 95% CI, 1.02-2.23), and more instrumental activities of daily living limitations (OR, 1.07; 95% CI, 1.01-1.12) were associated with higher hospice enrollment. A higher proportion of Black and Hispanic decedents with dementia used ED (645 of 809 [79.7%] and 274 of 357 [76.8%] vs 2753 of 3892 [70.7%]; P < .001) and inpatient services (625 of 809 [77.3%] and 275 of 357 [77.0%] vs 2630 of 3892 [67.5%]; P < .001) and incurred roughly 60% higher inpatient expenditures at the end of life compared with White decedents (estimated mean: Black, $23 279; 95% CI, $20 690-$25 868; Hispanic, $23 471; 95% CI, $19 532-$27 410 vs White, $14 609; 95% CI, $13 800-$15 418). A higher proportion of Black and Hispanic than White beneficiaries with dementia who were enrolled in hospice were subsequently admitted to the ED (56 of 309 [18.1%] and 22 of 153 [14.4%] vs 191 of 1967 [9.7%]; P < .001) or hospital (48 of 309 [15.5%] and 17 of 153 [11.1%] vs 119 of 1967 [6.0%]; P < .001) before death. The proportion of dementia beneficiaries completing advance care planning was lower among Black (146 of 704 [20.7%]) and Hispanic (66 of 308 [21.4%]) beneficiaries compared with White beneficiaries (1871 of 3274 [57.1%]). A higher proportion of Black and Hispanic decedents with dementia had written instructions choosing all care possible to prolong life (30 of 144 [20.8%] and 12 of 65 [18.4%] vs 72 of 1852 [3.9%]), whereas a higher proportion of White decedents preferred to limit care in certain situations (1708 of 1840 [92.8%] vs 114 of 141 [80.9%] and 51 of 64 [79.7%]), withhold treatments (1448 of 1799 [80.5%] vs 87 of 140 [62.1%] and 41 of 62 [66.1%]), and forgo extensive life-prolonging measures (1712 of 1838 [93.1%] vs 120 of 138 [87.0%] and 54 of 65 [83.1%]).

CONCLUSIONS AND RELEVANCE

The results of this cohort study highlight unique end-of-life care utilization and treatment preferences across racial and ethnic groups among patients with dementia. Medicare should consider alternative payment models to promote culturally competent end-of-life care and reduce low-value interventions and costs among the population with dementia.

Mechanical Ventilation and Survival in Patients With Advanced Dementia in Medicare Advantage

CONTEXT

Medicare Advantage (MA) cares for an increasing proportion of traditional Medicare (TM) patients although, the association of MA on low-value care among hospitalized patients is uncertain.

OBJECTIVES

We sought to determine whether invasive mechanical ventilation (IMV) use or mortality differs among hospitalized patients with advanced dementia (AD) enrolled in MA vs. TM and the influence of hospital MA concentration.

METHODS

Retrospective cohort of hospitalized Medicare patients from 2016 to 2017 who were ≥66 years old with AD (n=147,153) and had a hospitalization with an assessment completed during a nursing home stay ≤120 days prior to that hospitalization indicating AD and severe cognitive/functional impairment. MA enrollment was ascertained at hospitalization; IMV use and 30- and 365-day mortality were determined via Medicare data. Multivariable logistic regression models clustered by hospital were used.

RESULTS

Among hospitalized Medicare patients with AD, 27,253 (19%) were enrolled in MA, mean age was 84 (95% CI: 83.9-84.0) and 92,736 (63%) were female. Enrollment in MA was associated with increased IMV use (Adjusted Odds Ratio(AOR)=1.11, 95% CI: 1.04-1.18), 30- (Adjusted Hazard Ratio(AHR)=1.09, 95% CI: 1.05-1.12) and 365-day mortality (AHR=1.12, 95% CI: 1.08-1.16) compared to TM. Use of IMV was not different based on concentration of MA at the hospital level.

CONCLUSION

MA may reduce hospitalizations, however, once hospitalized, patients with AD enrolled in MA experience higher rates of IMV use and worse 30- and 365-day mortality compared to TM patients. Higher hospital concentration of MA did not reduce use of IMV. MA may not offer significant benefits in reducing low-value care among patients hospitalized with serious illness, questioning the benefits of this care model.

Determinants of Total End-of-Life Health Care Costs of Medicare Beneficiaries: A Quantile Regression Forests Analysis

BACKGROUND

To identify and rank the importance of key determinants of end-of-life (EOL) health care costs, and to understand how the key factors impact different percentiles of the distribution of health care costs.

METHOD

We applied a principled, machine learning-based variable selection algorithm, using Quantile Regression Forests, to identify key determinants for predicting the 10th (low), 50th (median), and 90th (high) quantiles of EOL health care costs, including costs paid for by Medicare, Medicaid, Medicare Health Maintenance Organizations (HMOs), private HMOs, and patient's out-of-pocket expenditures.

RESULTS

Our sample included 7 539 Medicare beneficiaries who died between 2002 and 2017. The 10th, 50th, and 90th quantiles of EOL health care cost are $5 244, $35 466, and $87 241, respectively. Regional characteristics, specifically, the EOL-Expenditure Index, a measure for regional variation in Medicare spending driven by physician practice, and the number of total specialists in the hospital referral region were the top 2 influential determinants for predicting the 50th and 90th quantiles of EOL costs but were not determinants of the 10th quantile. Black race and Hispanic ethnicity were associated with lower EOL health care costs among decedents with lower total EOL health care costs but were associated with higher costs among decedents with the highest total EOL health care costs.

CONCLUSIONS

Factors associated with EOL health care costs varied across different percentiles of the cost distribution. Regional characteristics and decedent race/ethnicity exemplified factors that did not impact EOL costs uniformly across its distribution, suggesting the need to use a "higher-resolution" analysis for examining the association between risk factors and health care costs.

Intensity of end-of-life care for gynecologic cancer patients by primary oncologist specialty

Objective

The association of primary oncologist specialty, medical oncology versus gynecologic oncology, on intensity of care at the end of life in elderly patients with gynecologic cancer is unclear.

Methods

This retrospective cohort study used Surveillance, Epidemiology and End Results-Medicare (SEER-M) data. Subjects were fee-for-service Medicare enrollees aged 65 years and older who died of a gynecologic cancer between January 2006 and December 2015. The primary outcome was a composite score for high-intensity care received in the last month of life. Secondary outcomes included invasive procedures and Medicare spending in the last month of life. Simple and multivariable linear and logistic regression analyses evaluated differences in outcomes by primary oncologist specialty. Linear regressions were repeated after creating a more similar control group through nearest-neighbor propensity score matching.

Results

Of 12 189 patients, 7705 (63%) had a medical primary oncologist in the last year of life. In adjusted analyses, patients with a gynecologic versus medical primary oncologist received lower rates of high-intensity end-of-life care (53.9% vs 56.6%; p=0.018). Results were similar for the propensity score-matched cohorts. However, having a gynecologic versus medical primary oncologist was associated with higher rates of invasive procedures in the last month of life (43% vs 41%; p=0.014) and higher Medicare spending ($83 859 vs $74 849; p=0.004).

Conclusions

Both specialties engage in overall high levels of intense end-of-life care, with differences by specialty in aspects of aggressive care and spending at the end of life. Physician-level training could be a target for educational or quality improvement initiatives to improve end-of-life cancer care delivery.

Evaluation of Family Characteristics and Multiple Hospitalizations at the End of Life: Evidence from the Utah Population Database

Background: Scant research has examined the relationship between family characteristics and end-of-life (EOL) outcomes despite the importance of family at the EOL. Objectives: This study examined factors associated with the size and composition of family relationships on multiple EOL hospitalizations. Design: Retrospective analysis of the Utah Population Database, a statewide population database using linked administrative records. Setting/subjects: We identified adults who died of natural causes in Utah, United States (n = 216,913) between 1998 and 2016 and identified adult first-degree family members (n = 743,874; spouses = 13.2%; parents = 3.6%; children = 51.7%; siblings = 31.5%). Measurements: We compared demographic, socioeconomic, and death characteristics of decedents with and without first-degree family. Using logistic regression models adjusting for sex, age, race/ethnicity, marital status, comorbidity, and causes of death, we examined the association of first-degree family size and composition, on multiple hospitalizations in the last six months of life. Results: Among decedents without documented first-degree family members in Utah (16.0%), 57.7% were female and 7 in 10 were older than 70 years. Nonmarried (aOR = 0.90, 95% CI = 0.88-0.92) decedents and decedents with children (aOR = 0.97, 95% CI = 0.94-0.99) were less likely to have multiple EOL hospitalizations. Family size was not associated with multiple EOL hospitalizations. Conclusions: First-degree family characteristics vary at the EOL. EOL care utilization may be influenced by family characteristics-in particular, presence of a spouse. Future studies should explore how the quality of family networks, as well as extended family, impacts other EOL characteristics such as hospice and palliative care use to better understand the EOL care experience.

Survival and Health Care Costs with IMV vs. NIV in Dementia Patients Admitted with Pneumonia and Respiratory Failure

RATIONALE

Invasive mechanical ventilation (IMV) may be burdensome for persons with advanced dementia. Research has found that IMV use in persons with dementia has increased in the US, Spain, and Canada.

OBJECTIVES

Compare the outcomes and health care costs among hospitalized advanced dementia patients treated with non-invasive ventilation (NIV) versus IMV.

METHODS

Retrospective cohort study of hospitalized patients aged 66 and older with pneumonia, or septicemia with pneumonia, treated either with NIV or IMV between 2015 and 2017. Persons were included if they had a Minimum Data Set (MDS) assessment between 1 and 120 days prior to hospitalization indicating the person had advanced dementia with 4+ impairments in the Activities of Daily Living. Propensity matched analysis was performed using clinical information from the MDS, measures of Chronic Condition Warehouse (CCW) chronic disease indicators, and prior utilization measures. Main outcome measures were survival and health care costs up to one year post discharge.

RESULTS

Among the 27,483 hospitalizations between 2015 and 2017, 12.5% were treated with IMV and 8.2% received NIV. A propensity matched model comparing IMV to NIV with clinical data from the MDS, CCW indicators of chronic diseases, and prior utilization found matches for 96.3% of hospitalizations with the use of IMV. NIV matched cases had a higher 30-day mortality rate compared to IMV cases (58.7% vs 51.9%, p<=.001) but this survival benefit did not persist, as one-year mortality was slightly higher among IMV compared to NIV (86.5% vs 85.9%, p>.05). One-year health care costs after matching were higher among those treated with IMV compared to NIV (mean $57,122 vs. $33,696, p<.001).

CONCLUSIONS

Among advanced dementia patients hospitalized with pneumonia or septicemia with pneumonia, improvement in 30-day survival for those treated with IMV compared to NIV must be weighed against lack of one-year survival benefit and substantially higher costs.

Medical cost of advanced illnesses in the last-year of life-retrospective database study

OBJECTIVE

This study aims to quantify medical care utilisation, and to describe the cost trajectories of individuals with advanced illnesses in the last-year of life, differentiated by advanced cancer, end-stage organ failure and progressive neurological disorders.

METHODS

This retrospective database study included decedents who had previous inpatient or outpatient encounters at a public hospital in Singapore. Patients with advanced diseases were identified based on diagnostic codes and clinical criteria. Using a look-back approach, the amount of healthcare services utilised and the corresponding mean monthly and annual costs to the healthcare system in the last 12-months of life were quantified.

RESULTS

The last 12-months of life among 6,598 decedents was associated with £20,524 (95% confidence interval: £20,013-£21,036) in medical costs, of which 80% was accounted for by inpatient admissions. Costs increased sharply in the last 2-months of life, with a large proportion of monthly costs accounted for by inpatient admissions which rose rapidly from 61% at 12-months prior to death to 94% in the last-month of life. Compared to patients with cancer, individuals diagnosed with non-cancer advanced illnesses accumulated 1.6 times more healthcare costs in the last-year of life with significant differences across patients with end-stage organ failure and progressive neurological disorders.

CONCLUSION

Healthcare costs varied across disease conditions at the end-of-life. With advance care planning and close collaboration between the inpatient clinical team and the community providers, it may be possible to re-direct some of the hospitalisation costs to community-based palliative care services.

Cost-Effectiveness of Baricitinib Compared With Standard of Care: A Modeling Study in Hospitalized Patients With COVID-19 in the United States

Purpose

In the Phase III COV-BARRIER (Efficacy and Safety of Baricitinib for the Treatment of Hospitalised Adults With COVID-19) trial, treatment with baricitinib, an oral selective Janus kinase 1/2 inhibitor, in addition to standard of care (SOC), was associated with significantly reduced mortality over 28 days in hospitalized patients with coronavirus disease–2019 (COVID-19), with a safety profile similar to that of SOC alone. This study assessed the cost-effectiveness of baricitinib + SOC versus SOC alone (which included systemic corticosteroids and remdesivir) in hospitalized patients with COVID-19 in the United States.

Methods

An economic model was developed to simulate inpatients' stay, discharge to postacute care, and recovery. Costs modeled included payor costs, hospital costs, and indirect costs. Benefits modeled included life-years (LYs) gained, quality-adjusted life-years (QALYs) gained, deaths avoided, and use of mechanical ventilation avoided. The primary analysis was performed from a payor perspective over a lifetime horizon; a secondary analysis was performed from a hospital perspective. The base-case analysis modeled the numeric differences in treatment effectiveness observed in the COV-BARRIER trial. Scenario analyses were also performed in which the clinical benefit of baricitinib was limited to the statistically significant reduction in mortality demonstrated in the trial.

Findings

In the base-case payor perspective model, an incremental total cost of 17,276 US dollars (USD), total QALYs gained of 0.6703, and total LYs gained of 0.837 were found with baricitinib + SOC compared with SOC alone. With the addition of baricitinib, survival was increased by 5.1% and the use of mechanical ventilation was reduced by 1.6%. The base-case incremental cost-effectiveness ratios were 25,774 USD/QALY gained and 20,638 USD/LY gained; a “mortality-only” scenario analysis yielded similar results of 26,862 USD/QALY gained and 21,433 USD/LY gained. From the hospital perspective, combination treatment with baricitinib + SOC was more effective and less costly than was SOC alone in the base case, with an incremental cost of 38,964 USD per death avoided in the mortality-only scenario.

Implications

In hospitalized patients with COVID-19 in the United States, the addition of baricitinib to SOC was cost-effective. Cost-effectiveness was demonstrated from both the payor and the hospital perspectives. These findings were robust to sensitivity analysis and to conservative assumptions limiting the clinical benefits of baricitinib to the statistically significant reduction in mortality demonstrated in the COV-BARRIER trial.

Advance care planning in patients undergoing surgery to resect pancreatic adenocarcinoma: Underlying tension between balancing hope and realism

BACKGROUND

The timing and the dose of Advanced Care Planning in patients with pancreatic ductal adenocarcinoma undergoing curative-intent resection are generally dictated by the surgeon performing the operation.

METHODS

A qualitative investigation using 1:1 interviews with 40 open-ended questions was conducted with a convenience sample of 10 high-volume pancreatic surgeons from across the country. The grounded theory approach was used for data analysis.

RESULTS

A total of 10 interviews were conducted with expert pancreatic surgeons-6 males and 4 females. During preoperative counseling, all surgeons attempt to motivate patients by emphasizing hope, optimism, and the fact that surgery offers the only opportunity for cure. All surgeons discuss the possibility of recurrence as well as postoperative complications; however, a majority perceived that patients do not fully appreciate the likelihood of recurrence or postoperative complications. All surgeons acknowledged the importance of end-of-life conversations when death is imminent. Seventy percent of surgeons had mixed opinions regarding benefits of preoperative Advanced Care Planning in the preoperative setting, while 20% felt it was definitely beneficial, particularly that delivery of care aligned with patient goals. All surgeons emphasized that Advanced Care Planning should be led by a physician who both knows the patient well and understands the nuances of pancreatic ductal adenocarcinoma management. Most common barriers to in-depth Advanced Care Planning discussion reported by surgeons include taking away hope, lack of time, and concern for sending "mixed messages."

CONCLUSION

We identified that surgeons experience a fundamental tension between promoting realistic long-term goals and expectations versus focusing on hope and enabling an overly optimistic perception of prognosis.

Cost Effectiveness of Watch and Wait Versus Resection in Rectal Cancer Patients with Complete Clinical Response to Neoadjuvant Chemoradiation

BACKGROUND

Watch and wait (WW) protocols have gained increasing popularity for patients diagnosed with locally advanced rectal cancer and presumed complete clinical response after neoadjuvant chemoradiation. While studies have demonstrated comparable survival and recurrence rates between WW and radical surgery, the decision to undergo surgery has significant effects on patient quality of life. We sought to conduct a cost-effectiveness analysis comparing WW with abdominoperineal resection (APR) and low anterior resection (LAR) among patients with stage II/III rectal cancer.

METHODS

In this comparative-effectiveness study, we built Markov microsimulation models to simulate disease progression, death, costs, and quality-adjusted life-years (QALYs) for WW or APR/LAR. We assessed cost effectiveness using the incremental cost-effectiveness ratio (ICER), with ICERs under $100,000/QALY considered cost effective. Probabilities of disease progression, death, and health utilities were extracted from published, peer-reviewed literature. We assessed costs from the payer perspective.

RESULTS

WW dominated both LAR and APR at a willingness to pay (WTP) threshold of $100,000. Our model was most sensitive to rates of distant recurrence and regrowth after WW. Probabilistic sensitivity analysis demonstrated that WW was the dominant strategy over both APR and LAR over 100% of iterations across a range of WTP thresholds from $0-250,000.

CONCLUSIONS

Our study suggests WW could reduce overall costs and increase effectiveness compared with either LAR or APR. Additional clinical research is needed to confirm the clinical efficacy and cost effectiveness of WW compared with surgery in rectal cancer.

Five Steps Towards Avoiding Narrative Traps in Decision-Making

Narratives provide simple rules about how we ought to live and what our priorities ought to be. They are especially appealing in times of high uncertainty. Using the uncertainty surrounding Covid-19 as an illustration, we show how a narrative to preserve life has become dominant, and we illustrate how it has been reinforced by several behavioural biases. We argue that being able to identify and critically evaluate the impact of dominant narratives is vital to ensuring optimal decision-making. To facilitate this, we offer five recommendations-the ABCDE of decision-making-that can help to reduce the "narrative trap" in decision-making in any uncertain environment.

Catalog of Age- and Medical Condition-Specific Healthcare Costs in the United States to Inform Future Costs Calculations in Cost-Effectiveness Analysis

OBJECTIVES

This study aims to develop a catalog of annual age- and medical condition-specific healthcare costs per capita among those who are living at a certain age (survivors) and the costs attributable to death itself for those who die at that age (decedents) in the United States. These estimates can be used to inform future cost calculations in cost-effectiveness analysis (CEA).

METHODS

We discussed a theoretical framework to incorporate futures costs in CEA. We used the nationally representative Medical Expenditure Panel Survey data to estimate costs among survivors and death costs. For survivors, we obtained cost estimates nonparametrically using kernel-based regression and locally weighted scatterplot smoothing. We estimated costs attributable to death using inverse probability weights comparing decedents with appropriately weighted survivors at a given age after controlling for more than 270 clinical condition classifications, demographics, and interactions. Cost estimates were expressed in 2019 US dollar and also separately by sex and specific clinical conditions.

RESULTS

Average healthcare costs per capita among survivors, expectedly, rose over age from $2062 (95% confidence interval [CI] $1553-$2478) during the first year of life to $14 307 (95% CI $13 706-$14 956) at 85 years or older. Average costs of death were $44 569 (95% CI $14 304-$67 369) during the first year of life and declined by -$321 (95% CI -$620 to -$22) per 1 year older.

CONCLUSIONS

The US catalog of healthcare costs among survivors and decedents can facilitate calculations of future costs in CEA as recommended by the Second Panel on Cost-Effectiveness in Health and Medicine.