Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study

Regional Variation in End-of-Life Care just before Death among the oldest old in Japan : A descriptive study

BACKGROUND

The use of life-sustaining treatment (LST) in the final stage of life is a major policy concern due to increased costs, while its intensity does not correlate with quality. Previous reports have shown declining trends in LST use in Japan. However, regional practice variations remain unclear. This study aims to describe regional variations in LST use before death among the oldest old in Japan.

METHODS

A descriptive study was conducted among patients aged 85 or older who passed away between April 2013 and March 2014. The study utilized health insurance claims from Japan's National Database (NDB) to examine the use of cardiopulmonary resuscitation (CPR), mechanical ventilation (MV), and admission to the acute care ward (ACW) in the last 7 days of life.

RESULTS

Among 224,391 patients, the proportion of patients receiving LST varied by region. CPR ranged from 8.6% (Chubu) to 12.9% (Shikoku), MV ranged from 7.1% (Chubu) to 12.3% (Shikoku), and admission to ACW ranged from 4.5% (Chubu) to 10.1% (Kyushu-Okinawa). The adjusted odds ratios (AOR) for regional variation compared with Kanto were as follows: CPR (in Shikoku, 1.85 [95% CI 1.73 - 1.98]), MV (in Shikoku, 1.75 [1.63 - 1.87]), and ACW admission (in Kyushu-Okinawa, 1.69 [1.52 - 1.88]).

CONCLUSION

The study presents descriptive information regarding regional differences in the utilization of LST for the oldest old. Further research is necessary to identify the factors that contribute to these variations and to address the challenge of improving the quality of end-of-life care.

Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs

Introduction

Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients' clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence.

Aim of the study

To explore decisions to limit non-beneficial life support interventions, their correlation with patients' clinical data, and their effect on the cost of care in the ICU.

Material and Methods

We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions.

Results

NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001).

Conclusions

Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.

Medical care costs at the end of life among older adults with cancer: a national health insurance data-based cohort study

OBJECTIVE

Along with aging, the elderly population with cancers is increasing. The costs of end-of-life (EOL) care are particularly high among cancer patients. The purpose of this study was to investigate the trends in medical costs in the last year of life among older adults with cancer.

DESIGN, SETTING, AND PARTICIPANTS

Using the Health Insurance Review and Assessment Services (HIRA) database for the period 2016-2019, we identified older adults aged ≥ 65 years who had a primary diagnosis of cancers and high-intensity treatment at least once in the intensive care unit (ICU) of tertiary hospitals.

MAIN OUTCOMES AND MEASURES

High-intensity treatment was defined as receiving at least one of the following treatments: cardiopulmonary resuscitation, mechanical ventilation, extracorporeal membrane oxygenation, hemodialysis, and transfusion. The EOL medical treatment costs were calculated by dividing periods 1, 2, 3, 6, and 12 months from the time of death, respectively.

RESULTS

The mean total EOL medical expense per older adult during the year before death was $33,712. The cost of EOL medical expenses for three months and one month before subjects' death accounted for 62.6% ($21,117) and 33.8% ($11,389) of total EOL costs, respectively. Among subjects who died while receiving high-intensity treatment in the ICU, the costs associated with medical treatments that occurred during the last month before death were 42.4% ($13,841) of the total EOL expenses during the year.

CONCLUSION

The findings indicate that EOL care expenditures for the older population with cancer are highly concentrated until the last month. The intensity of medical care is an important and challenging issue in terms of care quality and cost suitability. Efforts are needed to properly use medical resources and provide optimal EOL care for older adults with cancer.

Home or hospital as the place of end-of-life care and death: A survey among Chinese residents of Macao

Objectives

The study was the first to explore Chinese residents' preferred place of care at the end of life and preferred place of death in Macao.

Methods

A cross-sectional questionnaire survey was conducted online and face-to-face. The questionnaire was designed in Chinese, and both online and face-to-face surveys were conducted in Chinese. The study was conducted in Macao. Macao residents aged 18 years and older were recruited.

Results

A total of 737 responses were valid, 65% were female, aged between 19 and 101 years; 43.4% of respondents preferred to be cared for at home in the last 6 months; however, less than one-fifth preferred to die at home. One-third of respondents chose to die in the hospice, and over a quarter of them preferred to die in hospitals. Compared with people aged between 18 and 39 years, people aged between 40 and 64 years did not want to be cared for at home in the last 6 months, and they did not want to die at home either.

Conclusion

The results of the study suggested that there is a need for palliative home care in Macao, and the government should consider developing such a service and review current laws and regulations in supporting the service. Education is equally important for healthcare professionals, enabling them to support palliative care development in the community.

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.

Cost of End-of-Life Inpatient Encounters in Patients with Chronic Kidney Disease in the United States: A Report from the DISCOVER CKD Retrospective Cohort

Introduction

Real-world data reporting healthcare resource utilisation and costs associated with end-of-life care for patients with chronic kidney disease (CKD) are limited. We examined length of hospitalisation and costs associated with end-of-life inpatient encounters using retrospective data from DISCOVER CKD.

Methods

Data on inpatient encounters for patients with CKD aged ≥ 18 years between January 2016 and March 2020 were extracted from the US Premier Hospital Database. Encounters ending in death were identified and grouped by reason for the encounter, using the International Classification of Diseases, Tenth Revision, and by their insurance coverage. Encounters were evaluated overall and stratified according to cardiovascular (CV), kidney failure and infection-related reasons, and by their coverage by commercial, Medicaid, Medicare or other insurers. Length of hospitalisation and total costs were calculated for encounters.

Results

Among 237,734 encounters ending in death, the mean [standard deviation (SD)] age was 74.2 (12.4) years, and 45.3% of patients were female. In total, 25,118, 4210 and 76,307 encounters were classified as relating to CV reasons, kidney failure and infection, respectively. Among all encounters, the mean (SD) length of hospitalisation ranged from 9.1 (11.2) (Medicare) to 12.8 (18.4) (Medicaid) days. Across insurers, encounters related to kidney failure were associated with the longest hospitalisations compared with CV and infection [mean range (days): 10.7–15.9 vs. 7.5–10.5 and 8.7–12.7, respectively]. The median [interquartile range (IQR)] total cost of any inpatient encounter was $17,057 ($8040–35,873). Kidney failure-related encounters had higher costs compared with CV and infection [median (IQR), $18,469 ($8673–38,315) vs. $17,503 ($7766–39,693) and $16,403 ($7762–34,910), respectively]. Medicaid-covered encounters had the highest costs of all insurers [median (IQR), $16,189 ($7725–33,443)].

Conclusions

Among patients with CKD, end-of-life encounters were most frequently related to infection. Encounters relating to kidney failure incurred the highest costs.

Trial registration

ClinicalTrials.gov identifier: NCT04034992.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-02010-3.

Place of death and phenomenon of going home to die in Chinese adults: A prospective cohort study

BACKGROUND

China is embracing an ageing population without sustainable end-of-life care services. However, changes in place of death and trends of going home to die (GHTD) from the hospital remains unknown.

METHODS

A total of 42,956 participants from the China Kadoorie Biobank, a large Chinese cohort, who died between 2009 and 2017 was included into analysis. GHTD was defined as death at home within 7 days after discharge from the hospital. A modified Poisson regression was used to investigate temporal trends of the place of death and GHTD, and estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association of GHTD with health insurance (HI) schemes.

FINDINGS

From 2009 to 2017, home remained the most common place of death (71·5%), followed by the hospital (21·6%). The proportion of GHTD for Urban and Rural Residents' Basic Medical Insurance (URRBMI) beneficiaries was around six times higher than that for Urban Employee Basic Medical Insurance (UEBMI) beneficiaries (66·0% vs 11·6%). Besides, a substantial increase in the proportion of GHTD throughout the study period was observed regardless of HI schemes (4·4% annually for URRBMI, and 5·4% for UEBMI). Compared with UEBMI beneficiaries, URRBMI beneficiaries were more likely to experience GHTD, with an adjusted PR (95% CI) of 1·19 (95% CI: 1·12, 1·27) (P<0·001).

INTERPRETATION

In China, most of deaths occurred at home, with a large proportion of decedents GHTD from the hospital, especially for URRBMI beneficiaries. Substantial variation in the phenomenon of GHTD across HI schemes indicates inequalities in end-of-life care utilization.

FUNDING

The National Natural Science Foundation of China, the Kadoorie Charitable Foundation, the National Key R&D Program of China, the Chinese Ministry of Science and Technology.

Predictors and Assessment of Hospice Use for End-Stage Renal Disease Patients in Taiwan

OBJECTIVES

Hospice and early palliative care are generally considered as an alternative and supportive care to offer symptoms relief and optimize the quality of life among end-stage renal disease (ESRD) patients, but hospice care remains underutilized. This study aimed to examine patient and health system characteristics and develop a patient assessment scale to evaluate ESRD patients for hospice care after the implementation of non-cancer hospice care reimbursement policy in 2009 in Taiwan.

METHOD

We conducted a retrospective cohort study using nationwide population-based datasets. Adult long-term dialysis patients between 2009 and 2012 were included. Multivariable logistic regression and the Firth penalized likelihood estimation were used to estimate the likelihood of receiving hospice care. A receiver operating characteristic curve (ROC) analysis and C-statistic were calculated to determine the optimal models for a patient assessment of hospice use.

RESULTS

Patients who were older, comorbid with anemia (odds ratio [OR] 3.53, 95% CI 1.43-8.70) or sepsis (OR 1.62, 95% CI 1.08-2.44), with longer dialysis durations, more hospitalizations (OR 4.68, 95% CI 2.56-8.55), or primary provider care with hospice (OR 5.15, 95% CI 2.80-9.45) were more likely to receive hospice care. The total score of the patient assessment scale of hospice care was 0-28 with a cut-off value of 19 based on the results of the receiver operating characteristic curve.

CONCLUSION

Given the "Patient Right to Autonomy Act" implemented in Taiwan in 2019 to promote the concept of a "good quality of death", this patient assessment scale may help health professionals target ESRD patients for hospice care and engage in shared decision making and the advance care planning process.

Identification of factors associated with high-cost use of inpatient care in chronic kidney disease: a registry study

OBJECTIVE

To explore factors behind inpatient admissions by high-cost users (HCUs) in pre-end-stage chronic kidney disease (CKD).

DESIGN

Retrospective analysis of CKD.QLD Registry and hospital admissions of the Queensland Government Department of Health recorded between 1 July 2011 and 30 June 2016.

SETTING

Queensland public and private hospitals.

PARTICIPANTS

5096 individuals with CKD who consented to the CKD.QLD Registry via 1 of 11 participating sites.

MAIN OUTCOMES

Associations of HCU status with patient characteristics, pathways and diagnoses behind hospital admissions at 12 months.

RESULTS

Age, advanced CKD, primary renal diagnosis, cardiovascular disease and hypertension were predictors of the high-cost outcome. HCUs were more likely than non-HCUs to be admitted by means of episode change (relative risk: 5.21; 95% CI 5.02 to 5.39), 30-day readmission (2.19; 2.13 to 2.25), scheduled readmission (1.29; 1.11 to 1.46) and emergency (1.07; 1.02 to 1.13), for diagnoses of the nervous (1.94; 1.74 to 2.15), circulatory (1.24; 1.14 to 1.34) and respiratory (1.2; 1.03 to 1.37) systems and other factors influencing health status (1.92; 1.74 to 2.09).

CONCLUSIONS

The high relevance of episode change and other factors influencing health status revealed that a substantial part of excess demand for inpatient care was associated with discordant conditions often linked to frailty, decline in psychological health and social vulnerability. This suggests that multidisciplinary models of care that aim to manage discordant comorbidities and address psychosocial determinants of health, such as renal supportive care, may play an important role in reducing inpatient admissions in this population.

Better continuity of care improves the quality of end-of-life care among elderly patients with end-stage renal disease

Continuity of care (COC) has been emphasized in research on terminal cancer patients to increase the quality of end-of-life care; however, limited research has been conducted on end-stage renal disease patients. We applied a retrospective cohort design on 29,095 elderly patients with end-stage renal disease who died between 2005 and 2013. These patients were identified from the National Health Insurance Research Database of Taiwan. The provider Continuity of Care Index (COCI) and site COCI were calculated on the basis of outpatient visits during the 6–12 months before death. We discovered that increases in the provider COCI were significantly associated with reductions in health expenditures after adjusting for confounders, especially in inpatient and emergency departments, where the treatment intensity is high. Higher provider and site COC were also associated with lower utilization of acute care and invasive treatments in the last month before death. Provider COC had a greater effect on end-of-life care expenditures than site COC did, which indicated significant care coordination gaps within the same facility. Our findings support the recommendation of prioritizing the continuity of end-of-life care, especially provider continuity, for patients with end-stage renal disease.

Impact of socioeconomic status on end-of-life costs: a systematic review and meta-analysis

BACKGROUND

Socioeconomic inequalities in access to, and utilization of medical care have been shown in many jurisdictions. However, the extent to which they exist at end-of-life (EOL) remains unclear.

METHODS

Studies in MEDLINE, EMBASE, CINAHL, ProQuest, Web of Science, Web of Knowledge, and OpenGrey databases were searched through December 2019 with hand-searching of in-text citations. No publication date or language limitations were set. Studies assessing SES (e.g. income) in adults, correlated to EOL costs in last year(s) or month(s) of life were selected. Two independent reviewers performed data abstraction and quality assessment, with inconsistencies resolved by consensus.

RESULTS

A total of twenty articles met eligibility criteria. Two meta-analyses were performed on studies that examined total costs in last year of life - the first examined costs without adjustments for confounders (n = 4), the second examined costs that adjusted for confounders, including comorbidities (n = 2). Among studies which did not adjust for comorbidities, SES was positively correlated with EOL costs (standardized mean difference, 0.13 [95% confidence interval, 0.03 to 0.24]). However, among studies adjusting for comorbidities, SES was inversely correlated with EOL expenditures (regression coefficient, -$150.94 [95% confidence interval, -$177.69 to -$124.19], 2015 United States Dollars (USD)). Higher ambulatory care and drug expenditure were consistently found among higher SES patients irrespective of whether or not comorbidity adjustment was employed.

CONCLUSION

Overall, an inequality leading to higher end-of-life expenditure for higher SES patients existed to varying extents, even within countries providing universal health care, with greatest differences seen for outpatient and prescription drug costs. The magnitude and directionality of the relationship in part depended on whether comorbidity risk-adjustment methodology was employed.

Prevalence of kidney damage in Chinese elderly: a large-scale population-based study

Background

In China, both population aging and kidney damage has become emerging public health challenges. Despite the number of elders is huge, data on kidney damage in this population are scarce. The present study aimed to describe the prevalence of kidney damage among older adults in Wuhan, China.

Methods

To describe the prevalence of kidney damage among Chinese elderly, the health screening data of 350,881 adults older than 65 years in Wuhan, China were collected and analyzed. Kidney damage was defined as eGFR less than 60 mL/min per 1·73 m² or the presence of proteinuria. Decreased renal function was defined as an eGFR < 60 mL/min/1.73 m². Proteinuria was defined as urine protein ≥1+ and without urine WBC or nitrite positive. The associated risk factors of eGFR decline and kidney damage were analyzed by multivariate logistic regression.

Results

The age-standardized prevalence of kidney damage, decreased renal function and proteinuria was 17.2, 13.5 and 5.3%. Among the patients, up to 74.4% was stage 3. The prevalence of kidney damage and eGFR decline were higher in suburbs than in urban (18.3% vs 16.0 and 14.6% vs 12.4%). Factors independently associated with kidney damage were age, female, BMI, abdominal circumference, hypertension, diabetes, stroke and coronary heart disease.

Conclusions

Kidney damage has become an important public health problem in Chinese elderly. More attention should be paid to elderly lived in suburbs or rural area in our further work.

Reducing costs at the end of life through provider incentives for hospice care: A retrospective cohort study

BACKGROUND

Costs of medical care have been found to be highest at the end of life.

AIM

To evaluate the effect of provider reimbursement for hospice care on end-of-life costs.

DESIGN

The policy expanded access to hospice care for end-stage renal disease patients, a policy previously limited to cancer patients only. This study employed a difference-in-differences analysis using a generalized linear model. The main outcome is inpatient expenditures in the last 30 days of life.

SETTING/PARTICIPANTS

A cohort of 151,509 patients with chronic kidney disease or cancer, aged 65 years or older, who died between 2005 and 2012 in the National Health Insurance Research Database, which contains all enrollment and inpatient claims data for Taiwan.

RESULTS

Even as end-of-life costs for cancer are declining over time, expanding hospice care benefits to end-stage renal disease patients is associated with an additional reduction of 7.3% in end-of-life costs per decedent, holding constant patient and provider characteristics. On average, end-of-life costs are also high for end-stage renal disease (1.88 times higher than those for cancer). The cost savings were larger among older patients-among those who died at 80 years of age or higher, the cost reduction was 9.8%.

CONCLUSION

By expanding hospice care benefits through a provider reimbursement policy, significant costs at the end of life were saved.

End-of-Life Care Preference: Examination of Chinese Adults with Children and Those Who Lost Their Only Child

BACKGROUND

Little is known about the end-of-life (EOL) care preference and its associated factors among community-dwelling adults in Mainland China. This study investigated the EOL care preference and its associated factors among community-dwelling Chinese adults in Shanghai, China.

METHODS

A cross-sectional survey was conducted in Shanghai, China, from April to June in 2013. A total of 1200 older adults aged 60 years and older and another 200 middle-aged and older adults aged 45 years and older who lost their only child were included in the current study. In the current study, the EOL care preference included three categories: preferred family care, preferred care provided by visiting healthcare professionals, and preferred care in a specialized EOL care institute. Childlessness was coded as lost the only child, had children but not coresiding, and had coresiding children. Mor and Hiris's model of choices of setting at the EOL was used to explore the EOL care preference and its associated factors, including sociodemographic characteristics, support networks, functional characteristics, and healthcare system. Multinomial logistic regressions were used to estimate the factors associated with their EOL care preference.

RESULTS

In terms of EOL care preference, adults who lost their only child preferred care provided by a specialized EOL care institute (58.43%), while adults who had children preferred family care at home (46.72% for adults who did not coreside with children and 49.04% for those who did). Results from multinomial logistic regressions showed that adults with higher income, having properties, and having children tended to opt for family care at home. Participants with friends' support preferred EOL care provided by visiting healthcare professionals or specialized EOL care institutions over family care at home.

CONCLUSIONS

Income, wealth, having children, and having friends' support were significant factors that were associated with the EOL care preference among Chinese adults. Home-based EOL care, professional and individualized hospice, or palliative care provided by institutions need to be developed in China.