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Jones T, Luth EA, Cleland CM, Brody AA. Race and Ethnicity Are Related to Undesirable Home Health Care Outcomes in Seriously Ill Older Adults. J Am Med Dir Assoc 2024; 25:104983. [PMID: 38604244 PMCID: PMC11139601 DOI: 10.1016/j.jamda.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVES Medicare Home Health Care (HHC) services are integral to the care of homebound seriously ill older adults requiring ongoing specialized medical care. Although disparities in health outcomes are well documented in inpatient and primary care, disparities experienced by historically marginalized racial and ethnic groups underrepresented in HHC are understudied. This study aimed to examine the relationship between individual characteristics and differences in HHC health outcomes for seriously ill older adults. DESIGN Secondary data analysis, repeated measure. SETTING AND PARTICIPANTS Seriously ill older adults who received HHC in 2016 in the HHC Outcome and Assessment Information Set (OASIS). METHODS Start of care and discharge data from the 2016 HCC OASIS were used to examine the relationship between individual characteristics and differences in HHC health outcomes identified by the Centers for Medicare and Medicaid Services as key indicators of quality in HHC, including dyspnea, pain frequency, cognitive functioning, and presence of unhealed pressure ulcer stage II or higher. A generalized ordered logit model with partial proportional odds was used for the ordinal categorical outcomes and a logistic regression was used for the binary dependent variable. RESULTS Findings indicated that of 227,402 seriously ill individuals with an HHC episode in 2016, those from underrepresented racial and ethnic groups had between 14% and 57% higher odds of worse health outcomes compared with non-Hispanic white patients with the exception of pain frequency. CONCLUSIONS AND IMPLICATIONS For people living with serious illness, there are significant differences in Medicare HHC health outcomes when comparing underrepresented racial or ethnic beneficiaries with white counterparts. More research is needed to understand how health care processes such as referral patterns or time to care initiation, and structural factors such as HHC agency quality and neighborhood social deprivation are related to health differences observed in the population.
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Affiliation(s)
- Tessa Jones
- Division of General Internal Medicine and the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Elizabeth A Luth
- Institute for Health, Health Care Policy, and Aging Research, Department of Family Medicine and Community Health, Robert Wood Johnson Medical School, Rutgers University, Rutgers, NJ, USA
| | - Charles M Cleland
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Abraham A Brody
- HIGN, New York University Rory Meyers College of Nursing, and Division of Geriatric Medicine and Palliative Care, New York University Grossman School of Medicine, New York, NY, USA
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2
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Fischer C, Bednarz D, Simon J. Methodological challenges and potential solutions for economic evaluations of palliative and end-of-life care: A systematic review. Palliat Med 2024; 38:85-99. [PMID: 38142280 PMCID: PMC10798028 DOI: 10.1177/02692163231214124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
BACKGROUND Given the increasing demand for palliative and end-of-life care, along with the introduction of costly new treatments, there is a pressing need for robust evidence on value. However, comprehensive guidance is missing on methods for conducting economic evaluations in this field. AIM To identify and summarise existing information on methodological challenges and potential solutions/recommendations for economic evaluations of palliative and end-of-life care. DESIGN We conducted a systematic review of publications on methodological considerations for economic evaluations of adult palliative and end-of-life care as per our PROSPERO protocol CRD42020148160. Following initial searches, we conducted a two-stage screening process and quality appraisal. Information was thematically synthesised, coded, categorised into common themes and aligned with the items specified in the Consolidated Health Economic Evaluation Reporting Standards statement. DATA SOURCES The databases Medline, Embase, HTADatabase, NHSEED and grey literature were searched between 1 January 1999 and 5 June 2023. RESULTS Out of the initial 6502 studies, 81 were deemed eligible. Identified challenges could be grouped into nine themes: ambiguous and inaccurate patient identification, restricted generalisability due to poor geographic transferability of evidence, narrow costing perspective applied, difficulties defining comparators, consequences of applied time horizon, ambiguity in the selection of outcomes, challenged outcome measurement, non-standardised measurement and valuation of costs as well as challenges regarding a reliable preference-based outcome valuation. CONCLUSION Our review offers a comprehensive context-specific overview of methodological considerations for economic evaluations of palliative and end-of-life care. It also identifies the main knowledge gaps to help prioritise future methodological research specifically for this field.
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Affiliation(s)
- Claudia Fischer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Damian Bednarz
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria
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Zdrale G, Essary A, Bremer S, Peng W, Chen W, Kalpas E. Identifying High-Cost, High-Need Patients in a Network of Community Hospitals. J Prim Care Community Health 2024; 15:21501319241233410. [PMID: 38400584 PMCID: PMC10894528 DOI: 10.1177/21501319241233410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
We examined healthcare costs at HonorHealth, a community-based academic health center comprised of 5 hospitals and numerous ambulatory care facilities. Patient encounters that resulted in admission in 2019 were included in the study. Mean costs in 2019 for high costs and high needs (HCHN) patients were compared with all remaining patients using a framework developed by the National Academy of Medicine. HCHN patients were older (71 vs 52 years), with a lower percentage of females (41.7% vs 59.8%), more frequently White (90.1% vs 87.5%), less frequently married (52.4% vs 54.5%), with a longer length of stay (6.5 vs 3.0 days) and higher mean charges ($134 743 vs $16 414). The mean cost per patient in the HCHN group decreased by age group ($192, 963, $165 200, $144 584, $134 795, and $108 356) for 0 to 18, 19 to 44, 45 to 64, 65 to 84, and 85+ years, respectively. HCHN patients were more publicly insured (49% vs 38%). Targeted interventions to treat HCHN may lead to lower healthcare costs and improved health outcomes within this system.
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Affiliation(s)
- Gabriel Zdrale
- Arizona State University, Tempe, AZ, USA
- HonorHealth, Scottsdale, AZ, USA
| | - Alison Essary
- HonorHealth, Scottsdale, AZ, USA
- Northern Arizona University, Phoenix, AZ, USA
| | | | | | - Weiqi Chen
- Arizona State University, Tempe, AZ, USA
| | - Edward Kalpas
- Arizona State University, Tempe, AZ, USA
- HonorHealth, Scottsdale, AZ, USA
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Nze Ossima A, Szfetel D, Denoyel B, Beloucif O, Texereau J, Champion L, Vié JF, Durand-Zaleski I. 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. Medicine (Baltimore) 2023; 102:e34555. [PMID: 37543784 PMCID: PMC10403027 DOI: 10.1097/md.0000000000034555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2023] Open
Abstract
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.
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Affiliation(s)
- Arnaud Nze Ossima
- Semeia, Paris, France
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, Paris, France
| | | | | | - Omar Beloucif
- Fédération des Prestataires de Santé à Domicile (FEDEPSAD), Paris, France
| | - Joelle Texereau
- Fédération des Prestataires de Santé à Domicile (FEDEPSAD), Paris, France
- AP-HP Service de Physiologie-Explorations Fonctionnelles, Hôpital Cochin, Université de Paris, Paris, France
| | - Louis Champion
- Fédération des Prestataires de Santé à Domicile (FEDEPSAD), Paris, France
| | | | - Isabelle Durand-Zaleski
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, Paris, France
- INSERM UMR 1153 CRESS, Clinical Epidemiology (Methods) Research Team, Paris Descartes University, Paris, France
- Université Paris Est Créteil, Créteil France
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5
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Cross SH, Kavalieratos D. Public Health and Palliative Care. Clin Geriatr Med 2023; 39:395-406. [PMID: 37385691 PMCID: PMC10571066 DOI: 10.1016/j.cger.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Meeting the needs of people at the end of life (EOL) is a public health (PH) concern, yet a PH approach has not been widely applied to EOL care. The design of hospice in the United States, with its focus on cost containment, has resulted in disparities in EOL care use and quality. Individuals with non-cancer diagnoses, minoritized individuals, individuals of lower socioeconomic status, and those who do not yet qualify for hospice are particularly disadvantaged by the existing hospice policy. New models of palliative care (both hospice and non-hospice) are needed to equitably address the burden of suffering from a serious illness.
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Affiliation(s)
- Sarah H Cross
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA
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Hong N, Root A, Handel B. The Role of Information and Nudges on Advance Directives and End-of-Life Planning: Evidence From a Randomized Trial. Med Care Res Rev 2023; 80:283-292. [PMID: 36935565 DOI: 10.1177/10775587231157800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Despite the substantial personal and economic implications of end-of-life decisions, many individuals fail to document their wishes, which often leads to patient dissatisfaction and unnecessary medical spending. We conducted a randomized trial of 1,200 patients aged 55 years and older to facilitate advance directive (AD) completion and better understand why patients fail to engage in high-value planning. We found that including a physical AD form with paper letters as a nudge to decrease hassle costs increased AD completion by 9.0 percentage points (95% confidence interval [CI] = [4.2, 13.9] percentage points). The intervention was especially effective for individuals aged 70 years and older, as AD completion increased by 17.5 percentage points (95% CI = [5.7, 9.4] percentage points). When compared with the impact of costless electronic reminders, each additional AD completion from the letter interventions costs as little as US$37. Our findings suggest that simple, inexpensive interventions with paper communication as behavioral nudges can be effective, especially in older populations.
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Affiliation(s)
- Nianyi Hong
- Congressional Budget Office, Washington, DC, USA
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7
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Zhang Y, Gupta A, Nicholson S, Li J. Elevated end-of-life spending: A new measure of potentially wasteful health care spending at the end of life. Health Serv Res 2023; 58:186-194. [PMID: 36303444 PMCID: PMC9836947 DOI: 10.1111/1475-6773.14093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Yongkang Zhang
- Department of Population Health SciencesWeill Cornell Medical College, Cornell UniversityNew YorkNew YorkUSA
| | - Atul Gupta
- Department of Health Care ManagementThe Wharton School, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sean Nicholson
- Department of EconomicsBrooks School of Public Policy, Cornell UniversityIthacaNew YorkUSA
| | - Jing Li
- The Comparative Health Outcomes, Policy and Economics Institute, Department of PharmacySchool of Pharmacy, University of WashingtonSeattleWashingtonUSA
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Hansen AV, Mortensen LH, Ekstrøm CT, Trompet S, Westendorp R. Predicting mortality and visualizing health care spending by predicted mortality in Danes over age 65. Sci Rep 2023; 13:1203. [PMID: 36681729 PMCID: PMC9867694 DOI: 10.1038/s41598-023-28102-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023] Open
Abstract
Health care expenditure in the last year of life makes up a high proportion of medical spending across the world. This is often framed as waste, but this framing is only meaningful if it is known at the time of treatment who will go on to die. We analyze the distribution of health care spending by predicted mortality for the Danish population over age 65 over the year 2016, with one-year mortality predicted by a machine learning model based on sociodemographics and use of health care services for the two years before entry into follow-up. While a reasonably good model can be built, extremely few individuals have high ex-ante probability of dying, and those with a predicted mortality of more than 50% account for only 2.8% of total health care expenditure. Decedents outspent survivors by a factor of more than ten, but compared to survivors with similar predicted mortality they spent only 2.5 times as much. Our results suggest that while spending in the last year of life is indeed high, this is nearly all spent in situations where there is a reasonable expectation that the patient can survive.
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Affiliation(s)
- Anne Vinkel Hansen
- Methods and Analysis, Statistics Denmark, , Danmarks Statistik, Sejrøgade 11, 2100, Copenhagen, Denmark.
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark.
| | - Laust Hvas Mortensen
- Methods and Analysis, Statistics Denmark, , Danmarks Statistik, Sejrøgade 11, 2100, Copenhagen, Denmark
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Claus Thorn Ekstrøm
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Stella Trompet
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Rudi Westendorp
- Methods and Analysis, Statistics Denmark, , Danmarks Statistik, Sejrøgade 11, 2100, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Davis MP, Vanenkevort EA, Elder A, Young A, Correa Ordonez ID, Wojtowicz MJ, Ellison H, Fernandez C, Mehta Z, Behm B, Digwood G, Panikkar R. The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs. Am J Hosp Palliat Care 2023; 40:52-60. [PMID: 35503515 DOI: 10.1177/10499091221098062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
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10
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Sina-Odunsi AJ, Sina-Odunsi AB. COVID-19 and the current state of palliative care in the United States. Health Promot Perspect 2022; 12:273-276. [PMID: 36686046 PMCID: PMC9808903 DOI: 10.34172/hpp.2022.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/14/2022] [Indexed: 01/15/2023] Open
Abstract
Palliative care is becoming increasingly pertinent to be strengthened across health systems around the world, and the United States is not an exception. The emergence of the COVID-19 pandemic has disrupted provision and access to palliative care among patients with serious and complex illnesses, critically ill persons, and their families in the United States. Prior to the emergence of the pandemic, the United States faced a number of challenges ranging from racial discrimination, a stressed medical workforce, a lack of passable reimbursement for palliative care, and legal barriers, among others. Unfortunately, these issues have gotten worse amid the pandemic. This further revealed the need to invest more in innovative strategies that will ensure the provision of palliative care services during public health emergencies. In this article, we comment on the current state of palliative care in the United States.
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Affiliation(s)
- Ayobami Jadesola Sina-Odunsi
- All Saints University College of Medicine, Saint Vincent and The Grenadines,Corresponding Author: Ayobami Jadesola Sina-Odunsi, Emails: ,
| | - Ayomide Busayo Sina-Odunsi
- School of Medicine, University of Aberdeen, Aberdeen, United Kingdom,AB Global Health Initiative, Nigeria
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11
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Riley S, Sarbey B. The Unexamined Benefits of the Expansive Legalization of Medical Assistance-in-Dying. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:655-665. [PMID: 36156765 DOI: 10.1007/s11673-022-10211-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 05/17/2022] [Indexed: 06/16/2023]
Abstract
If you slide far enough down the slippery slope envisioned by opponents of medical assistance-in-dying (MAiD), you eventually land in a ghastly society with industrialized euthanasia, rampant suicide, and devalued life. But what if the slippery slope leads us somewhere better? This paper explores the benefits of eliminating nearly all MAiD prohibitions and regulations. We anticipate three positive effects for public health: 1. Expanded access to those currently not qualified from MAiD by removing ineffective access criteria; 2. Harm reduction by making MAiD safer and by rerouting suicidal patients into alternate care; and 3. Improvements to the health system through lowered healthcare costs and increased patient activation in end-of-life care. Safeguards and prohibitions deny those who wish to die the ability to do so to prevent the potential danger of a few being subjected to an undesired early death.
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Affiliation(s)
- Sean Riley
- The Ohio State University Wexner Medical Center, 2050 Kenny Rd, Columbus, OH, 43215, USA.
| | - Ben Sarbey
- Duke University, 1364 Campus Dr., Durham, NC, 27705, USA
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12
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Lam MB, Friend TH, Erfani P, Orav EJ, Jha AK, Figueroa JF. ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study. J Gen Intern Med 2022; 37:3275-3282. [PMID: 35022958 PMCID: PMC9550919 DOI: 10.1007/s11606-021-07183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN Retrospective analysis of Medicare claims. PATIENTS We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.
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Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, MA, Boston, USA.
| | - Tynan H Friend
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- School of Public Health, Brown University, Providence, RI, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, MA, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Hafez SA, Snethen JA, Taani M, Ngui E, Ellis J, Baothman AA. Primary Caregivers Caring for a Child at End of Life in Saudi Arabia. Palliat Med Rep 2022; 3:140-148. [PMID: 36059911 PMCID: PMC9438442 DOI: 10.1089/pmr.2021.0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shahad A. Hafez
- Nursing Program, Batterjee Medical College, Aseer, Saudi Arabia
- Sigma Theta Tau International (STTI), Eta Nu Chapter, Milwaukee, Wisconsin, USA
| | - Julia A. Snethen
- Sigma Theta Tau International (STTI), Eta Nu Chapter, Milwaukee, Wisconsin, USA
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Murad Taani
- Sigma Theta Tau International (STTI), Eta Nu Chapter, Milwaukee, Wisconsin, USA
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Emmanuel Ngui
- School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Julie Ellis
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
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Teno JM. Seriously Ill Individuals—A Canary in the Coal Mine for Medicare’s Transition to Accountable Health Care? JAMA HEALTH FORUM 2022; 3:e222306. [DOI: 10.1001/jamahealthforum.2022.2306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joan M. Teno
- School of Medicine, Oregon Health & Science University, Portland
- School of Public Health, Brown University, Providence, Rhode Island
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15
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May P, De Looze C, Feeney J, Matthews S, Kenny RA, Normand C. Do Mini-Mental State Examination and Montreal Cognitive Assessment predict high-cost health care users? A competing risks analysis in The Irish Longitudinal Study on Ageing. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5766. [PMID: 35702991 PMCID: PMC9328350 DOI: 10.1002/gps.5766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 05/27/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Policymakers want to better identify in advance the 10% of people who account for approximately 75% of health care costs. We evaluated how well Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) predicted high costs in Ireland. METHODS/DESIGN We used five waves from The Irish Longitudinal Study on Ageing, a biennial population-representative survey of people aged 50+ (2010-2018). We used competing risks analysis where our outcome of interest was "high costs" (top 10% at any wave) and the competing outcome was dying or loss to follow-up without first having the high-cost outcome. Our binary predictors of interest were a 'low score' (bottom 10% in the sample) in MMSE (≤25 pts) and MoCA (≤19 pts) at baseline, and we calculated sub-hazard ratios after controlling for sociodemographic, clinical and functional factors. RESULTS Of 5856 participants, 1427 (24%) had the 'high cost' outcome; 1463 (25%) had a competing outcome; and 2966 (51%) completed eight years of follow-up without either outcome. In multivariable regressions a low MoCA score was associated with high costs (SHR: 1.38 (95% CI: 1.2-1.6) but a low MMSE score was not. Low MoCA score at baseline had a higher true positive rate (40%) than did low MMSE score (35%). The scores had similar association with exit from the study. CONCLUSIONS MoCA had superior predictive accuracy for high costs than MMSE but the two scores identify somewhat different types of high-cost user. Combining the approaches may improve efforts to identify in advance high-cost users.
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Affiliation(s)
- Peter May
- The Irish Longitudinal Study on AgeingSchool of MedicineTrinity College DublinDublinIreland
- Centre for Health Policy and ManagementTrinity College DublinDublinIreland
| | - Céline De Looze
- The Irish Longitudinal Study on AgeingSchool of MedicineTrinity College DublinDublinIreland
| | - Joanne Feeney
- The Irish Longitudinal Study on AgeingSchool of MedicineTrinity College DublinDublinIreland
| | - Soraya Matthews
- Centre for Health Policy and ManagementTrinity College DublinDublinIreland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on AgeingSchool of MedicineTrinity College DublinDublinIreland
| | - Charles Normand
- Centre for Health Policy and ManagementTrinity College DublinDublinIreland
- Cicely Saunders Institute of Palliative CarePolicy and RehabilitationKing's College LondonLondonUK
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16
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Li L, Hu L, Ji J, Mckendrick K, Moreno J, Kelley AS, Mazumdar M, Aldridge M. Determinants of Total End-of-Life Health Care Costs of Medicare Beneficiaries: A Quantile Regression Forests Analysis. J Gerontol A Biol Sci Med Sci 2022; 77:1065-1071. [PMID: 34153101 PMCID: PMC9071433 DOI: 10.1093/gerona/glab176] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Lihua Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, New York, USA
- Tisch Cancer Institute, New York, New York, USA
| | - Liangyuan Hu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, New York, USA
- Tisch Cancer Institute, New York, New York, USA
| | - Jiayi Ji
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, New York, USA
- Tisch Cancer Institute, New York, New York, USA
| | - Karen Mckendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, New York, USA
- Tisch Cancer Institute, New York, New York, USA
| | - Melissa Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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17
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Khandelwal N, May P, Downey LM, Engelberg RA, Curtis JR. Advance Identification of Patients With Chronic Conditions and Acute Respiratory Failure at Greatest Risk for High-Intensity, Costly Care. J Pain Symptom Manage 2022; 63:618-626. [PMID: 34793946 PMCID: PMC8930607 DOI: 10.1016/j.jpainsymman.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/12/2021] [Accepted: 11/10/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Patients with underlying chronic illness requiring mechanical ventilation for acute respiratory failure are at risk for poor outcomes and high costs. OBJECTIVES Identify characteristics at time of intensive care unit (ICU) admission that identify patients at highest risk for high-intensity, costly care. METHODS Retrospective cohort study using electronic health and financial records (2011-2017) for patients requiring ≥48 hours of mechanical ventilation with ≥1 underlying chronic condition at an academic healthcare system. Main outcome was total cost of index hospitalization. Exposures of interest included number and type of chronic conditions. We used finite mixture models to identify the highest-cost group. RESULTS 4,892 patients met study criteria. Median cost for index hospitalization was $135,238 (range, $9,748 -$3,176,065). Finite mixture modelling identified three classes with mean costs of $89,980, $150,603, and $277,712. Patients more likely to be in the high-cost class were: 1) < 72 years old (OR: 2.03; 95% CI:1.63, 2.52); 2) with dementia (OR: 1.55; 95% CI:1.17, 2.06) or chronic renal failure (OR: 1.27; 95% CI:1.08, 1.48); 3) weight loss ≥ 5% in year prior to hospital admission (OR: 1.25; 95% CI:1.05, 1.48); and 4) hospitalized during prior year (OR: 1.92; 95% CI:1.58, 2.35). CONCLUSION Among patients with underlying chronic illness and acute respiratory failure, we identified characteristics associated with the highest costs of care. Identifying these patients may be of interest to healthcare systems and hospitals and serve as one indication to invest resources in palliative and supportive care programs that ensure this care is consistent with patients' goals.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine (N.K.), University of Washington, Harborview Medical Center, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (N.K., L.M.D., R.A.E., J.R.C.), University of Washington, Harborview Medical Center, Seattle, Washington, USA.
| | - Peter May
- Trinity College Dublin (P.M.), Centre for Health Policy and Management, Dublin, Ireland; Trinity College Dublin (P.M.), The Irish Longitudinal study on Ageing (TILDA), Dublin, Ireland
| | - Lois M Downey
- Cambia Palliative Care Center of Excellence (N.K., L.M.D., R.A.E., J.R.C.), University of Washington, Harborview Medical Center, Seattle, Washington, USA; Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine (L.M.D., R.A.E., J.R.C.), University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence (N.K., L.M.D., R.A.E., J.R.C.), University of Washington, Harborview Medical Center, Seattle, Washington, USA; Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine (L.M.D., R.A.E., J.R.C.), University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence (N.K., L.M.D., R.A.E., J.R.C.), University of Washington, Harborview Medical Center, Seattle, Washington, USA; Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine (L.M.D., R.A.E., J.R.C.), University of Washington, Harborview Medical Center, Seattle, Washington, USA
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18
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Tay DL, Ornstein KA, Meeks H, Utz RL, Smith KR, Stephens C, Hashibe M, Ellington L. Evaluation of Family Characteristics and Multiple Hospitalizations at the End of Life: Evidence from the Utah Population Database. J Palliat Med 2022; 25:376-387. [PMID: 34448596 PMCID: PMC8968848 DOI: 10.1089/jpm.2021.0071] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Djin L. Tay
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Huong Meeks
- Utah Population Database, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Rebecca L. Utz
- Department of Sociology, University of Utah, Salt Lake City, Utah, USA
| | - Ken R. Smith
- Department of Department of Family and Consumer Studies, University of Utah, Salt Lake City, Utah, USA
- Population Science, Huntsman Cancer Institute, University of Utah, Utah, USA
| | | | - Mia Hashibe
- Department of Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
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19
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Sallnow L, Smith R, Ahmedzai SH, Bhadelia A, Chamberlain C, Cong Y, Doble B, Dullie L, Durie R, Finkelstein EA, Guglani S, Hodson M, Husebø BS, Kellehear A, Kitzinger C, Knaul FM, Murray SA, Neuberger J, O'Mahony S, Rajagopal MR, Russell S, Sase E, Sleeman KE, Solomon S, Taylor R, Tutu van Furth M, Wyatt K. Report of the Lancet Commission on the Value of Death: bringing death back into life. Lancet 2022; 399:837-884. [PMID: 35114146 PMCID: PMC8803389 DOI: 10.1016/s0140-6736(21)02314-x] [Citation(s) in RCA: 170] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - Afsan Bhadelia
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Yali Cong
- Peking University Health Science Center, Beijing, China
| | | | | | | | | | | | | | | | | | | | | | | | - Julia Neuberger
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Sarah Russell
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eriko Sase
- Georgetown University, Washington, DC, USA
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20
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Kaur P, Wu HY, Hum A, Heng BH, Tan WS. Medical cost of advanced illnesses in the last-year of life-retrospective database study. Age Ageing 2022; 51:6406695. [PMID: 34673931 DOI: 10.1093/ageing/afab212] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Palvinder Kaur
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
| | - Huei Yaw Wu
- Department of Palliative Medicine, Tan Tock Seng Hospital Singapore, Singapore 308433
- Palliative Care Centre for Excellence in Research and Education, Singapore 308436
| | - Allyn Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital Singapore, Singapore 308433
- Palliative Care Centre for Excellence in Research and Education, Singapore 308436
| | - Bee Hoon Heng
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
| | - Woan Shin Tan
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
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21
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Zuvekas SH, Kashihara D. The Impacts of the COVID-19 Pandemic on the Medical Expenditure Panel Survey. Am J Public Health 2021; 111:2157-2166. [PMID: 34878880 PMCID: PMC8667843 DOI: 10.2105/ajph.2021.306534] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 11/04/2022]
Abstract
The COVID-19 pandemic caused substantial disruptions in the field operations of all 3 major components of the Medical Expenditure Panel Survey (MEPS). The MEPS is widely used to study how policy changes and major shocks, such as the COVID-19 pandemic, affect insurance coverage, access, and preventive and other health care utilization and how these relate to population health. We describe how the MEPS program successfully responded to these challenges by reengineering field operations, including survey modes, to complete data collection and maintain data release schedules. The impact of the pandemic on response rates varied considerably across the MEPS. Investigations to date show little effect on the quality of data collected. However, lower response rates may reduce the statistical precision of some estimates. We also describe several enhancements made to the MEPS that will allow researchers to better understand the impact of the pandemic on US residents, employers, and the US health care system. (Am J Public Health. 2021;111(12):2157-2166. https://doi.org/10.2105/AJPH.2021.306534).
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Affiliation(s)
- Samuel H Zuvekas
- Samuel H. Zuvekas and David Kashihara are with the Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD
| | - David Kashihara
- Samuel H. Zuvekas and David Kashihara are with the Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD
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22
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Blankart CR, van Gool K, Papanicolas I, Bernal‐Delgado E, Bowden N, Estupiñán‐Romero F, Gauld R, Knight H, Abiona O, Riley K, Schoenfeld AJ, Shatrov K, Wodchis WP, Figueroa JF. International comparison of spending and utilization at the end of life for hip fracture patients. Health Serv Res 2021; 56 Suppl 3:1370-1382. [PMID: 34490633 PMCID: PMC8579204 DOI: 10.1111/1475-6773.13734] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To identify and explore differences in spending and utilization of key health services at the end of life among hip fracture patients across seven developed countries. DATA SOURCES Individual-level claims data from the inpatient and outpatient health care sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC). STUDY DESIGN We retrospectively analyzed utilization and spending from acute hospital care, emergency department, outpatient primary care and specialty physician visits, and outpatient drugs. Patterns of spending and utilization were compared in the last 30, 90, and 180 days across Australia, Canada, England, Germany, New Zealand, Spain, and the United States. We employed linear regression models to measure age- and sex-specific effects within and across countries. In addition, we analyzed hospital-centricity, that is, the days spent in hospital and site of death. DATA COLLECTION/EXTRACTION METHODS We identified patients who sustained a hip fracture in 2016 and died within 12 months from date of admission. PRINCIPAL FINDINGS Resource use, costs, and the proportion of deaths in hospital showed large variability being high in England and Spain, while low in New Zealand. Days in hospital significantly decreased with increasing age in Canada, Germany, Spain, and the United States. Hospital spending near date of death was significantly lower for women in Canada, Germany, and the United States. The age gradient and the sex effect were less pronounced in utilization and spending of emergency care, outpatient care, and drugs. CONCLUSIONS Across seven countries, we find important variations in end-of-life care for patients who sustained a hip fracture, with some differences explained by sex and age. Our work sheds important insights that may help ongoing health policy discussions on equity, efficiency, and reimbursement in health care systems.
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Affiliation(s)
- Carl Rudolf Blankart
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
- Hamburg Center for Health EconomicsUniversität HamburgHamburgGermany
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation (CHERE)University of TechnologySydneyAustralia
| | - Irene Papanicolas
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Department of Health PolicyLondon School of EconomicsLondonUK
| | | | - Nicholas Bowden
- Department of Women's and Children's HealthUniversity of OtagoDunedinNew Zealand
| | | | - Robin Gauld
- Otago Business School and Centre for Health Systems and TechnologyUniversity of OtagoDunedinNew Zealand
| | | | - Olukorede Abiona
- Centre for Health Economics Research and Evaluation (CHERE)University of TechnologySydneyAustralia
| | - Kristen Riley
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Andrew J. Schoenfeld
- Division of Orthopedic SurgeryBrigham & Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Kosta Shatrov
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
| | - Walter P. Wodchis
- Institute of Health Policy Management & EvaluationUniversity of TorontoTorontoOntarioCanada
- Institute for Better Health, Trillium Health PartnersMississaugaOntarioCanada
| | - Jose F. Figueroa
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
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23
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Bharadwaj P, Taylor S, Randhawa MS, Gill G, Solomon A. Identifying the Time of Intervention When Managing Populations: Know Your Data. J Palliat Med 2021; 24:1592-1593. [PMID: 34726518 DOI: 10.1089/jpm.2021.0417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Parag Bharadwaj
- Palliative Care, MemorialCare Medical Group, Fountain Valley, California, USA
| | - Sarah Taylor
- MemorialCare Medical Foundation, Fountain Valley, California, USA
| | | | - Gagandeep Gill
- MemorialCare Medical Foundation, Fountain Valley, California, USA
| | - Adam Solomon
- MemorialCare Medical Foundation, Fountain Valley, California, USA
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24
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Quinn KL, Hsu AT, Meaney C, Qureshi D, Tanuseputro P, Seow H, Webber C, Fowler R, Downar J, Goldman R, Chan R, McGrail K, Isenberg SR. Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital. Palliat Med 2021; 35:1671-1681. [PMID: 33781119 PMCID: PMC8532234 DOI: 10.1177/02692163211002045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking. AIM The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use. SETTINGS AND PARTICIPANTS We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died. RESULTS Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use. CONCLUSIONS Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, Toronto and Ottawa, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Amy T Hsu
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danial Qureshi
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Colleen Webber
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Rob Fowler
- Tory Trauma Program, Sunnybrook Hospital, Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario
| | - James Downar
- Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Russell Goldman
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care and Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Raphael Chan
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
| | - Sarina R Isenberg
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Ottawa, ON, Canada
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Hughes K, Achauer S, Baker EF, Knowles HC, Clayborne EP, Goett RR, Moussa M. Addressing end-of-life care in the chronically ill: Conversations in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12569. [PMID: 34632450 PMCID: PMC8486416 DOI: 10.1002/emp2.12569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 11/23/2022] Open
Abstract
Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.
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Affiliation(s)
- Katarina Hughes
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | - Samantha Achauer
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | | | | | - Elizabeth P. Clayborne
- Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | | | - Mohamad Moussa
- Emergency MedicineUniversity of Toledo College of Medicine and Life SciencesToledoOhioUSA
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Dalmau-Bueno A, García-Altés A, Amblàs J, Contel JC, Santaeugènia S. Determinants of the number of days people in the general population spent at home during end-of-life: Results from a population-based cohort analysis. PLoS One 2021; 16:e0253483. [PMID: 34264956 PMCID: PMC8282074 DOI: 10.1371/journal.pone.0253483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/04/2021] [Indexed: 11/22/2022] Open
Abstract
Background The number of days spent at home in the last six months of life has been proposed as a comprehensive indicator of high-value patient-centered care; however, information regarding the determinants of this outcome is scarce, particularly among the general population. We investigated the determinants of spending time at home within the six months preceding death. Methods Population-based, retrospective analysis of administrative databases of the Catalan government. The analysis included adult (≥18 years) individuals who died in Catalonia (North-east Spain) in 2017 and met the McNamara criteria for palliative care. The primary outcome was the number of days spent at home within the last 180 days of life. Other variables included the cause of death, demographic characteristics, and socioeconomic status, stratified as very low, low, mid, and high level. Results The analysis included 40,137 individuals (19,510 women; 20,627 men), who spent a median of 140 days (IQR 16–171) at home within the six months preceding death (women 140 [16–171]; men 150 [100–171]). Female gender was an independent factor of staying fewer days at home (OR 0.80 [95% CI 0.77–0.82]; p<0.001). Higher socioeconomic levels were significantly associated with an increasing number of days at home in both genders: among women, ORs of the low, middle, and high levels were 1.09 (0.97–1.22), 1.54 (1.36–1.75), and 2.52 (1.69–3.75) (p<0.001), respectively; the corresponding ORs among men were 1.27 (1.12–1.43), 1.56 (1.38–1.77), 2.82 (2.04–3.88) (p<0.001). The presence of dementia was a strong predictor of spending less time at home in women (0.41 (0.38–0.43); p<0.001) and men (0.45 (0.41–0.48); p<0.001). Conclusions Our results suggest that end-of-life care is associated with gender and socioeconomic inequalities; women and individuals with lower socioeconomic status spend less time at home within the last 180 days of life.
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Affiliation(s)
| | - Anna García-Altés
- Catalan Agency for Health Quality and Evaluation (AQuAS), Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.,Institut d'Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain
| | - Jordi Amblàs
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC), Vic, Spain.,Chronic Care Program, Department of Health, Barcelona, Spain
| | - Joan Carles Contel
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC), Vic, Spain.,Chronic Care Program, Department of Health, Barcelona, Spain
| | - Sebastià Santaeugènia
- Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC), Vic, Spain.,Chronic Care Program, Department of Health, Barcelona, Spain
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27
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Jiao B, Basu A. Catalog of Age- and Medical Condition-Specific Healthcare Costs in the United States to Inform Future Costs Calculations in Cost-Effectiveness Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:957-965. [PMID: 34243839 DOI: 10.1016/j.jval.2021.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Boshen Jiao
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA.
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
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28
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Livne R. Toward a sociology of finitude: life, death, and the question of limits. THEORY AND SOCIETY 2021; 50:891-934. [PMID: 34025007 PMCID: PMC8121639 DOI: 10.1007/s11186-021-09448-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 06/12/2023]
Abstract
Progressing beyond the given has been a key modern tendency. Yet modern societies are currently facing the problem of how to put limits on progress, expansion, and growth, live within them, and preserve (rather than transcend) the present. Drawing on economic sociology scholarship on valuation and morality in economic life, this article develops and applies the term economization to analyze the enactment of limits on progress. The question of end-of-life care-when to stop medical efforts to prolong life, postpone death, and advance the scientific frontier-serves as an illustrative empirical case that sheds light on limit-setting in general. My analysis of this case combines historical, ethnographic, and in-depth interview data on US palliative care clinicians, who specialize in making life-and-death decisions in acute care hospitals.
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Affiliation(s)
- Roi Livne
- Department of Sociology, University of Michigan, Ann Arbor, MI USA
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29
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Glass DP, Wang SE, Minardi PM, Kanter MH. Concordance of End-of-Life Care With End-of-Life Wishes in an Integrated Health Care System. JAMA Netw Open 2021; 4:e213053. [PMID: 33822069 PMCID: PMC8025115 DOI: 10.1001/jamanetworkopen.2021.3053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE There is widespread consensus on the challenges to meeting the end-of-life wishes of decedents in the US. However, there is broad but not always recognized success in meeting wishes among decedents 65 years and older. OBJECTIVE To assess how well end-of-life wishes of decedents 65 years and older are met in the last year of life. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study involved 3 planned samples of family members or informants identified as the primary contact in the medical record of Kaiser Permanente Southern California decedents. The first sample was 715 decedents, 65 years or older, who died between April 1 and May 31, 2017. The second was a high-cost sample of 332 decedents, 65 years or older, who died between June 1, 2016, and May 31, 2017, and whose costs in the last year of life were in the top 10% of the costs of all decedents. The third was a lower-cost sample with 655 decedents whose costs were not in the top 10%. The survey was fielded between December 19, 2017, and February 8, 2018. MAIN OUTCOMES AND MEASURES Meeting end-of-life wishes, discussions with next of kin and physicians, types of discordant care, and perceptions of amount of care received. RESULTS Surveys were completed by 715 of the 2281 next of kin in the all-decedent sample (mean [SD] decedent age, 80.9 [8.9] years; 361 [50.5%] male) for a 31% response rate; in 332 of the 1339 next of kin in the high-cost sample (mean [SD] decedent age, 75.5 [7.1] years; 194 [48.4%] male) for a 25% response rate; and in 659 of 2058 in the lower-cost sample (mean [SD] decedent age, 81.6 [8.8] years) for a 32% response rate. Respondents noted that high percentages of decedents received treatment that was concordant with their desires: 601 (88.9%) had their wishes met, 39 (5.9%) received a treatment they did not want, and 554 (84.1%) filled out an advance directive. A total of 509 respondents (82.5%) believed the amount of care was the right amount. Those with the highest costs had their wishes met at lower rates than those with lower costs (250 [80.1%] vs 553 [89.6%]). CONCLUSIONS AND RELEVANCE In this Kaiser Permanente Southern California cohort, a large proportion of decedents 65 years and older had end-of-life discussions and documentation, had their wishes met, and received the amount of care they thought appropriate.
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Affiliation(s)
- David P. Glass
- Department of Research and Evaluation, Kaiser Permanente Southern California
- Department of Health Systems Science, Bernard J. Tyson School of Medicine, Kaiser Permanente, Pasadena, California
| | - Susan E. Wang
- Life Care Planning and Serious Illness Care, Southern California Permanente Medical Group, Los Angeles
| | | | - Michael H. Kanter
- Department of Clinical Science, Bernard J. Tyson School of Medicine, Kaiser Permanente, Pasadena, California
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30
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Galvin AE, Friedman DB, Hébert JR. Focus on disability-free life expectancy: implications for health-related quality of life. Qual Life Res 2021; 30:2187-2195. [PMID: 33733432 PMCID: PMC7970769 DOI: 10.1007/s11136-021-02809-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 10/31/2022]
Abstract
BACKGROUND Since the end of the industrial revolution, advances in public health and clinical medicine have contributed to dramatic decreases in infant and childhood mortality, improvements in health-related quality of life (HRQoL), increases in overall life expectancy (LE), and rectangularization of survival curves. OBJECTIVES In this article, we focus on disability that has occurred with the overall lengthening of LE in many populations and the implications this has for decreased HRQoL. METHODS We utilize the concept of rectangularization of population survival to depict the rising prevalence of disability associated with increased LE, especially among racial and ethnic minorities and people of low socioeconomic status (SES) and relate this to HRQoL. RESULTS Disability-free life expectancy (DFLE) and healthy life expectancy (HLE) are defined in terms of HRQoL. Specific attention is focused on disability experienced by disparate populations around the globe. By focusing on disparities in DFLE, and the need to expand LE to include HLE as a central component of HRQoL, this work provides an important counterpoint to the attention that has been paid to LE disparities according to race, gender, ethnicity, education, and SES. DISCUSSION By calling attention to those factors that appear to be the most important drivers of the differences in quality and length of DFLE between different groups (i.e., the components of the social gradient, exposure to chronic stress, systemic inflammation, and the psychological and biological mechanisms associated with the gut-brain axis) and, by logical extension, HRQoL, we hope to promote research in this arena with the ultimate goal of improving DFLE, HLE, and overall HRQoL, especially in disparate populations around the globe.
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Affiliation(s)
- Ashley E Galvin
- Statewide Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Suite 241-2, Columbia, SC, 29208, USA.,Pediatric Hematology-Oncology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02215, USA
| | - Daniela B Friedman
- Statewide Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Suite 241-2, Columbia, SC, 29208, USA.,Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA.,Office for the Study of Aging, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
| | - James R Hébert
- Statewide Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Suite 241-2, Columbia, SC, 29208, USA. .,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St, Columbia, SC, 29208, USA.
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31
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Rimar A, Friedman MI, Quinteros MG, Gooch RA, Masick KD, DaCosta N, Spooner RL. Changing the Care Paradigm for Patients: Advanced Illness Beds Care Model. Am J Hosp Palliat Care 2020; 38:1336-1341. [PMID: 33356792 DOI: 10.1177/1049909120984384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Over 90 million Americans suffer from advanced illness (AI) and spend their last days of life in critical care units receiving costly, unwanted, aggressive medical care. OBJECTIVE Evaluate the impact of a specialized care model in medical/surgical units for hospitalized geriatric patients and patients with complex care requirements where designated AI beds align care with patient's wishes/goals, minimize aggressive interventions, and influence efficient resource utilization. DESIGN US based multi-facility retrospective, longitudinal descriptive study of screened positive AI patients in AI Beds (N = 1,237) from 3 facilities from 2015 to 2017. RESULTS Patient outcomes included 60% referrals to AI beds from ICU, a decrease of 39-49% in average ICU LOS, a 23% reduction of AI bed patient expirations, 9.0% referrals to hospice, and projected cost savings of $4,361.66/patient, US dollars. CONCLUSION Allocating AI beds to deliver care to AI patients resulted in a decreased cost of care by reducing overall hospital LOS, mortality, and efficient use of both critical care and hospital resources.
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Affiliation(s)
- Alexander Rimar
- Department of Medicine, Geriatrics and Palliative Care, 5945Lenox Hill Hospital, New York, NY, USA
| | - M Isabel Friedman
- Clinical Transformation, 5799Northwell Health, New Hyde Park, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Maria G Quinteros
- Department of Medicine, Geriatrics and Palliative Care, 25049Long Island Jewish Medical Center, Northwell Health, New Hyde Park, NY, USA
| | - Rebecca A Gooch
- Clinical Transformation, 5799Northwell Health, New Hyde Park, NY, USA
| | - Kevin D Masick
- Krasnoff Quality Management Institute, 5799Northwell Health, New Hyde Park, NY, USA.,Hofstra University, Hempstead, NY, USA
| | - Nicholas DaCosta
- Clinical Transformation, 5799Northwell Health, New Hyde Park, NY, USA
| | - Rachael L Spooner
- Clinical Transformation, 5799Northwell Health, New Hyde Park, NY, USA
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32
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Cost Analysis of Cancer in Brazil: A Population-Based Study of Patients Treated by Public Health System From 2001-2015. Value Health Reg Issues 2020; 23:137-147. [PMID: 33227545 DOI: 10.1016/j.vhri.2020.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the federal government expenditures with oncological care, for the most incident cancer types among the Brazilian population, using registries of all patients treated by the Brazilian National Health Service (SUS) between 2001 and 2015. We adopted the formal healthcare sector perspective in this study, with the costs per patient estimated by the reimbursement price paid by the Ministry of Health to service providers. METHODS The costs were adjusted by the follow-up time for each patient. We performed multivariate regression analysis using ordinary least squares. We analyzed 952 960 patients aged ≥19 years who underwent cancer treatment, between 2001 and 2015, for breast, prostate, colorectal, cervix, lung, and stomach cancers. RESULTS The annual mean costs per patient (in USD purchasing power parity) was $9572.30, varying from $5782.10 for breast cancer to $16 656 for cervical cancer. Several variables predicted higher costs of cancer treatment, namely: to be male (+14%), with younger age ranges at treatment initiation, resident in the Northeast region (+26%), treated for colorectal cancer (+482%), with treatment initiation from 2010 to 2014, tumor stages III and IV (III: +182%; IV: +165%), hospitalization for other reasons besides the cancer treatment, and suffering from some a comorbidity. CONCLUSIONS Given the forthcoming Brazilian demographic changes, which strongly suggest that the economic burden of cancer is about to increase in the near future, our estimates provide relevant information to produce useful projections about future cancer-related costs.
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Amdahl J, Weycker D, Farkouh R, Huang L, Eichten C, Oster G. Pediatric Vaccines and Cost-Effectiveness Thresholds: How Much is Too Much to Pay for Prevention? Infect Dis Ther 2020; 10:1-13. [PMID: 33170498 PMCID: PMC7652907 DOI: 10.1007/s40121-020-00367-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/24/2020] [Indexed: 11/28/2022] Open
Abstract
Cost-effectiveness evaluations play an important role in recommendations for use of pediatric vaccines that are set forth by the US Advisory Committee on Immunization Practices (ACIP). The fact that these evaluations are undertaken and accorded weight suggests that a critical value for designating pediatric vaccines as cost-effective (or not) must exist. For recommended pediatric vaccines, however, reported incremental cost-effectiveness ratios (ICERs) have varied greatly, and there does not appear to be an explicit threshold used by the ACIP to define how much is too much to pay for the prevention of communicable diseases in children. Further complicating this issue is the fact that conventional ICER thresholds—expressed in terms of cost per quality-adjusted life-year (QALY) gained—accord value only to length and quality of life and may not reflect our preferences as individuals or a society. For example, risk, an important attribute of many healthcare decisions, is ignored by the QALY model, as is the distribution of health benefits across different members of society. Are we indeed indifferent about risk and do we really believe that the value of disease prevention in children should be measured by the same “yardstick” as that for older adults? Accordingly, do we really believe that “a QALY is a QALY”? These issues, which are reviewed and discussed in this article, are more than just of theoretical interest; the answers impact how public health policy is determined, which impacts the lives and well-being of entire populations as well as the budgets of payers.
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Affiliation(s)
| | | | | | | | | | - Gerry Oster
- Policy Analysis Inc., Chestnut Hill, MA, USA
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34
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Higginson IJ, Yi D, Johnston BM, Ryan K, McQuillan R, Selman L, Pantilat SZ, Daveson BA, Morrison RS, Normand C. Associations between informal care costs, care quality, carer rewards, burden and subsequent grief: the international, access, rights and empowerment mortality follow-back study of the last 3 months of life (IARE I study). BMC Med 2020; 18:344. [PMID: 33138826 PMCID: PMC7606031 DOI: 10.1186/s12916-020-01768-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND At the end of life, formal care costs are high. Informal care (IC) costs, and their effects on outcomes, are not known. This study aimed to determine the IC costs for older adults in the last 3 months of life, and their relationships with outcomes, adjusting for care quality. METHODS Mortality follow-back postal survey. SETTING Palliative care services in England (London), Ireland (Dublin) and the USA (New York, San Francisco). PARTICIPANTS Informal carers (ICrs) of decedents who had received palliative care. DATA ICrs reported hours and activities, care quality, positive aspects and burdens of caregiving, and completed the Texas Revised Inventory of Grief (TRIG). ANALYSIS All costs (formal, informal) were calculated by multiplying reported hours of activities by country-specific costs for that activity. IC costs used country-specific shadow prices, e.g. average hourly wages and unit costs for nursing care. Multivariable logistic regression analysis explored the association of potential explanatory variables, including IC costs and care quality, on three outcomes: positive aspects and burdens of caregiving, and subsequent grief. RESULTS We received 767 completed surveys, 245 from London, 282 Dublin, 131 New York and 109 San Francisco. Most respondents were women (70%); average age was 60 years. On average, patients received 66-76 h per week from ICrs for 'being on call', 52-55 h for ICrs being with them, 19-21 h for personal care, 17-21 h for household tasks, 15-18 h for medical procedures and 7-10 h for appointments. Mean (SD) IC costs were as follows: USA $32,468 (28,578), England $36,170 (31,104) and Ireland $43,760 (36,930). IC costs accounted for 58% of total (formal plus informal) costs. Higher IC costs were associated with less grief and more positive perspectives of caregiving. Poor home care was associated with greater caregiver burden. CONCLUSIONS Costs to informal carers are larger than those to formal care services for people in the last three months of life. If well supported ICrs can play a role in providing care, and this can be done without detriment to them, providing that they are helped. Improving community palliative care and informal carer support should be a focus for future investment.
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Affiliation(s)
- Irene J Higginson
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK. .,King's College Hospital Foundation Trust, Bessemer Road, London, SE5 9PJ, UK.
| | - Deokhee Yi
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.
| | - Bridget M Johnston
- The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
| | - Karen Ryan
- Mater Misericordiae Hospital, Eccles Street, Dublin 7, Ireland
| | | | - Lucy Selman
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephen Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Barbara A Daveson
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Charles Normand
- Department of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Bessemer Road, London, SE5 9PJ, UK.,The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
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35
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Hachem LD, Bernstein M. Ethical issues in geriatric cranial neurosurgery. Neurosurg Focus 2020; 49:E3. [PMID: 33002872 DOI: 10.3171/2020.7.focus20447] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/17/2020] [Indexed: 11/06/2022]
Abstract
The global demographic shift to an older population has led to the emergence of the new field of geriatric neurosurgery. Beyond the complexities of disease states and multimorbidity, advanced age brings with it intricate ethical issues pertaining to both the practice and provision of medical and surgical care. In this paper, the authors describe the central ethical themes seen across the spectrum of common neurosurgical conditions in the elderly and highlight the use of foundational ethical principles to help guide treatment decision-making.
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Affiliation(s)
- Laureen D Hachem
- 1Division of Neurosurgery, Department of Surgery, University of Toronto; and
| | - Mark Bernstein
- 1Division of Neurosurgery, Department of Surgery, University of Toronto; and.,2Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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36
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Borboa JDZ, Chande RH. Determinants of health expenditures during the last year of life of the Mexican population aged 50 or over. PAPELES DE POBLACION 2020; 26:11-38. [PMID: 35529537 PMCID: PMC9075756 DOI: 10.22185/24487147.2020.105.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
During the last year of life of the elderly health deteriorates the most, thus becoming the period of time when needs of medical services, personal care requirements and related costs are at highest. Using the Mexican Health and Aging Study, differences by sex in the determinants for out-of-pocket health expenditures during the last year of life of people 50 and over are discussed. Three levels of out-of-pocket expenses disbursement are contemplated: none, medium-low, and high. Controlling by sociodemographic variables, findings suggest that the number of hospital nights is the main determinant of health expenses, even above those related to diseases that are regarded as main causes of death. This fact impacts both out-of-pocket expences and the costs for medical institution. It is another issue in the over-hauling of the public health system.
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Affiliation(s)
| | - Roberto Ham Chande
- Departamento de Estudio de Población del El Colegio de la Frontera Norte
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37
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Primary care service use by end-of-life cancer patients: a nationwide population-based cohort study in the United Kingdom. BMC FAMILY PRACTICE 2020; 21:76. [PMID: 32349696 PMCID: PMC7191808 DOI: 10.1186/s12875-020-01127-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND End of life (EoL) care becomes more complex and increasingly takes place in the community, but there is little data on the use of general practice (GP) services to guide care improvement. This study aims to determine the trends and factors associated with GP consultation, prescribing and referral to other care services amongst cancer patients in the last year of life. METHODS A retrospective cohort study of cancer patients who died in 2000-2014, based on routinely collected primary care data (the Clinical Practice Research DataLink, CPRD) covering a representative sample of the population in the United Kingdom. Outcome variables were number of GP consultations (primary), number of prescriptions and referral to other care services (yes vs no) in the last year of life. Explanatory variables included socio-demographics, clinical characteristics and the status of palliative care needs recognised or not. The association between outcome and explanatory variables were evaluated using multiple-adjusted risk ratio (aRR). RESULTS Of 68,523 terminal cancer patients, 70% were aged 70+, 75% had comorbidities and 45.5% had palliative care needs recognised. In the last year of life, a typical cancer patient had 43 GP consultations (Standard deviation (SD): 31.7; total = 3,031,734), 71.5 prescriptions (SD: 68.0; total = 5,074,178), and 21(SD: 13.0) different drugs; 58.0% of patients had at least one referral covering all main clinical specialities. More comorbid conditions, prostate cancer and having palliative care needs recognised were associated with more primary care consultations, more prescriptions and a higher chance of referral (aRRs 1.07-2.03). Increasing age was related to fewer consultations (aRRs 0.77-0.96), less prescriptions (aRR 1.09-1.44), and a higher chance of referral (aRRs 1.08-1.16) but less likely to have palliative care needs recognised (aRRs 0.53-0.89). CONCLUSIONS GPs are very involved in end of life care of cancer patients, most of whom having complex care needs, i.e. older age, comorbidity and polypharmacy. This highlights the importance of enhancing primary palliative care skills among GPs and the imperative of greater integration of primary care with other healthcare professionals including oncologists, palliative care specialists, geriatricians and pharmacists. Research into the potential of deprescribing is warranted. Older patients have poorer access to both primary care and palliative care need to be addressed in future practices.
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Yash Pal R, Kuan WS, Tiah L, Kumar R, Wong YKY, Shi L, Zheng CQ, Lin J, Liang S, Segara UC, Yong WC, Chan NGC, Chua MT, Ibrahim I. End-of-life management protocol offered within emergency room (EMPOWER): study protocol for a multicentre study. BMJ Open 2020; 10:e036598. [PMID: 32350018 PMCID: PMC7213875 DOI: 10.1136/bmjopen-2019-036598] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Patients at their end-of-life (EOL) phase frequently visit the emergency department (ED) due to their symptoms, yet the environment and physicians in ED are not traditionally equipped or trained to provide palliative care. This multicentre study aims to measure the current quality of EOL care in ED to identify gaps, formulate improvements and implement the improved EOL care protocol. We shall also evaluate healthcare resource utilisation and its associated costs. METHODS AND ANALYSIS This study employs a quasiexperimental interrupted time series design using both qualitative and quantitative methods, involving the EDs of three tertiary hospitals in Singapore, over a period of 3 years. There are five phases in this study: (1) retrospective chart reviews of patients who died within 5 days of ED attendance; (2) pilot phase to validate the CODE questionnaire in the local context; (3) preimplementation phase; (4) focus group discussions (FGDs); and (5) postimplementation phase. In the prospective cohort, patients who are actively dying or have high likelihood of mortality this admission, and whose goal of care is palliation, will be eligible for inclusion. At least 140 patients will be recruited for each preimplementation and postimplementation phase. There will be face-to-face interviews with patients' family members, review of medical records and self-administered staff survey to evaluate existing knowledge and confidence. The FGDs will involve hospital and community healthcare providers. Data obtained from the retrospective cohort, preimplementation phase and FGDs will be used to guide prospective improvement and protocol changes. Patient, family and staff relevant outcomes from these changes will be measured using time series regression. ETHICS AND DISSEMINATION The study protocol has been reviewed and ethics approval obtained from the National Healthcare Group Domain Specific Review Board, Singapore. The results from this study will be actively disseminated through manuscript publications and conference presentations. TRIAL REGISTRATION NUMBER NCT03906747.
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Affiliation(s)
- Rakhee Yash Pal
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ling Tiah
- Accident & Emergency Medicine, Changi General Hospital, Singapore
| | - Ranjeev Kumar
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | | | - Luming Shi
- Singapore Clinical Research Institute, Singapore
| | | | - Jingping Lin
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Sufang Liang
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Uma Chandra Segara
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Woon Chai Yong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Palliative Care, National University Cancer Institute, Singapore
| | - Noreen Guek Cheng Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Palliative Care, National University Cancer Institute, Singapore
| | - Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Irwani Ibrahim
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Shah R, Borrebach JD, Hodges JC, Varley PR, Wisniewski MK, Shinall MC, Arya S, Johnson J, Nelson JB, Youk A, Massarweh NN, Johanning JM, Hall DE. Validation of the Risk Analysis Index for Evaluating Frailty in Ambulatory Patients. J Am Geriatr Soc 2020; 68:1818-1824. [PMID: 32310317 DOI: 10.1111/jgs.16453] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frailty is a marker of dependency, disability, hospitalization, and mortality in community-dwelling older adults. However, existing tools for measuring frailty are too cumbersome for rapid point-of-care assessment. The Risk Analysis Index (RAI) of frailty is validated in surgical populations, but its performance outside surgical populations is unknown. OBJECTIVE Validate the RAI in ambulatory patients. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of outpatient surgical clinics within the University of Pittsburgh Medical Center Healthcare System between July 1, 2016, and December 31, 2016. Frailty was assessed using the RAI. Current Procedural Terminology codes following RAI assessment identified patients with and without minor office-based procedures (eg, joint injection, laryngoscopy). MAIN OUTCOMES AND MEASURES All-cause 1-year mortality, assessed by stratified Cox proportional hazard models. RESULTS Of 28,059 patients, 13,861 were matched to a minor, office-based procedure and 14,198 did not undergo any procedure. The mean (SD) age was 56.7 (17.2) years; women constituted 15,797 (56.3%) of the cohort. Median time (interquartile range 25th-75th percentile) to measure RAI was 30 (22-47) seconds. Mortality among the frail was two to five times that of patients with normal RAI scores. For example, the hazard ratio for frail ambulatory patients without a minor procedure was 3.69 (95% confidence interval [CI] = 2.51-5.41), corresponding to 30-, 180-, and 365-day mortality rates of 2.9%, 11.2%, and 17.4%, respectively, compared to 0.3%, 2.3%, and 4.0% among patients with normal RAI scores. Discrimination of mortality (overall, and censored at 30, 180, and 365 days) was excellent, ranging from c = 0.838 (95% CI = 0.773-0.902) for 30-day mortality after minor procedures to c = 0.909 (95% CI = 0.855-0.964) without a procedure. CONCLUSION RAI is a valid, easily administered tool for point-of-care frailty assessment in ambulatory populations that may help clinicians and patients make better informed decisions about care choices-especially among patients considered high risk with a potentially limited life span. J Am Geriatr Soc 68:1818-1824, 2020.
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Affiliation(s)
- Rupen Shah
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jeffrey D Borrebach
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jacob C Hodges
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh, Pittsburgh,, Pennsylvania, USA
| | - Mary Kay Wisniewski
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA, and Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Jonas Johnson
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center; Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center and Nebraska Western Iowa Veterans Affairs Health System, Omaha, Nebraska, USA
| | - Daniel E Hall
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh,, Pennsylvania, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Variability of cost trajectories over the last year of life in patients with advanced breast cancer in the Netherlands. PLoS One 2020; 15:e0230909. [PMID: 32271794 PMCID: PMC7145011 DOI: 10.1371/journal.pone.0230909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 03/11/2020] [Indexed: 12/02/2022] Open
Abstract
Objective In breast cancer patients, treatment at the end of life accounts for a major share of medical spending. However, little is known about the variability of cost trajectories between patients. This study aims to identify underlying latent groups of advanced breast cancer patients with similar cost trajectories over the last year before death. Methods Data from deceased advanced breast cancer patients, diagnosed between 2010 and 2017, were retrieved from the Southeast Netherlands Advanced Breast Cancer (SONABRE) Registry. Costs of hospital care over the last twelve months before death were analyzed, and the variability of longitudinal patterns between patients were explored using group-based trajectory modeling. Descriptive statistics and multinomial logistic regression were applied to investigate differences between the identified latent groups. Results We included 558 patients. Over the last twelve months before death, mean hospital costs were €2,255 (SD = €492) per month. Costs increased over the last five months and reached a maximum of €3,614 in the last month of life, driven by hospital admissions, while spending for medication declined over the last three months of life. Based on patients’ individual cost trajectories, we identified six latent groups with distinct longitudinal patterns, of which only two showed a marked increase in costs over the last twelve months before death. Latent groups were constituted of heterogeneous patients, and clinical characteristics explained membership only to a limited extent. Conclusions The average costs of advanced breast cancer patients increased towards the end of life. However, we uncovered several latent groups of patients with divergent cost trajectories, which did not reflect the overall increasing trend. The mechanisms underlying the variability in cost trajectories warrants further research.
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Duberstein PR, Chen M, Hoerger M, Epstein RM, Perry LM, Yilmaz S, Saeed F, Mohile SG, Norton SA. Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review. J Pain Symptom Manage 2020; 59:894-915.e14. [PMID: 31639495 PMCID: PMC8928482 DOI: 10.1016/j.jpainsymman.2019.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care. OBJECTIVE The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice. METHODS We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored. RESULTS We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs. CONCLUSION Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.
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Affiliation(s)
- Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway, New Jersey, USA.
| | - Michael Chen
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Michael Hoerger
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA; Tulane Cancer Center, Tulane University, New Orleans, Louisiana, USA
| | - Ronald M Epstein
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Laura M Perry
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Sule Yilmaz
- Margaret Warner School of Human Development, Rochester, New York, USA
| | - Fahad Saeed
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sally A Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester, Rochester, New York, USA
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Yi D, Johnston BM, Ryan K, Daveson BA, Meier DE, Smith M, McQuillan R, Selman L, Pantilat SZ, Normand C, Morrison RS, Higginson IJ. Drivers of care costs and quality in the last 3 months of life among older people receiving palliative care: A multinational mortality follow-back survey across England, Ireland and the United States. Palliat Med 2020; 34:513-523. [PMID: 32009542 DOI: 10.1177/0269216319896745] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Care costs rise towards the end of life. International comparison of service use, costs and care experiences can inform quality and improve access. AIM The aim of this study was to compare health and social care costs, quality and their drivers in the last 3 months of life for older adults across countries. Null hypothesis: no difference between countries. DESIGN Mortality follow-back survey. Costs were calculated from carers' reported service use and unit costs. SETTING Palliative care services in England (London), Ireland (Dublin) and the United States (New York, San Francisco). PARTICIPANTS Informal carers of decedents who had received palliative care participated in the study. RESULTS A total of 767 questionnaires were returned: 245 in England, 282 in Ireland and 240 in the United States. Mean care costs per person with cancer/non-cancer were US$37,250/US$37,376 (the United States), US$29,065/US$29,411 (Ireland), US$15,347/US$16,631 (England) and differed significantly (F = 25.79/14.27, p < 0.000). Cost distributions differed and were most homogeneous in England. In all countries, hospital care accounted for > 80% of total care costs; community care 6%-16%, palliative care 1%-15%; 10% of decedents used ~30% of total care costs. Being a high-cost user was associated with older age (>80 years), facing financial difficulties and poor experiences of home care, but not with having cancer or multimorbidity. Palliative care services consistently had the highest satisfaction. CONCLUSION Poverty and poor home care drove high costs, suggesting that improving community palliative care may improve care value, especially as palliative care expenditure was low. Major diagnostic variables were not cost drivers. Care costs in the United States were high and highly variable, suggesting that high-cost low-value care may be prevalent.
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Affiliation(s)
- Deokhee Yi
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Bridget M Johnston
- The Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Karen Ryan
- Mater Misericordiae Hospital, Eccles Street, Dublin, Ireland
| | - Barbara A Daveson
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Diane E Meier
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Melinda Smith
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | | | - Lucy Selman
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Steven Z Pantilat
- Palliative Care Program, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Charles Normand
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,The Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Irene J Higginson
- Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,King's College Hospital NHS Foundation Trust, Bessemer Road, London, UK
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May P, Normand C, Morrison RS. Economics of Palliative Care for Cancer: Interpreting Current Evidence, Mapping Future Priorities for Research. J Clin Oncol 2020; 38:980-986. [PMID: 32023166 DOI: 10.1200/jco.18.02294] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 05/25/2024] Open
Abstract
The National Cancer Institute estimates that $154 billion will be spent on care for people with cancer in 2019, distributed across the year after diagnosis (31%), the final year of life (31%), and continuing care between those two (38%). Projections of future costs estimate persistent growth in care expenditures. Early research studies on the economics of palliative care have reported a general pattern of cost savings during inpatient hospital admissions and the end-of-life phase. Recent research has demonstrated more complex dynamics, but expanding palliative care capacity to meet clinical guidelines and population health needs seems to save costs. Quantifying these cost savings requires additional research, because there is significant variance in estimates of the effects of treatment on costs, depending on the timing of intervention, the primary diagnosis, and the overall illness burden. Because ASCO guidelines state that palliative care should be provided concurrently with other treatment from the point of diagnosis onward for all metastatic cancer, new and ambitious research is required to evaluate the cost effects of palliative care across the entire disease trajectory. We propose a series of ways to reach the guideline goals.
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Affiliation(s)
- Peter May
- Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing (TILDA), Dublin, Ireland
| | - Charles Normand
- Trinity College Dublin, Dublin, Ireland
- King's College London, London, United Kingdom
| | - R Sean Morrison
- Icahn School of Medicine at Mount Sinai, New York, NY
- James J. Peters VA Medical Center, New York, NY
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Commercial ICT Smart Solutions for the Elderly: State of the Art and Future Challenges in the Smart Furniture Sector. ELECTRONICS 2020. [DOI: 10.3390/electronics9010149] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Within a ubiquitous environment, home and office furniture can be maximally utilized to provide ease, especially if the items are designed based on smart technology. For this reason, the acceptance of smart furniture has soared over the years. Given the vast influence of the Internet of Things (IoT) and Industry 4.0 on technological advancement in furniture design, it is imperative to examine information and communication technology (ICT) solutions for the elderly in the context of smart furniture design and implementation. This article presents a review of the state-of-the-art literature in smart solutions for the elderly based on publications under ICT smart solutions for these elderly, along with smart furniture options and manufacturer activities in terms of fixing market prices for these furniture materials. Furthermore, patenting rights on some existing smart furniture designs for the elderly, given the current trends in worldwide acceptance, are examined. Moreover, this article also highlights opportunities introduced by IoT-based solutions for the elderly as current trends in research and their effects on human life. Some smart product examples from different enterprises are also presented. New, innovative and active designs must be developed, focusing upon human healthcare, and in turn providing greater comfort and convenience for elderly people. To fulfil these requirements, the also selected technical aspects of new Smart Furniture solutions in connection to the cost of these solutions are discussed. Simultaneously, Smart Furniture solutions need to be flexible, low-cost, easy to buy and install without expert knowledge, and widely available on the market.
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Benson KR, Aggarwal S, Carter JN, von Eyben R, Pradhan P, Prionas ND, Bui JL, Soltys SG, Hancock S, Gensheimer MF, Koong AC, Chang DT. Predicting Survival for Patients With Metastatic Disease. Int J Radiat Oncol Biol Phys 2020; 106:52-60. [DOI: 10.1016/j.ijrobp.2019.10.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/10/2019] [Accepted: 10/12/2019] [Indexed: 10/25/2022]
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Anderson M, Revie CW, Stryhn H, Neudorf C, Rosehart Y, Li W, Osman M, Buckeridge DL, Rosella LC, Wodchis WP. Defining 'actionable' high- costhealth care use: results using the Canadian Institute for Health Information population grouping methodology. Int J Equity Health 2019; 18:171. [PMID: 31707981 PMCID: PMC6842471 DOI: 10.1186/s12939-019-1074-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 10/09/2019] [Indexed: 11/15/2022] Open
Abstract
Background A small proportion of the population consumes the majority of health care resources. High-cost health care users are a heterogeneous group. We aim to segment a provincial population into relevant homogenous sub-groups to provide actionable information on risk factors associated with high-cost health care use within sub-populations. Methods The Canadian Institute for Health Information (CIHI) Population Grouping methodology was used to define mutually exclusive and clinically relevant health profile sub-groups. High-cost users (> = 90th percentile of health care spending) were defined within each sub-group. Univariate analyses explored demographic, socio-economic status, health status and health care utilization variables associated with high-cost use. Multivariable logistic regression models were constructed for the costliest health profile groups. Results From 2015 to 2017, 1,175,147 individuals were identified for study. High-cost users consumed 41% of total health care resources. Average annual health care spending for individuals not high-cost were $642; high-cost users were $16,316. The costliest health profile groups were ‘long-term care’, ‘palliative’, ‘major acute’, ‘major chronic’, ‘major cancer’, ‘major newborn’, ‘major mental health’ and ‘moderate chronic’. Both ‘major acute’ and ‘major cancer’ health profile groups were largely explained by measures of health care utilization and multi-morbidity. In the remaining costliest health profile groups modelled, ‘major chronic’, ‘moderate chronic’, ‘major newborn’ and ‘other mental health’, a measure of socio-economic status, low neighbourhood income, was statistically significantly associated with high-cost use. Interpretation Model results point to specific, actionable information within clinically meaningful subgroups to reduce high-cost health care use. Health equity, specifically low socio-economic status, was statistically significantly associated with high-cost use in the majority of health profile sub-groups. Population segmentation methods, and more specifically, the CIHI Population Grouping Methodology, provide specificity to high-cost health care use; informing interventions aimed at reducing health care costs and improving population health.
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Affiliation(s)
- Maureen Anderson
- Department of Health Management, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada. .,Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Crawford W Revie
- Department of Health Management, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada.,Department of Computing and Information Sciences, University of Strathclyde, Glasgow, Scotland
| | - Henrik Stryhn
- Department of Health Management, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Cordell Neudorf
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Population and Public Health, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Yvonne Rosehart
- Canadian Institute for Health Information, Ottawa, Ontario, Canada
| | - Wenbin Li
- Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Meriç Osman
- Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Laura C Rosella
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Walter P Wodchis
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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May P, Normand C, Del Fabbro E, Fine RL, Morrison RS, Ottewill I, Robinson C, Cassel JB. Economic Analysis of Hospital Palliative Care: Investigating Heterogeneity by Noncancer Diagnoses. MDM Policy Pract 2019; 4:2381468319866451. [PMID: 31535032 PMCID: PMC6737878 DOI: 10.1177/2381468319866451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 06/18/2019] [Indexed: 01/03/2023] Open
Abstract
Background. Single-disease-focused treatment and hospital-centric care are poorly suited to meet complex needs in an era of multimorbidity. Understanding variation in palliative care’s association with treatment choices is essential to optimizing interdisciplinary decision making in care of complex patients. Aim. To estimate the association between palliative care and hospital costs by primary diagnosis and multimorbidity for adults with one of six life-limiting conditions: heart failure, chronic obstructive pulmonary disease (COPD), liver failure, kidney failure, neurodegenerative conditions including dementia, and HIV/AIDS. Methods. Data from four studies (2002–2015) were pooled to provide an analytic dataset of 73,304 participants with mean costs $10,483, of whom 5,348 (7%) received palliative care. We estimated average effect of palliative care on direct hospital costs among the treated, using propensity scores to control for observed confounding. Results. Palliative care was associated with a statistically significant reduction in total direct costs for heart failure (estimated treatment effect: −$2666; 95% confidence interval [CI]: −$3440 to −$1892), neurodegenerative conditions (−$3523; −$4394 to −$2651), COPD (−$1613; −$2217 to −$1009), kidney failure (−$3589; −$5132 to −$2045), and liver failure (−$7574; −$9232 to −$5916). The association for liver failure patients was statistically significantly larger than for any other disease group. Cost-saving associations were also statistically larger for patients with multimorbidity than single disease for two of the six groups: neurodegenerative and liver failure. Conclusions. Heterogeneity in treatment effect estimates was observable in assessing association between palliative care and hospital costs for adults with serious life-limiting illnesses other than cancer. The results illustrate the importance of careful definition of palliative care populations in research and practice, and raise further questions about the role of interdisciplinary decision making in treatment of complex medical illness.
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Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Egidio Del Fabbro
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | | | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai, New York
| | - Isabel Ottewill
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | | | - J Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
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Abstract
PURPOSE OF REVIEW Care near the end of life is expensive and frequently not aligned with the expressed preferences of decedents, creating an opportunity to improve value, or increase quality while lowering cost. This review examines publications from 2017 and 2018 on interventions and policies associated with high-value end-of-life care. Innovations in video and web-based advance care planning are promising to improve preference-congruent care at low cost. RECENT FINDINGS The patterns of care within hospice and in particular increased investment in patient care in hospice are shown to improve value. A meta-analysis demonstrated the role of inpatient palliative care consultations in decreasing hospitalization costs, as did several studies on inpatient palliative care units. Internationally, a range of home-based palliative care programs, implemented at the population level, demonstrated cost savings and reduced intensive care near the end of life. Finally, public policies that funded medical and long-term care and address broader inequalities were demonstrated to decrease low-value care near the end of life. SUMMARY This review demonstrates the efficacy of a range of approaches to improve value of care at the end of life, both within the health system and across public policy sectors.
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49
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Heydari H, Hojjat-Assari S, Almasian M, Pirjani P. Exploring health care providers' perceptions about home-based palliative care in terminally ill cancer patients. BMC Palliat Care 2019; 18:66. [PMID: 31387564 PMCID: PMC6685152 DOI: 10.1186/s12904-019-0452-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/30/2019] [Indexed: 12/24/2022] Open
Abstract
Background According to the World Health Organization, palliative care is one of the main components of healthcare. As the incidence of cancer is increasing in the world, home-based palliative care can be beneficial for many patients. This study was designed to explore health care providers’ perceptions about home-based palliative care in terminally ill cancer patients. Methods This qualitative study was carried out using the conventional content analysis from October 2016 to September 2018 in Iran. Participants were home care providers who were selected using purposive sampling. The data were collected through 18 individual interviews, and a focus group meeting. Data were analyzed based on the method proposed by Lundman and Graneheim. Results from the data analysis, 511 initial codes were extracted, which were categorized into the two main categories of challenges and opportunities for home-based palliative care and 10 subcategories. The subcategories of challenges included deficiencies in inter-sectoral and inter-professional cooperation, lack of infrastructures for end-of-life care, challenges related to the management of death, challenges of transferring patients to home, providing non-academic palliative care, lack of political commitment of the government and Spiritual vacuum. The category of opportunities included subcategories of cost-effectiveness, moving towards socializing health, and structure of the health system. Conclusions Home-based palliative care requires government and health system support. Structural and process modification in the healthcare can provide conditions in which terminally ill cancer patients receive appropriate care in home and experience death with dignity through support of family, friends and healthcare.
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Affiliation(s)
- Heshmatolah Heydari
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran. .,Department of Community Health Nursing, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran.
| | - Suzanne Hojjat-Assari
- French Institute of Research and High Education (IFRES-INT), Paris, France.,Department of Home-based palliative care, ALA Cancer Prevention and Control Center (MACSA), Tehran, Iran
| | - Mohammad Almasian
- School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Pooneh Pirjani
- Department of Home-based palliative care, ALA Cancer Prevention and Control Center (MACSA), Tehran, Iran
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50
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Abstract
Palliative care is a field of medicine that delivers patient-centered care for individuals and their families suffering from serious illness at all stages of the disease trajectory. It addresses the major priorities of relieving suffering, establishing goals of care, and managing physical symptoms while integrating the psychosocial, cultural, spiritual, and existential complexities of coping with chronic illness. This article discusses the role of palliative care in the health care system. It reviews the importance of prognostication, disease trajectory, and communication. The role of the primary care physician as part of a multidisciplinary team member delivering primary palliative care is emphasized.
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Affiliation(s)
- Alan R Roth
- Department of Family Medicine, Palliative Care Medicine, Hospice and Palliative Medicine Fellowship Program, Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Jamaica, NY 11418, USA.
| | - Angelo R Canedo
- MediSys Health Network, Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Jamaica, NY 11418, USA
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