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Berta P, Lovaglio PG, Verzillo S. How have casemix, cost and hospital stay of inpatients in the last year of life changed over the past decade? Evidence from Italy. Health Policy 2021; 125:1031-1039. [PMID: 34175137 PMCID: PMC8310922 DOI: 10.1016/j.healthpol.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 11/23/2022]
Abstract
Healthcare utilisation and expenditure are highly concentrated in hospital inpatient services, in particular in end-of-life care with the peak occurring in the very last year of life, regardless of patient age. Few scientific studies have investigated hospital costs and stays of patients at the end of life, and even fewer studies have analysed their evolution over time. In this paper, we exploit hospitalisation data for the Lombardy region of Italy with the aim of studying the evolution of hospital casemix, costs and stays of chronic patients, and compare the last year of life of two cohorts of patients who died in 2005 and 2014. Despite an overall three-year increase in the age at death, the results showed a significant decrease in hospital costs and use due to reduced interventions and length of hospital stays. However, this was not associated with an increase in quality of life/conditions (as indicated by clinical casemix as a proxy) for end-of-life patients; patients' casemix characteristics and clinical condition, as measured by the number of comorbidities, disease severity, prevalence of pulmonary disease and heart failure diagnosis, significantly worsened over the decade. This gives rise to important health policy concerns on how to identify effective policies and possible changes in healthcare system organisation to move from hospital-centred care to a community-centred approach whose value has been demonstrated during the COVID-19 pandemic.
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Affiliation(s)
- Paolo Berta
- CRISP - Interuniversity Research Centre on Public Services, University of Milano Bicocca, Milan, Italy; Department of Statistics and Quantitative Methods, University of Milano Bicocca, Milan, Italy
| | - Pietro Giorgio Lovaglio
- CRISP - Interuniversity Research Centre on Public Services, University of Milano Bicocca, Milan, Italy; Department of Statistics and Quantitative Methods, University of Milano Bicocca, Milan, Italy
| | - Stefano Verzillo
- CRISP - Interuniversity Research Centre on Public Services, University of Milano Bicocca, Milan, Italy; European Commission, Joint Research Centre (JRC), Ispra Italy.
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Age-specific patterns of health care expenditure in dying people. Public Health 2017; 152:17-19. [DOI: 10.1016/j.puhe.2017.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 06/02/2017] [Indexed: 11/18/2022]
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Cardona-Morrell M, Hillman K. Development of a tool for defining and identifying the dying patient in hospital: Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL). BMJ Support Palliat Care 2015; 5:78-90. [PMID: 25613983 PMCID: PMC4345773 DOI: 10.1136/bmjspcare-2014-000770] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/23/2014] [Accepted: 11/23/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To develop a screening tool to identify elderly patients at the end of life and quantify the risk of death in hospital or soon after discharge for to minimise prognostic uncertainty and avoid potentially harmful and futile treatments. DESIGN Narrative literature review of definitions, tools and measurements that could be combined into a screening tool based on routinely available or obtainable data at the point of care to identify elderly patients who are unavoidably dying at the time of admission or at risk of dying during hospitalisation. MAIN MEASUREMENTS Variables and thresholds proposed for the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL screening tool) were adopted from existing scales and published research findings showing association with either in-hospital, 30-day or 3-month mortality. RESULTS Eighteen predictor instruments and their variants were examined. The final items for the new CriSTAL screening tool included: age ≥65; meeting ≥2 deterioration criteria; an index of frailty with ≥2 criteria; early warning score >4; presence of ≥1 selected comorbidities; nursing home placement; evidence of cognitive impairment; prior emergency hospitalisation or intensive care unit readmission in the past year; abnormal ECG; and proteinuria. CONCLUSIONS An unambiguous checklist may assist clinicians in reducing uncertainty patients who are likely to die within the next 3 months and help initiate transparent conversations with families and patients about end-of-life care. Retrospective chart review and prospective validation will be undertaken to optimise the number of prognostic items for easy administration and enhanced generalisability. Development of an evidence-based tool for defining and identifying the dying patient in hospital: CriSTAL.
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Affiliation(s)
- Magnolia Cardona-Morrell
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Kensington, NSW 2052, Australia
| | - Ken Hillman
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales & Liverpool Hospital, Liverpool BC 1871, New South Wales, Australia
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Scott IA, Mitchell GK, Reymond EJ, Daly MP. Difficult but necessary conversations--the case for advance care planning. Med J Aust 2014; 199:662-6. [PMID: 24237095 DOI: 10.5694/mja13.10158] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 06/26/2013] [Indexed: 12/25/2022]
Abstract
Many patients at the end of life receive care that is inappropriate or futile and, if given the opportunity to discuss their care preferences well ahead of death, may well have chosen to forgo such care. Advance care planning (ACP) is a process of making decisions about future health care for patients in consultation with clinicians, family members and important others, and to safeguard such decisions if patients were to lose decisional capacity. Although ACP has existed as an idea for decades, acceptance and operationalisation of ACP within routine practice has been slow, despite evidence of its benefits. The chief barriers have been social and personal taboos about discussing the dying process, avoidance by medical professionals of responsibility for initiating, coordinating and documenting discussions about ACP, absence of robust and standardised procedures for recording and retrieving ACP documents across multiple care settings, and legal and ethical concerns about the validity of such documents. For ACP to become part of mainstream patient-centred care, accountable clinicians working in primary care, hospitals and nursing homes must effectively educate colleagues and patients about the purpose and mechanics of ACP, mandate ACP for all eligible patients, document ACP in accessible formats that enable patient wishes to accurately guide clinical management, devise methods for reviewing ACP decisions when clinically appropriate, and evaluate congruence between expressed patient wishes and actual care received. Public awareness campaigns coupled with implementation of ACP programs sponsored by collaborations between hospital and health services, Medicare locals and residential care facilities will be needed in making system-wide ACP a reality.
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Affiliation(s)
- Ian A Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
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HILLMAN KM. Failure to recognise patients at the end of life in acute hospitals. Acta Anaesthesiol Scand 2014; 58:1-2. [PMID: 24341690 DOI: 10.1111/aas.12231] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- K. M. HILLMAN
- Liverpool Hospital; South West Sydney Clinical School; The Simpson Centre for Health Services Research affiliated with the Australian Institute of Health Innovation; University of New South Wales; Liverpool BC NSW Australia
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Chinta R, Burns DJ, Manolis C, Nighswander T. "Cost creep due to age creep" phenomenon: pattern analyses of in-patient hospitalization costs for various age brackets in the United States. Hosp Top 2013; 91:69-80. [PMID: 24255935 DOI: 10.1080/00185868.2013.848159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The expectation that aging leads to a progressive deterioration of biological functions leading to higher healthcare costs is known as the healthcare cost creep due to age creep phenomenon. The authors empirically test the validity of this phenomenon in the context of hospitalization costs based on more than 8 million hospital inpatient records from 1,056 hospitals in the United States. The results question the existence of cost creep due to age creep after the age of 65 years as far as average hospitalization costs are concerned. The authors discuss implications for potential knowledge transfer for cost minimization and medical tourism.
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Affiliation(s)
- Ravi Chinta
- a Department of Management and Entrepreneurship of the Williams College of Business , Xavier University , Cincinnati , Ohio
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Population ageing and its implications on aggregate health care demand: empirical evidence from 22 OECD countries. ACTA ACUST UNITED AC 2009; 9:391-402. [DOI: 10.1007/s10754-009-9057-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Accepted: 03/06/2009] [Indexed: 11/27/2022]
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BMI: a simple, rapid and clinically meaningful index of under-nutrition in the oldest old? Br J Nutr 2008; 101:1300-5. [DOI: 10.1017/s0007114508076289] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Moorin RE, Holman CDJ. The cost of in-patient care in Western Australia in the last years of life: A population-based data linkage study. Health Policy 2008; 85:380-90. [PMID: 17913279 DOI: 10.1016/j.healthpol.2007.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 08/09/2007] [Accepted: 08/27/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aimed to explore patterns of health expenditure for in-patient care in the last 3 years of life so as to understand how age and time to death contribute to health-care expenditure. METHOD Records of all deaths occurring in Western Australia from 1997 to 2000 inclusive were extracted from the WA mortality register and linked to records from the hospital morbidity data system (HMDS) via the WA Data Linkage System. Inflation adjusted hospital costs were assigned to all in-patient events occurring within 3 years of death from five major causes of death using DRG costing information. RESULTS Prior to the last 5 months of life the mean cost of hospitalisation was positively associated with age; however, the magnitude of the cost increase in the last 5 months of life was inversely related to age such that the cost in the last month of life was similar across age groups. CONCLUSION The finding that increased costs are associated with proximity to death, but that the magnitude of the increase is inversely associated with age, has implications for the ongoing debate about whether proximity to death or age is the dominant driver of health-care costs. The results of this study suggest that models forecasting future health-care expenditure should take into account the interaction of age, time to death and cause of death. In addition, we propose that due to the differences observed across causes of death it may be that a single general population model may not be capable of fully capturing the relationship and that this may be why the debate regarding age and time to death has yet to be resolved in the literature.
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Affiliation(s)
- Rachael Elizabeth Moorin
- Australian Centre for Economic Research on Health (UWA node), School of Population Health, The University of Western Australia, Crawley, WA, Australia.
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Calver J, Bulsara M, Boldy D. In-patient hospital use in the last years of life: a Western Australian population-based study. Aust N Z J Public Health 2007; 30:143-6. [PMID: 16681335 DOI: 10.1111/j.1467-842x.2006.tb00107.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To estimate the likelihood and costs of in-patient care in the last three years of life. METHODS A population-based retrospective cohort study using linked hospital and death records to evaluate in-patient use by Western Australians who died in 2002. RESULTS Age was unrelated to the likelihood of in-patient admission and inversely related to in-patient costs, after adjustment for sex, cause of death and proximity to death. In-patient costs increased in the final three quarters before death. In the last quarter before death, the predicted average quarterly in-patient cost increased 2.8 fold from quarter two and 3.8 fold from quarter three. CONCLUSIONS Older decedents were not more likely to be hospitalised than younger decedents in the final three years of life. Moreover, once hospitalised, their in-patient costs were lower. In-patient costs were heavily concentrated in the three last quarters of life. IMPLICATIONS Remaining lifetime is a significant predictor of in-patient costs. Failure to account for proximity to death will overemphasise the impact of population ageing on health care expenditure, because older people have a higher probability of dying.
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Affiliation(s)
- Janine Calver
- Centre for Research into Aged Care Services, Curtin University of Technology, Western Australia.
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Payne G, Laporte A, Deber R, Coyte PC. Counting backward to health care's future: using time-to-death modeling to identify changes in end-of-life morbidity and the impact of aging on health care expenditures. Milbank Q 2007; 85:213-57. [PMID: 17517114 PMCID: PMC2690327 DOI: 10.1111/j.1468-0009.2007.00485.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
In most developed countries, as the largest population cohorts approach the age of sixty-five, the impact of population aging on health care expenditures has become a topic of growing interest. This articles examines trends in elderly disability and end-of-life morbidity, estimations of the cost of dying, and models of expenditures as a function of both age and time-to-death and finds broad improvement in mortality and morbidity among the elderly in the developed world. Reduced mortality and low growth in the costs associated with dying could reduce forecasted expenditures, but high growth in expenditures for those not close to death and for nonhospital services could create new economic pressures on health care systems.
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Affiliation(s)
- Greg Payne
- University of Toronto, Toronto, ON, Canada
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Abstract
Contemporary medicine has much to its credit, but has created an insatiable demand for new technologies and more health services, fed by commercial promotion, professional advocacy and sociopolitical pressure. Total health expenditure at the national level is now almost 10% of gross domestic product and is expected to top 16% by 2020. After recent inquiries into the failings of its public health system, the Queensland Government has committed itself to a 25% increase in expenditure on health over the next 5 years. But will it lead to better population health, and is it sustainable? The return-on-investment curve for modern health care may be flattening out, in an environment of growing numbers of older patients with chronic illnesses, maldistribution of services and hospital overcrowding. A change in thinking is required if current medical practice is to avoid imploding when confronted with the next major economic downturn. Health policy, service funding and clinical training must focus on critical appraisal of the effectiveness of health care technologies and the structure and financing of health care systems. Practising clinicians will be obliged to provide leadership in determining value for money in the choice of health care for specific patient populations and how that care is delivered.
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Affiliation(s)
- Ian A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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Affiliation(s)
- Simon Chapman
- School of Public Health, University of Sydney, Building A27, Sydney, NSW 2006, Australia.
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15
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Coory MD. Ageing and healthcare costs in Australia: a case of policy‐based evidence? Med J Aust 2004; 180:581-3. [PMID: 15174990 DOI: 10.5694/j.1326-5377.2004.tb06096.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2003] [Accepted: 03/24/2004] [Indexed: 11/17/2022]
Abstract
There have been dire predictions that population ageing will result in skyrocketing health costs. However, numerous studies have shown that the effect of population ageing on health expenditure is likely to be small and manageable. Pessimism about population ageing is popular in policy debates because it fits with ideological positions that favour growth in the private sector and seek to contain health expenditure in the public sector. It might also distract attention from the need to evaluate the appropriateness and effectiveness of current patterns of care. Pessimistic scenarios have stifled debate and limited the number of policy options considered. Policy making in Australia would be improved if we took a more realistic view of the effect of population ageing on health expenditure.
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Affiliation(s)
- Michael D Coory
- Epidemiology Services Unit, Queensland Health, GPO Box 48, Brisbane, QLD 4001, Australia.
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Mann E, Koller M, Mann C, van der Cammen T, Steurer J. Comprehensive Geriatric Assessment (CGA) in general practice: results from a pilot study in Vorarlberg, Austria. BMC Geriatr 2004; 4:4. [PMID: 15151704 PMCID: PMC434505 DOI: 10.1186/1471-2318-4-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2004] [Accepted: 05/19/2004] [Indexed: 01/19/2023] Open
Abstract
Background Most comprehensive geriatric assessment (CGA) programs refer to hospital-based settings. However the body of geriatric healthcare is provided by general practitioners in their office. Structured geriatric problem detection by means of assessment instruments is crucial for efficient geriatric care giving in the community. Methods We developed and pilot tested a German language geriatric assessment instrument adapted for general practice. Nine general practices in a rural region of Austria participated in this cross-sectional study and consecutively enrolled 115 persons aged over 75 years. The prevalence of specific geriatric problems was assessed, as well as the frequency of initiated procedures following positive and negative tests. Whether findings were new to the physician was studied exemplarily for the items visual and hearing impairment and depression. The acceptability was recorded by means of self-administered questionnaires. Results On average, each patient reported 6.4 of 14 possible geriatric problems and further consequences resulted in 43.7% (27.5% to 59.8%) of each problem. The items with either the highest prevalence and/or the highest number of initiated actions by the GPs were osteoporosis risk, urinary incontinence, decreased hearing acuity, missing pneumococcal vaccination and fall risk. Visual impairment was newly detected in only 18% whereas hearing impairment and depression was new to the physician in 74.1% and 76.5%, respectively. A substantial number of interventions were initiated not only following positive tests (43.7% per item; 95% CI 27.5% to 59.8%), but also as a consequence of negative test results (11.3% per item; 95% CI 1.7% to 20.9%). The mean time expenditure to accomplish the assessment was 31 minutes (SD 10 min). Patients (89%) and all physicians confirmed the CGA to provide new information in general on the patient's health status. All physicians judged the CGA to be feasible in everyday practice. Conclusion This adapted CGA was feasible and well accepted in the general practice sample. High frequencies of geriatric problems were detected prompting high numbers of problem-solving initiatives. But a substantial number of actions of the physicians following negative tests point to the risks of too aggressive treatment of elderly patients with possibly subsequent negative effects.
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Affiliation(s)
- Eva Mann
- General Practice, Habsburgerstrasse 1, 6830-Rankweil, Austria
| | - Michael Koller
- Horten-Zentrum für praxisorientierte Forschung und Wissenstransfer, Universitätsspital Zürich, Bolleystrasse 40, Postfach Nord, CH-8091 Zürich, Switzerland
| | - Christian Mann
- Landeskrankenhaus and Academic Teaching Hospital, Carinagasse 47, 6800 Feldkirch, Austria
| | - Tischa van der Cammen
- Head Section of Geriatric Medicine, Department of Internal Medicine, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Johann Steurer
- Horten-Zentrum für praxisorientierte Forschung und Wissenstransfer, Universitätsspital Zürich, Bolleystrasse 40, Postfach Nord, CH-8091 Zürich, Switzerland
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Brimhall BB, Dean T, Hunt EL, Siegrist RB, Reiquam W. Age and laboratory costs for hospitalized medical patients. Arch Pathol Lab Med 2003; 127:169-77. [PMID: 12562230 DOI: 10.5858/2003-127-169-aalcfh] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the hypothesis that older hospitalized patients have higher laboratory costs than younger patients in the same severity-adjusted diagnosis-related group (DRG). DESIGN We obtained hospital case mix data sets (1995-1997) from the Massachusetts Division of Health Care Finance and Policy. We selected discharge abstracts from 4 medical DRGs, at 5 large academic hospitals (n = 15,265) and 5 midsized community hospitals (n = 10,540), for analysis. We converted laboratory and blood product charges to direct costs using the department-specific ratio of cost to charges. We adjusted diagnostic groups for severity of comorbid conditions and complications using the refined DRG method. MAIN OUTCOME MEASURES Hospital length of stay (LOS), laboratory direct cost (LDC) per hospitalization, LDC per hospital day, and ratio of LDC to total direct cost. RESULTS Hospital LOS was longer for older patients in all comparisons. Laboratory direct cost per hospitalization was higher for older patients in some DRGs, but lower in other DRGs. Laboratory direct cost per hospital day was almost always less for older patients than for younger patients, both at academic and community hospitals. Data stratification by gender, admission status, and principal diagnosis yielded substantially the same pattern of cost differences observed within the larger data set. CONCLUSIONS Older medical patients have longer hospital stays and generally higher costs. These patients also have a significantly decreased rate of laboratory resource consumption over the course of hospitalization (LDC per hospital day), as well as lower laboratory costs as a proportion of total costs. Age-specific differences in LOS and cost parameters were essentially unchanged after controlling for several potential sources of bias.
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Affiliation(s)
- Bradley B Brimhall
- Department of Pathology, University of Colorado School of Medicine, Denver, USA.
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Evans RW. Costs and insurance coverage associated with permanent mechanical cardiac assist/replacement devices in the United States. J Card Surg 2002; 16:280-93. [PMID: 11833701 DOI: 10.1111/j.1540-8191.2001.tb00523.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Each year over 50,000 persons in the United States could potentially benefit from some form of permanent cardiac replacement or assistance. Approximately 7000 of these persons get on the waiting list for a transplant, and 2300 are transplanted. About 2000 patients are reportedly exposed to a mechanical cardiac assist device, most often as a bridge to transplant. The majority of persons who might benefit from cardiac replacement are never referred for treatment and, thus, the number of deaths on the waiting list is a misleading indicator of access to transplantation and overall patient mortality. The total economic burden associated with coronary artery disease and congestive heart failure now exceeds $140 billion each year, with approximately $700 million directly spent on heart transplant procedures alone. If a viable total artificial heart is devised to replace a failed heart, or a ventricular assist system to permanently assist a failing heart, direct aggregate expenditures alone are likely to be somewhere between $5.4 and $24.0 billion annually. Based on individual patient care costs, as well as aggregate national expenditures, insurers will be reluctant to pay for the permanent use of such devices, even though cost is reportedly not a consideration in coverage decisions. Today, medical benefits and added value are concepts that will shape the coverage determination process, as will increasingly liberal policies regarding payment for treatment costs in relationship to clinical trials. Nonetheless, resource allocation and rationing decisions loom large as strange "characters at play" on an international economic "stage," while being "directed" by worldwide health care needs.
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Himsworth RL, Goldacre MJ. Does time spent in hospital in the final 15 years of life increase with age at death? A population based study. BMJ (CLINICAL RESEARCH ED.) 1999; 319:1338-9. [PMID: 10567138 PMCID: PMC28281 DOI: 10.1136/bmj.319.7221.1338] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- R L Himsworth
- Institute of Public Health, University of Cambridge, Cambridge CB2 2SR
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Kapp MB. De facto health-care rationing by age. The law has no remedy. THE JOURNAL OF LEGAL MEDICINE 1998; 19:323-349. [PMID: 9775577 DOI: 10.1080/01947649809511066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- M B Kapp
- Department of Community Health and Psychiatry, Wright State University School of Medicine, Dayton, Ohio 45401-0927, USA
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