Health care expenditure towards the end of life

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The association between physical activity and hospital payments for acute admissions in the Australian population aged 45 and over

Physical activity (PA) is a key component of a healthy life, and it is hypothesised that individuals with higher levels of PA utilise fewer hospital resources. Quantifying the association between PA and hospital resource use is of interest to both payers and planners but estimates of its size in the general population are rare. In this paper we provide estimates of the association between PA and payments to hospitals in the Australian population over age 45. We use data from 45 and Up Study, a survey that contains health and lifestyle factors information about approximately 260,000 individuals over age 45 living in NSW, linked to hospital and death data. The linked data set allows to define a unique indicator for the level of PA over the week prior to the survey interview and to calculate payments to hospitals over the next year. We use Coarsened Exact Matching and multivariate analysis to study the relationship between PA and hospital payments, controlling for chronic health conditions, risk factors, standard socioeconomic variables and death. Our results clearly indicate that there is a statistically significant association between PA and lower hospital payments. While the size of the association depends to some extent on the covariates used in the model the conclusions are robust to changes in model specification. We also perform a sub-group analysis and show that the cost savings associated with PA are significantly larger for older and lower income populations. This study shows that if one is interested in lowering hospital expenditures then increasing PA levels is a policy that has the potential of being effective. It also shows that one does not need to target the entire population to achieve cost savings but can limit the intervention to the older population and/or the one in the lowest socioeconomic status.

The direct cost of care among surgical inpatients at a tertiary hospital in south west Nigeria

Introduction

This study was conducted to assess the direct cost of care and its determinants among surgical inpatients at university College Hospital, Ibadan.

Methods

A retrospective review of records of 404 inpatients that had surgery from January to December, 2010 was conducted. Information was extracted on socio-demographic variables, investigations, drugs, length of stay (LOS) and cost of carewith a semi-structured pro-forma. Mean cost of care were compared using t-test and Analysis of variance (ANOVA). Linear regression analysis was used to identify determinants of cost of care. Level of significance of 5% was used. In year 2010 $1 was equivalent to 150 naira ($1=₦ 150).

Results

The median age of patients was 30 years with inter-quartile range of 13-42 years. Males were 257(63. 6%). The mean overall cost of care was ₦66,983 ± ₦31,985. Cost of surgery is about 50% of total cost of care. Patient first seen at the Accident and Emergency had a significantly higher mean cost of care of ß = ₦17,207(95% CI: ₦4,003 to ₦30,410). Neuro Surgery (ß=₦36,210), and Orthopaedic Surgery versus General Surgery(ß=₦10,258),and Blood transfusion (ß=₦18,493) all contributed to cost of care significantly. Increase of one day in LOS significantly increased cost of care by ₦2,372. 57.

Conclusion

The evidence evaluated here shows that costs and LOS are interrelated. Attempt at reducing LOS will reduce the costs of care of surgical inpatient.

Is health care a luxury or a necessity or both? Evidence from Turkey

This study investigates the effect of per capita income on per capita health expenditures in Turkey over the period 1975-2007 by using ARDL bounds test approach to the cointegration considering both demand and supply side variables. Since we reject the null hypothesis that there is no cointegration among the series, we estimate long run and short run elasticities. The results show that while income has no effect on health expenditures in the long run, it is a necessity good in the short run that is a 1% increase in per capita income creates an 0.75% increase in per capita health expenditures. On the other hand, by examining the coefficient of demand and supply side variables, we found that average length of stay and number of physicians has negative effect, percentage of older people has positive effect and infant mortality rate has no effect on health expenditures in both short and long runs.

Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalisation

BACKGROUND

Anticipatory care for older patients who are frail involves both case identification and proactive intervention to reduce hospitalisation.

AIM

To identify a population who were at risk of admission to hospital and to provide an anticipatory care plan (ACP) for them and to ascertain whether using primary and secondary care data to identify this population and then applying an ACP can help to reduce hospital admission rates.

DESIGN AND SETTING

Cohort study of a service intervention in a general practice and a primary care team in Scotland.

METHOD

The ACP sets out patients' wishes in the event of a sudden deterioration in health. If admitted, a proactive approach was taken to transfer and discharge patients into the community. Cohorts were selected using the Nairn Case Finder, which matched patients in two practices for age, sex, multiple morbidity indexes, and secondary care outpatient and inpatient activity; 96 patients in each practice were studied for admission rate, occupied bed days and survival.

RESULTS

Survivors from the ACP cohort (n = 80) had 510 fewer days in hospital than in the 12 months pre-intervention: a significant reduction of 52.0% (P = 0.020). There were 37 fewer admissions of the survivors from that cohort post-intervention than in the preceding 12 months, with a significant reduction of 42.5% (P = 0.002). Mortality rates in the two cohorts were similar, but the number of patients who died in hospital and the hospital bed days used in the last 3 months of life were significantly lower for the decedents with an ACP than for the controls who had died (P = 0.007 and P = 0.045 respectively).

CONCLUSION

This approach produced statistically significant reductions in unplanned hospitalisation for a cohort of patients with multiple morbidities. It demonstrates the potential for providing better care for patients as well as better value for health and social care services. It is of particular benefit in managing end-of-life care.

Health care use and costs of adverse drug events emerging from outpatient treatment in Germany: a modelling approach

BACKGROUND

This study's aim was to develop a first quantification of the frequency and costs of adverse drug events (ADEs) originating in ambulatory medical practice in Germany.

METHODS

The frequencies and costs of ADEs were quantified for a base case, building on an existing cost-of-illness model for ADEs. The model originates from the U.S. health care system, its structure of treatment probabilities linked to ADEs was transferred to Germany. Sensitivity analyses based on values determined from a literature review were used to test the postulated results.

RESULTS

For Germany, the base case postulated that about 2 million adults ingesting medications have will have an ADE in 2007. Health care costs related to ADEs in this base case totalled 816 million Euros, mean costs per case were 381 Euros. About 58% of costs resulted from hospitalisations, 11% from emergency department visits and 21% from long-term care. Base case estimates of frequency and costs of ADEs were lower than all estimates of the sensitivity analyses.

DISCUSSION

The postulated frequency and costs of ADEs illustrate the possible size of the health problems and economic burden related to ADEs in Germany. The validity of the U.S. treatment structure used remains to be determined for Germany. The sensitivity analysis used assumptions from different studies and thus further quantified the information gap in Germany regarding ADEs.

CONCLUSIONS

This study found costs of ADEs in the ambulatory setting in Germany to be significant. Due to data scarcity, results are only a rough indication.

What has influenced patient health-care expenditures in Japan?: variables of age, death, length of stay, and medical care

This study considers variables related to health-care expenditures associated with aging and long-term hospitalization in Japan. We focused on daily per capita inpatient health-care expenditures, and examined the impact of inpatient characteristics such as sex, age, survived or deceased, length of stay, adult disease, and type of medical care received during the duration of each stay. We analyzed data from the Survey of Medical-Care Activities in Public Health Insurance by multinomial logistic regression analyses. Age of patient had little impact on per capita inpatient health-care expenditures per day. As regards length of stay, inpatient stays of 8-14 days had a little impact on health-care expenditures. This study suggested that these results might be due to the kind of medical care received. More research is needed to determine the appropriate medical services to reduce long-term hospitalization. In the last month of care for patients who died, medical examinations had a great influence on health-care expenditures. This study showed that increasing medical examinations in the end-of-life care needs further investigation.

Age and closeness of death as determinants of health and social care utilization: a case-control study

BACKGROUND

We used case-control design to compare utilization of health and social services between older decedents and survivors, and to identify the respective impact of age and closeness of death on the utilization of services.

METHODS

Data were derived from multiple national registers. The sample consisted of 56,001 persons, who died during years 1998-2000 at the age of > or = 70, and their pairs matched on age, gender and municipality of residence, who were alive at least 2 years after their counterpart's death. Data include use of hospitals, long-term care and home care. Decedents' utilization within 2 years before death and survivors' utilization in the same period of time was assessed in three age groups (70-79, 80-89 and > or = 90 years) and by gender.

RESULTS

Decedents used hospital and long-term care more than their surviving counterparts, but the time patterns were different. In hospital care the differences between decedents and survivors rose in the last months of the study period, whereas in long-term care there were clear differences during the whole 2-year period. The differences were smaller in the oldest age group than in younger age groups.

CONCLUSION

Closeness of death is an important predictor of health and social service use in old age, but its influence varies between age groups. Not only the changing age structure, but also the higher average age at death affects the future need for services.

Hospital costs of older people in New South Wales in the last year of life

OBJECTIVE

To estimate hospital inpatient costs by age, time to death and cause of death among older people in the last year of life.

DESIGN AND SETTING

Cross-sectional analytical study of deaths and hospitalisations in New South Wales from linked population databases.

PARTICIPANTS

70,384 people aged 65 years and over who died in 2002 and 2003.

MAIN OUTCOME MEASURES

Hospital costs in the year before death.

RESULTS

Care of people aged 65 years and over in their last year of life accounted for 8.9% of all hospital inpatient costs. Hospital costs fell with age, with people aged 95 years or over incurring less than half the average costs per person of those who died aged 65-74 years ($7028 versus $17,927). Average inpatient costs increased greatly in the 6 months before death, from $646 per person in the sixth month to $5545 in the last month before death. Cardiovascular diseases (43.1% of deaths) were associated with an average of $11,069 in inpatient costs, while cancer (25.0% of deaths) accounted for $16,853. The highest average costs in the last year of life were for people who died of genitourinary system diseases ($18,948), and the highest average costs in the last month of life were for people who died of injuries ($8913).

CONCLUSION

Population ageing is likely to result in a shift of the economic burden of end-of-life care from the hospital sector to the long-term care sector, with consequences for the supply, organisation and funding of both sectors.

Measuring the symptom experience of seriously ill cancer and noncancer hospitalized patients near the end of life with the memorial symptom assessment scale

The objectives of this study were twofold: (1) to explore and compare the symptom experience of seriously ill hospitalized cancer and noncancer patients near the end of life using the Memorial Symptom Assessment Scale (MSAS) and (2) to determine if the MSAS is a valid and useful measure of symptom distress for patients with noncancer conditions. This was a prospective cohort study of hospitalized patients with end-stage congestive heart disease, chronic pulmonary disease, cirrhosis, or metastatic cancer. Eligible patients were interviewed to ascertain symptom prevalence, severity and distress using the MSAS and levels of fatigue using the Piper Fatigue Scale (PFS). Sixty-six patients with metastatic cancer and 69 patients with end-stage disease were enrolled in the study. There was a significant difference in the prevalence of selected physical symptoms, but not psychological symptoms, between cancer and noncancer patients. There were no significant differences in symptom distress scores, a computed score of frequency, severity and distress, if the symptom was present. In both groups the principal components factor analysis with varimax rotation yielded one factor comprising psychological symptoms and a second factor comprising three subgroups of physical symptoms. Internal consistency was high for the psychological subscale (Cronbach alpha coefficients of 0.85 for the cancer group and 0.77 for the noncancer group) and for the physical subscale groupings, with coefficients ranging between 0.78 to 0.87. The symptom scores were significantly correlated with perceptions of fatigue. These findings show that both seriously ill cancer and noncancer patients experience symptom distress, and that the MSAS seems to be a reliable measure of symptom distress in noncancer patients, as well as with cancer patients.