Trajectories of end-of-life medical and long-term care expenditures for older adults in Japan: retrospective longitudinal study using a large-scale linked database of medical and long-term care claims

Longitudinal trajectories of healthcare costs among high-need high-cost patients: a population-based retrospective cohort study in British Columbia, Canada

OBJECTIVES

We sought to identify groups of high-need high-cost (HNHC) patients with distinct cost trajectories and describe the sociodemographic and clinical characteristics associated with group membership.

DESIGN

A population-based retrospective cohort study, using administrative health data.

SETTING

British Columbia, Canada.

PARTICIPANTS

People who were HNHC in 2017, defined as incurring health system costs in the top 5% of the population, and were continuously registered in the Medical Service Plan from January 2015 to December 2019 and alive at the end of the study period.

OUTCOME MEASURES

The primary objective was to identify longitudinal patterns of healthcare costs using group-based trajectory modelling. Adopting a health sector perspective, we conducted person-level costing for hospital episodes, day surgeries, physician services, prescription medications, and home and community care services. The secondary objective was to explore sociodemographic and clinical characteristics associated with group membership using adjusted ORs and 95% CIs from a multinomial logit model.

RESULTS

Our final sample comprised 5.4 million British Columbians. In 2017, 224 285 people met our definition of an HNHC and were included in our analysis (threshold: $C7968). We selected a model with five groups. These groups included those with persistently very high costs (44%, mean 5-year total: $C124 622); persistent high costs (32%, mean 5 year total: $C38 997); rising costs (7%, mean 5-year total: $C43 140); declining costs (10%, mean 5-year total: $C30 545); and those with a cost spike (7%, mean 5-year total: $C19 601). Being older, being in the lowest income quintile and having a greater number of comorbid health conditions were associated with increased odds of being in the persistently very-high-cost trajectory group relative to each other group. There was heterogeneity in the association between individual comorbidities and trajectory group membership. Several comorbidities were associated with a statistically significant increase in the odds of being in the persistently very-high-cost group compared with all other groups (eg, diabetes, renal failure), while others were associated with decreased odds (eg, metastatic cancer, alcohol abuse).

CONCLUSION

This study unveils the complex and diverse cost trajectories of HNHC patients in British Columbia, highlighting the necessity for tailored healthcare strategies that address individual patient needs and circumstances. Notably, a high proportion of HNHC patients exhibit persistently high costs over a 5-year period, and available sociodemographic and clinical data are not predictive of group membership. Future research is needed to develop methods for predicting future HNHC patients and to identify evidence-based interventions that can improve patient outcomes and mitigate unnecessary healthcare utilisation and costs.

Healthcare Expenditure Trajectories in the Last 5 Years of Life: A Retrospective Cohort Study of Decedents with Advanced Cancer and End-Stage Organ Diseases

BACKGROUND

Patients with nonmalignant end-stage organ diseases often incur healthcare costs in the last year of life that are disproportionately higher than in the period prior. Studies on healthcare expenditure (HCE) trends in these patients have largely focused on the final year of life, and examining a longer-term trajectory could better support healthcare professionals to target the timing and methods of care management. In this study, we aim to describe the HCE trajectories of end-stage organ disease (ESOD) over the last 5 years of life, compared against advanced cancer (AC).

METHODS

We conducted a retrospective cohort study to profile decedents who had either a primary or secondary diagnosis of AC, advanced dementia, severe liver disease, as well as heart failure (HF), end-stage renal failure (ESRF), or respiratory failure (RF) in the last 5 years of their lives using a regional health system database in Singapore. Hospital-based HCE and utilization for each diagnosis group was reported cumulatively for 5 years, by year and by month. The proportion of the 5-year HCE incurred in each year was also reported.

RESULTS

Across all conditions, monthly HCE started to increase rapidly around 3 years prior to death, with 80% of the 5-year expenditure incurred in the same period. Expenditure among patients with ESODs other than dementia was £12,787 to £21,019 higher in comparison with patients with AC. Patients with RF incurred the highest 5-year HCE, driven by inpatient admissions.

CONCLUSIONS

Our findings highlight the importance of examining HCE trends in ESOD and their cost drivers over multiple years prior to the last year of life to inform healthcare policy and to review care processes to ensure appropriate and efficient end-of-life (EOL) care.

Trajectories of long-term care entitlements in severely disabled older adults using nationwide Dutch data

Long-term care trajectories typically vary in care types, transitions and durations. Understanding these patterns can help optimize care provision. This study aimed at (1) identifying formal long-term care trajectories of severely disabled older individuals, and (2) assessing the relationships between individual characteristics and these trajectories.Nationwide administrative data from the Centre for Care Needs Assessment were used. The sample included all 140,973 individuals older than 65 and with institutional care entitlements for somatic or psychogeriatric problems on July 1, 2015. The study period was from January 2010 to June 2019. Latent class growth analysis was performed to derive distinct care trajectories. Multinomial logistic regression analysis was used to examine the relationships between individual characteristics and these trajectories.Five trajectories were identified, varying in complexity and duration of needs in long-term care. Two were characterized by mostly mild (somatic) institutional care and three by (psychogeriatric) institutional care with increasing duration and intensity. Men and younger individuals were more likely to require intensive (psychogeriatric) institutional care.This study highlighted clear divergences among formal long-term care trajectories of severely disabled older individuals. Though less generous entitlement criteria may result in relatively lower expenditures in formal (institutional) care, they also imply increased use of alternatives, such as informal and community care. These insights can be used to tailor the provision of long-term care services in the future, and inform policy related to the financial sustainability of long-term care systems.

Last year of life care transitions between long-term care insurance services in Japan: Analysis of long-term care insurance claims data

AIM

We determined the number of care transitions in the year before death among older adults requiring long-term care (LTC) and those receiving public LTC insurance (LTCI) services in Japan, along with care transition pathways and factors associated with the number of care transitions.

METHODS

This study used data from the Japanese LTCI claims, which store national information on certification of needed LTC and LTCI claims data. Services received in the year before death were classified as in-home, facility, mixture of in-home and facility, and not using LTCI services. The transition count is presented, and Sankey diagrams are produced to visualize care transition pathways. We used a multivariable analysis to identify factors associated with the number of care transitions.

RESULTS

Of the participants, 276 896 (65.2%) experienced at least one transition in LTCI care settings in the year before death. Further, 72.0% of those requiring mild LTC underwent one or more transitions. Participants who were 75-84 years old (vs. 65-74 years old), male, without medical care needs, with symptoms of dementia, and with changes in LTC needs in the year before death were more likely to require care transitions. Moreover, participants with higher baseline LTC needs were less likely to require transitions.

CONCLUSION

Over half the participants requiring LTC underwent one or more care transitions in the year before death. Policy deliberations regarding enhancing care under the LTCI system at the end of life and optimizing care transitions are necessary. Geriatr Gerontol Int 2024; 24: 883-890.

Trajectories of medical care expenditure in the last year of life associated with long-term care utilization in frail older adults: A retrospective cohort study

BACKGROUND

Medical care and long-term care utilization in the last year of life of frail older adults could be a key indicator of their quality of life. This study aimed to identify the medical care expenditure (MCE) trajectories in the last year of life of frail older adults by investigating the association between MCE and long-term care utilization in each trajectory.

METHODS

The retrospective cohort study of three municipalities in Japan included 405 decedents (median age at death, 85 years; 189 women [46.7%]) from a cohort of 1,658 frail older adults aged ≥65 years who were newly certified as support level in the long-term care insurance program from April 2012 to March 2013. This study used long-term care and medical insurance claim data from April 2012 to March 2017. The primary outcome was MCE over the 12 months preceding death. Group-based trajectory modeling was conducted to identify the MCE trajectories. A mixed-effect model was employed to examine the association between long-term care utilization and MCE in each trajectory.

RESULTS

Participants were stratified into four groups based on MCE trajectories over the 12 months preceding death as follows: rising (n = 159, 39.3%), persistently high (n = 143, 35.3%), minimal (n = 56, 13.8%), and descending (n = 47, 11.6%) groups. Home-based long-term care utilization was associated with increased MCE in the descending trajectory (coefficient, 1.48; 95% confidence interval [CI], 1.35-1.62). Facility-based long-term care utilization was associated with reduced MCE in the rising trajectory (coefficient, 0.59; 95% CI, 0.50-0.69). Both home-based (coefficient, 0.92; 95% CI, 0.85-0.99) and facility-based (coefficient; 0.53; 95% CI, 0.41-0.63) long-term care utilization were associated with reduced MCE in the persistently high trajectory.

CONCLUSIONS

These findings may facilitate the integration of medical and long-term care models at the end of life in frail older adults.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cost-effectiveness of interferon-γ release assay for screening of latent tuberculosis infection in individuals with schizophrenia

Schizophrenia is recognized as a significant risk factor for tuberculosis (TB). This study aimed to evaluate the effectiveness and cost-effectiveness of interferon-γ release assay (IGRA) with preventive treatment for screening of latent tuberculosis infection (LTBI) in individuals with schizophrenia. A state transition model was developed from a healthcare payer perspective on a lifetime horizon. Ten strategies were compared by combining two different tests for LTBI, i.e. IGRA and tuberculin skin test (TST), and five different preventive treatments, i.e. 9-month isoniazid (9H), 3-month isoniazid and rifapentine (3HP) by directly observed therapy, 3HP by self-administered therapy, 3-month isoniazid and rifampin (3RH), and 4-month rifampin (4R). The main outcomes were costs, quality-adjusted life-years (QALYs), life expectancy life-years (LYs), incremental cost-effectiveness ratios, drug-sensitive tuberculosis (DS-TB) cases, and TB-related deaths. For both bacillus Calmette-Guérin (BCG)-vaccinated and non-BCG-vaccinated individuals, IGRA with 4R was the most cost-effective and TST with 3RH was the least effective. Among schizophrenic individuals in Japan, IGRA with 4R saved US$17.8 million, increased 58,981 QALYs and 935 LYs, and prevented 222 DS-TB cases and 75 TB-related deaths compared with TST with 3RH. In individuals with schizophrenia, IGRA with 4R is recommended for LTBI screening with preventive treatment to reduce costs, morbidity, and mortality from TB.

Current definitions of advanced multimorbidity: a protocol for a scoping review

INTRODUCTION

People living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity often have a high burden of palliative and end-of-life care needs, though they do not always access specialist palliative care services. A key reason for this is that they are often not identified as being in the last stages of their life by current healthcare providers and systems.This scoping review aims to identify and present the available evidence on how people with multimorbidity are currently included in research, policy and clinical practice.

METHODS AND ANALYSIS

Scoping review methodology, based on Arksey and O'Malley's framework, will be undertaken and presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Search terms have been generated using the key themes of 'multimorbidity', 'end of life' and 'palliative care'. Peer-reviewed research will be obtained through systematic searching of Medline, EMBASE, CINAHL, Scopus and PsycINFO. Grey literature will be searched in a systematic manner. Literature containing a definition for adults with multimorbidity in a terminal phase of their illness experience will be included. After screening studies for eligibility, included studies will be described in terms of setting and characteristics as well as using inductive content analysis to highlight the commonalities in definitions.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. The findings of the scoping review will be used internally as part of SPB's PhD thesis at the University of St Andrews through the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust (223499/Z/21/Z) and published in an open access, peer-reviewed journal for wider dissemination.

Identifying Characteristics Associated with the Concentration and Persistence of Medical Expenses among Middle-Aged and Elderly Adults: Findings from the China Health and Retirement Longitudinal Survey

Medical expenses, especially among middle-aged and elderly people, have increased in China over recent decades. However, few studies have analyzed the concentration or persistence of medical expenses among Chinese residents or vulnerable groups with longitudinal survey data. Based on the data of CHARLS (China Health and Retirement Longitudinal Study), this study sought to identify characteristics associated with the concentration and persistence of medical expenses among Chinese middle-aged and elderly adults and to help alleviate medical spending and the operational risk of social medical insurance. Concentration was measured using the cumulative percentages of ranked annual medical expenses and descriptive statistics were used to define the characteristics of individuals with high medical expenses. The persistence of medical expenses and associated factors were estimated using transfer rate calculations and Heckman selection modeling. The results show that total medical expenses were concentrated among a few adults and the concentration increased over time. People in the high medical expense group were more likely to be older, live in urban areas, be less wealthy, have chronic diseases, and attend higher-ranking medical institutions. Lagged medical expenses had a persistent positive effect on current medical expenses and the effect of a one-period lag was strongest. Individuals with chronic diseases during the lagged period had a higher likelihood of experiencing persistent medical expenses. Policy efforts should focus on preventive management, more efficient care systems, improvement of serious illness insurance level, and strengthening the persistent protection effect of social medical insurance to reduce the high medical financial risk and long-term financial healthcare burden in China.

Healthcare Cost Trajectories in the Last 2 Years of Life Among Patients With a Solid Metastatic Cancer: A Prospective Cohort Study

BACKGROUND

Most studies describe the "average healthcare cost trend" among patients with cancer. We aimed to delineate heterogeneous trajectories of healthcare cost during the last 2 years of life of patients with a metastatic cancer and to assess the associated sociodemographic and clinical characteristics and healthcare use.

PATIENTS AND METHODS

We analyzed a sample of 353 deceased patients from a cohort of 600 with a solid metastatic cancer in Singapore, and we used group-based trajectory modeling to identify trajectories of total healthcare cost during the last 2 years of life.

RESULTS

The average cost trend showed that mean monthly healthcare cost increased from SGD $3,997 during the last 2 years of life to SGD $7,516 during the last month of life (USD $1 = SGD $1.35). Group-based trajectory modeling identified 4 distinct trajectories: (1) low and steadily decreasing cost (13%); (2) steeply increasing cost in the last year of life (14%); (3) high and steadily increasing cost (57%); and (4) steeply increasing cost before the last year of life (16%). Compared with the low and steadily decreasing cost trajectory, patients with private health insurance (β [SE], 0.75 [0.37]; P=.04) and a greater preference for life extension (β [SE], -0.14 [0.07]; P=.06) were more likely to follow the high and steadily increasing cost trajectory. Patients in the low and steadily decreasing cost trajectory were most likely to have used palliative care (62%) and to die in a hospice (27%), whereas those in the steeply increasing cost before the last year of life trajectory were least likely to have used palliative care (14%) and most likely to die in a hospital (75%).

CONCLUSIONS

The study quantifies healthcare cost and shows the variability in healthcare cost trajectories during the last 2 years of life. Policymakers, clinicians, patients, and families can use this information to better anticipate, budget, and manage healthcare costs.