End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported

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.

A panel vector autoregression analysis for the dynamics of medical and long-term care expenditures

Although medical and long-term care expenditures for older adults are closely related, providing rigorous statistical analysis for their dynamic relationship is challenging. In this research, we propose a novel approach using the panel vector autoregression model to reveal the realized patterns of the interdependence. As an empirical application, we analyze monthly panel data on individuals in a city of Japan, where social insurance covers many formal services for long-term care. Our estimation results indicate the existence of intertemporal transition from expensive acute medical care to reasonable at-home medical care, then to at-home long-term care. Under this context, the enhancement of formal long-term care sector in Japan might have played an important role in the suppression of the total care cost in spite for its rapid aging over the past 2 decades. Additionally, we find that daycare plays multiple roles in Japanese long-term care, such as respite and rehabilitation, but there is no considerable transition from outpatient rehabilitation to daycare in the long-term care sector.

Enhancing the Adult and Paediatric Palliative Care System: Spanish Professionals' and Family Caregivers' Suggestions for Comprehensive Improvement

This research critically explores deficiencies in the palliative care system, focusing on evaluation and treatment aspects for both adult and paediatric patients. Using a qualitative methodology, the study engages healthcare professionals and family caregivers to uncover perspectives on the existing state of palliative care. Conducted through three focus groups and a semi-structured in-depth interview with participants recruited from Virgen de la Arrixaca University Clinical Hospital, this research illustrates critical issues, highlighting the insufficient healthcare workforce and resources to meet the comprehensive needs of patients and their families. Recommendations include holistic care addressing social, emotional, psychological, socio-familiar, and economic dimensions, supported by embedded support groups and the enforcement of relationships with palliative associations. This study also advocates for improved health institutional coordination, social worker support, and ongoing health professional satisfaction monitoring. In paediatric care, specific demands involve specialised units, medical team continuity, 24 h paediatrician care, and a more professional paediatric approach. Beyond problem identification, this study offers valuable insights for shaping health policies and tools, incorporating new indicators and introducing grief bereavement support in clinical reports, contributing to the advancement of patient evaluation in palliative care.

Unique characteristics of end-of-life hospitalizations in Parkinson disease

Introduction

Persons with Parkinson disease (PD) are hospitalized at higher rates, have longer lengths of stay, and are more likely to die in the hospital than age-matched peers. Although prior studies have compared inpatient outcomes between persons with and without PD, little is known about inpatient outcomes across the PD trajectory, or whether hospitalizations occurring in the last 6 months of life differ from earlier hospitalizations.

Methods

This cross-sectional study compared Medicare Part A and B beneficiaries aged 65 and older with a qualifying PD diagnosis who were hospitalized in 2017: decedents who died between 7/1/2017 and 12/31/2017 from all causes and were hospitalized at least once in their last 6 months of life, and non-decedents who were hospitalized between 1/1/2017 and 6/30/2017 and lived 6 or more months after discharge. End-of-life (EoL) hospitalizations were defined as those occurring in the last 6 months of life. Descriptive analyses compared patient-level variables (e.g., demographics, comorbidities, treatment intensity) and encounter-level variables (e.g., length of stay, total charges) between groups. Multivariable logistic regression models also compared rates of intensive care unit (ICU) admission and 30-day readmission between hospitalized decedents and hospitalized non-decedents, adjusting for age, sex, race/ethnicity, rural residence, and Charlson Comorbidity Index Score.

Results

Of 26,492 Medicare decedents with PD, 16,187 (61.1%) were hospitalized in their last 6 months of life. Of 347,512 non-decedents with PD, 62,851 (18.1%) were hospitalized in a 6-month period. Hospitalized decedents were slightly older than hospitalized non-decedents (82.3 [SD 7.40] vs. 79.5 [SD 7.54] years) and had significantly more comorbidities. Compared to non-EoL hospitalizations, EoL hospitalizations were slightly longer (5 [IQR 3-9] vs. 4 [IQR 3-7] days) and more expensive based on total charges per admission ($36,323 [IQR 20,091-69,048] vs. $32,309 [IQR 18,789-57,756]). In covariate-adjusted regression models using hospitalized non-decedents as the reference group, hospitalized decedents were more likely to experience an ICU admission (AOR 2.36; CI 2.28-2.45) and 30-day readmission (AOR 2.43; CI 2.34-2.54).

Discussion

Hospitalizations occurring in the last 6 months of life among persons with PD in the United States are longer, more costly, and more resource intensive than earlier hospitalizations and may stem from medical comorbidities. Once hospitalized, ICU admission and 30-day readmission may aid in prognostication and serve as markers of transition to the EoL period.

Healthcare Costs at the End of Life for Patients with Non-cancer Diseases and Cancer in Denmark

OBJECTIVES

To examine costs of care from a healthcare sector perspective within 1 year before death in patients with non-cancer diseases and patients with cancer.

METHODS

This nationwide registry-based study identified all Danish citizens dying from major non-cancer diseases or cancer in 2010-2016. Applying the cost-of-illness method, we included costs of somatic hospitals, including hospital-based specialist palliative care, primary care, prescription medicine and hospice expressed in 2022 euros. Costs of patients with non-cancer diseases and cancer were compared using regression analyses adjusting for sex, age, comorbidity, residential region, marital/cohabitation status and income level.

RESULTS

Within 1 year before death, mean total healthcare costs were €27,185 [95% confidence interval (CI) €26,970-27,401] per patient with non-cancer disease (n = 109,723) and €51,348 (95% CI €51,098-51,597) per patient with cancer (n = 108,889). The adjusted relative total healthcare costs, i.e. the ratio of the mean costs, of patients with non-cancer diseases was 0.64 (95% CI 0.63-0.66) at 12 months before death and 0.91 (95% CI 0.90-0.92) within 30 days before death compared with patients with cancer. Mean costs of hospital-based specialist palliative care and hospice in the year leading up to death were €17 (95% CI €13-20) and €90 (95% CI €77-102) per patient with non-cancer disease but €1552 (95% CI €1506-1598) and €3411 (95% CI €3342-3480) per patient with cancer.

CONCLUSIONS

Within 1 year before death, total healthcare costs, mainly driven by hospital costs, were substantially lower for patients with non-cancer diseases compared with patients with cancer. Moreover, the costs of hospital-based specialist palliative care and hospice were minimal for patients with non-cancer diseases.

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

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.

Clinical Decision Support Systems for Palliative Care Management: A Scoping Review

CONTEXT

With the expansion of palliative care services in clinical settings, clinical decision support systems (CDSSs) have become increasingly crucial for assisting bedside nurses and other clinicians in improving the quality of care to patients with life-limiting health conditions.

OBJECTIVES

To characterize palliative care CDSSs and explore end-users' actions taken, adherence recommendations, and clinical decision time.

METHODS

The CINAHL, Embase, and PubMed databases were searched from inception to September 2022. The review was developed following the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews guidelines. Qualified studies were described in tables and assessed the level of evidence.

RESULTS

A total of 284 abstracts were screened, and 12 studies comprised the final sample. The CDSSs selected focused on identifying patients who could benefit from palliative care based on their health status, making referrals to palliative care services, and managing medications and symptom control. Despite the variability of palliative CDSSs, all studies reported that CDSSs assisted clinicians in becoming more informed about palliative care options leading to better decisions and improved patient outcomes. Seven studies explored the impact of CDSSs on end-user adherence. Three studies revealed high adherence to recommendations while four had low adherence. Lack of feature customization and trust in guideline-based in the initial stages of feasibility and usability testing were evident, limiting the usefulness for nurses and other clinicians.

CONCLUSION

This study demonstrated that implementing palliative care CDSSs can assist nurses and other clinicians in improving the quality of care for palliative patients. The studies' different methodological approaches and variations in palliative CDSSs made it challenging to compare and validate the applicability under which CDSSs are effective. Further research utilizing rigorous methods to evaluate the impact of clinical decision support features and guideline-based actions on clinicians' adherence and efficiency is recommended.

How Safe Do Dying People Feel at Home? Patients' Perception of Safety While Receiving Specialist Community Palliative Care

BACKGROUND

There is a research gap regarding safety concerns of patients at the end of life. The aim of this study was, therefore, to explore whether patients under specialist community palliative care feel safe at home and which factors affect the perceived safety. Furthermore, we investigated if perception of safety is associated with different aspects of subsequent care.

METHODS

Using a standardized questionnaire, a cross-sectional survey was conducted among 100 specialist community palliative care patients. Logistic regression was used to examine the strength of the association between clinical and socio-demographic variables and the perception of safety. After a 6-month follow-up period, we analyzed differences in various care-related outcomes between patients with unaffected and impaired perceptions of safety.

RESULTS

In our study, one in five patients receiving specialist community palliative care expressed safety concerns. Subdomains of safety that were reported most frequently were physical disability (60%), physical symptoms (30%), psychological symptoms (26%), and side effects/complications of drug therapy (19%). Of the participants surveyed after the initial COVID-19 lockdown, 35.1% reported that they felt their safety had been adversely affected by the pandemic. Compromised safety perception was associated with higher levels of palliative care-related problems, and proximity to death.

CONCLUSIONS

Our study uncovered relevant safety concerns of palliative care patients receiving specialist community palliative care. The insights gained into patient-reported problems may help healthcare professionals to identify situations where patients feel unsafe. Further research should address primary and secondary prevention measures to improve the quality of end-of-life care in the home environment.

What is the cost-effectiveness of menu calorie labelling on reducing obesity-associated cancer burdens? An economic evaluation of a federal policy intervention among 235 million adults in the USA

OBJECTIVE

To assess the impact of menu calorie labelling on reducing obesity-associated cancer burdens in the USA.

DESIGN

Cost-effectiveness analysis using a Markov cohort state-transition model.

SETTING

Policy intervention.

PARTICIPANTS

A modelled population of 235 million adults aged ≥20 years in 2015-2016.

INTERVENTIONS

The impact of menu calorie labelling on reducing 13 obesity-associated cancers among US adults over a lifetime was evaluated for: (1) effects on consumer behaviours; and (2) additional effects on industry reformulation. The model integrated nationally representative demographics, calorie intake from restaurants, cancer statistics and estimates on associations of policy with calorie intake, dietary change with body mass index (BMI) change, BMI with cancer rates, and policy and healthcare costs from published literature.

MAIN OUTCOME MEASURES

Averted new cancer cases and cancer deaths and net costs (in 2015 US$) among the total population and demographic subgroups were determined. Incremental cost-effectiveness ratios from societal and healthcare perspectives were assessed and compared with the threshold of US$150 000 per quality-adjusted life year (QALY) gained. Probabilistic sensitivity analyses incorporated uncertainty in input parameters and generated 95% uncertainty intervals (UIs).

RESULTS

Considering consumer behaviour alone, this policy was associated with 28 000 (95% UI 16 300 to 39 100) new cancer cases and 16 700 (9610 to 23 600) cancer deaths averted, 111 000 (64 800 to 158 000) QALYs gained, and US$1480 (884 to 2080) million saved in cancer-related medical costs among US adults. The policy was associated with net cost savings of US$1460 (864 to 2060) million and US$1350 (486 to 2260) million from healthcare and societal perspectives, respectively. Additional industry reformulation would substantially increase policy impact. Greater health gains and cost savings were predicted among young adults, Hispanic and non-Hispanic Black individuals.

CONCLUSIONS

Study findings suggest that menu calorie labelling is associated with lower obesity-related cancer burdens and reduced healthcare costs. Policymakers may prioritise nutrition policies for cancer prevention in the USA.

Factors Associated with End-Of-Life Health Care Use and Spending in Korea in Comparison with the General Population

This study investigated the factors associated with end-of-life health care use and spending in Korea. Chronically ill decedents, who were hospitalized for one of nine chronic conditions during the year before death, were identified from the National Health Insurance Database in 2017. For comparison, the end-of-life care spending for all decedents and the annual health care spending for the general population were analyzed. The inpatient and outpatient end-of-life care spending for the chronically ill decedents were sixteen and seven times the annual inpatient and outpatient spending for the general population respectively. The regional income level was positively associated with both inpatient and outpatient spending among the decedents with a stronger association in the chronically ill decedents, while a negative association was found in the general population. No significant association was found between the inpatient spending and the number of hospital beds for the chronically ill decedents, whereas the number of beds in small to medium-sized hospitals was positively associated with inpatient spending for the total decedents and the general population. The findings suggest that hospitalization for end-of-life care depends more on the income of the patients, while the inpatient spending for total decedents and the general population are more likely to be affected by the supply of beds.

The Role of Information and Nudges on Advance Directives and End-of-Life Planning: Evidence From a Randomized Trial

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.

Formal health care costs among older people in Ireland: methods and estimates using The Irish Longitudinal Study on Ageing (TILDA)

Background: Reliable data on health care costs in Ireland are essential to support planning and evaluation of services. New unit costs and high-quality utilisation data offer the opportunity to estimate individual-level costs for research and policy. Methods: Our main dataset was The Irish Longitudinal Study on Ageing (TILDA). We used participant interviews with those aged 55+ years in Wave 5 (2018) and all end-of-life interviews (EOLI) to February 2020. We weighted observations by age, sex and last year of life at the population level. We estimated total formal health care costs by combining reported usage in TILDA with unit costs (non-acute care) and public payer reimbursement data (acute hospital admissions, medications). All costs were adjusted for inflation to 2022, the year of analysis. We examined distribution of estimates across the population, and the composition of costs across categories of care, using descriptive statistics. We identified factors associated with total costs using generalised linear models. Results: There were 5,105 Wave 5 observations, equivalent at the population level to 1,207,660 people aged 55+ years and not in the last year of life, and 763 EOLI observations, equivalent to 28,466 people aged 55+ years in the last year of life. Mean formal health care costs in the weighted sample were EUR 8,053; EUR 6,624 not in the last year of life and EUR 68,654 in the last year of life. Overall, 90% of health care costs were accounted for by 20% of users. Multiple functional limitations and proximity to death were the largest predictors of costs. Other factors that were associated with outcome included educational attainment, entitlements to subsidised care and serious chronic diseases. Conclusions: Understanding the patterns of costs, and the factors associated with very high costs for some individuals, can inform efforts to improve patient experiences and optimise resource allocation.

Direct health costs of amyotrophic lateral sclerosis in a multidisciplinary ALS unit in Catalonia (Spain)

Our research project computed the direct health costs of patients with amyotrophic lateral sclerosis (ALS) in a Spanish multidisciplinary unit and explored the main factors associated. Besides analyzing a context with universal health care provision, we used an administrative health care dataset from the most crucial center unit treating ALS in Catalonia (80% of total patients). Our results show that the direct health cost of caring for an ALS patient in our unit was 5,158€per patient/year. This cost was not influenced by the onset of the disease, sex or age, but it increased if the patient lived near our center since this facilitates the frequency of follow-up visits. Finally, the higher the educational level, the lower the direct health costs.

Elevated end-of-life spending: A new measure of potentially wasteful health care spending at the end of life

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.

Predicting mortality and visualizing health care spending by predicted mortality in Danes over age 65

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.

Looking into the black box of "Medical Innovation": rising health expenditures by illness type

There is agreement among health economists that on the whole medical innovation causes health care expenditures (HCE) to rise. This paper analyzes for which diagnoses HCE per patient have grown significantly faster than average HCE. We distinguish decedents (patients in their last 4 years of life) from survivors and use a unique dataset comprising detailed HCE of all members of a regional health insurance fund in Upper Austria for the period 2005-2018. Our results indicate that among decedents in particular, the expenditures for treatment of neoplasms have exceeded the general trend in HCE. This confirms that medical innovation for this group of diseases has been particularly strong over the last 15 years. For survivors, we find a noticeable growth in cases and cost per case for pregnancies and childbirth, and also for treatment of mental and behavioral disorders. We discuss whether these findings contradict the widespread interpretation of cost-increasing innovations as "medical progress" and offer some policy recommendations.

ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study

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.

Socioeconomic differences in inpatient care expenditure in the last year of life among older people: a retrospective population-based study in Stockholm County

OBJECTIVES

To investigate the association between inpatient care expenditure (ICE) and income group and the effect of demographic factors, health status, healthcare and social care utilisation on ICE in the last year of life.

DESIGN

Retrospective population-based study.

SETTING

Stockholm County.

PARTICIPANTS

Decedents ≥65 years in 2015 (N=13 538).

OUTCOME

ICE was calculated individually for the month of, and 12 months preceding death using healthcare register data from 2014 and 2015. ICE included the costs of admission and treatment in inpatient care adjusted for the price level in 2018.

RESULTS

There were difference between income groups and ICE incurred at the 75th percentile, while a social gradient was found at the 95th percentile where the highest income group incurred higher ICE (SEK45 307, 95% CI SEK12 055 to SEK79 559) compared with the lowest income groups. Incurring higher ICE at the 95th percentile was driven by greater morbidity (SEK20 333, 95% CI SEK12 673 to SEK29 993) and emergency department care visits (SEK77 995, 95% CI SEK64 442 to SEK79 549), while lower ICE across the distribution was associated with older age and residing in institutional care.

CONCLUSION

Gaining insight into patterns of healthcare expenditure in the last year of life has important implications for policy, particularly as socioeconomic differences were visible in ICE at a time of greater care need for all. Future policies should focus on engaging in advanced care planning and strengthening the coordination of care for older people.

One last effort. Are high out-of-pocket payments at the end of life a fatality?

Only few studies outside of the US have addressed the issue of out-of-pocket payments (OOP) at the end of life because of a lack of data. We use an exclusive dataset from a major French health insurance company (MGEN), including claim data, both mandatory and voluntary health insurance details, income and individual characteristics, for individuals aged 65 or older who died in 2017. We address three main issues: (1) What is the magnitude of OOP in France at the end of life? (2) How are OOP distributed, and do they present a financial risk to patients? (3) What are the determinants of OOP and what health system reforms could reduce them? Our results indicate that OOP expenses increase in the last year of life and accelerate in the last trimester. Despite some outliers, the French system is successful in protecting individuals from catastrophic OOP. Using generalised linear models, we confirm that improving the pathways of care could generate savings and partially reduce households' financial burden. However, OOP are elastic to income and driven essentially by personal convenience demands. Using concentration curves and Gini coefficients, we show that providing additional insurance against end-of-life OOP would likely be regressive, i.e., socially non-desirable.

Advance directives completion and hospital out-of-pocket expenditures

INTRODUCTION

Health care costs remain high at the end of life. It is not known if there is a relationship between advance directive (AD) completion and hospital out-of-pocket costs. This analysis investigated whether AD completion was associated with lower hospital out-of-pocket costs at end of life.

METHODS

We used Health and Retirement Study participants who died between 2000 and 2014 (N = 9228) to examine the association between AD completion status and hospital out-of-pocket spending in the last 2 years of life through the use of a two-part model controlling for socioeconomic status, death-related characteristics and health insurance coverage.

RESULTS

About 44% of decedents had completed ADs. Having an AD was significantly associated with $673 lower hospital out-of-pocket costs, with a higher magnitude of savings among younger decedents. Decedents who completed ADs 3 months or less before death had higher out-of-pocket costs ($1854 on average) than those who completed ADs more than 3 months before death ($1176 on average).

CONCLUSIONS

AD completion was significantly associated with lower hospital out-of-pocket costs, with greater out-of-pocket savings among younger decedents. Early AD completers experienced lower costs than decedents who completed ADs closer to death.

Economic burden of patients living with heart disease in the last years of life in Australia: a retrospective analysis using linked data

AIMS

People living with heart disease are at elevated risk of hospitalization during the last years of their life. The aim of this study was to describe hospitalization-related usage patterns, and associated cost burden, for patients living with heart disease in the last 6 years of their life.

METHODS AND RESULTS

The study was an observational cohort study, using routinely collected and linked data from hospital admission (HA), emergency department (ED) presentation and death registry data in Queensland, Australia. The study sample included 1000 randomly selected patients who died in 2017 due to any cause who had been living with heart disease for at least the prior 6 years. The two main outcomes of interest in this study were cost of HAs and cost of ED presentation in the last 6 years before death. Total cost was calculated as a sum of direct and overhead costs from each of the hospital presentations. The mean HA per patient in the sixth year, second year, and last year prior to death was 5.3, 6.6, and 7.5, respectively, with a similar pattern observed for ED presentations. The associated costs per patient from HA followed a similar trajectory increasing gradually from $17 711 in the sixth year to $26 658 in the second last year prior to death. A similar pattern was observed for ED presentation costs.

CONCLUSION

The large increase cost in the last year of life was primarily attributable to higher treatment cost per HA at end of life.

Impact analysis of expanding anti-TNF therapy for Crohn's disease

Aim: To estimate the impact of universal anti-TNF therapy in patients with moderate-to-severe Crohn's disease. Materials & methods: Developed a population-level Markov model to estimate the impact on health outcomes and medical expenditures of expanding anti-TNF therapy use versus current treatment practices. Results: Reductions in deaths (2600), hip fractures (980), major adverse cardiac events (2700) and patient out-of-pocket medical spending (2%) over 5 years. Total societal costs would be US$22,100 higher per patient per year, primarily due to the high cost of anti-TNF therapy. Conclusion: Expanding anti-TNF therapy use among US adult patients with moderate-to-severe Crohn's disease would reduce morbidity and mortality, decrease disease-related medical costs and increase treatment costs compared with current practice. Despite the higher costs, this approach could substantially benefit patients.

Medical cost of advanced illnesses in the last-year of life-retrospective database study

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.

Proportion of deaths in hospital in European countries: trends and associations from panel data (2005-2017)

BACKGROUND

End-of-life care attracts major policy interest. Place of death is an important metric of individual experience and health system performance. Most people prefer to die at home, but hospital is the most common place of death in high-income countries. Little is known about international trends in place of death over time.

METHODS

We aimed to collate population-level data on place of death in Europe from 2005 to 2017, and to evaluate association with national characteristics and policy choices. We sought data on hospital as the place of death from the 32 European Economic Area countries. We identified national economic, societal, demographic and health system predictors from Eurostat, OECD and the WHO. We analyzed these cross-national panel data using linear regression with panel-corrected standard errors.

RESULTS

Our analytic dataset included 30 countries accounting for over 95% of Europe's population. Average national proportion of deaths occurring in hospital in the study period ranged from 26% to 68%, with a median of 52%. Trends vary markedly by region and wealth, with low and decreasing rate in the North-West, and high and increasing prevalence in the South and East. Controlling for demographic and economic factors, strong palliative care provision and generous government finance of long-term care were associated with fewer hospital deaths.

CONCLUSIONS

We found modifiable policy choices associated with hospital mortality, as well as wider structural economic and societal factors. Policymakers can act to reduce the proportion of dying in hospital.

International comparison of spending and utilization at the end of life for hip fracture patients

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.

An international comparison of long-term care trajectories and spending following hip fracture

OBJECTIVE

The objectives of this study are to compare the relative use of different postacute care settings in different countries and to compare three important outcomes as follows: total expenditure, total days of care in different care settings, and overall longevity over a 1-year period following a hip fracture.

DATA SOURCES

We used administrative data from hospitals, institutional and home-based long-term care (LTC), physician visits, and medications compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) from five countries as follows: Canada, France, Germany, the Netherlands, and Sweden.

DATA EXTRACTION METHODS

Data were extracted from existing administrative data systems in each participating country.

STUDY DESIGN

This is a retrospective cohort study of all individuals admitted to acute care for hip fracture. Descriptive comparisons were used to examine aggregate institutional and home-based postacute care. Care trajectories were created to track sequential care settings after acute-care discharge through institutional and community-based care in three countries where detailed information allowed. Comparisons in patient characteristics, utilization, and costs were made across these trajectories and countries.

PRINCIPAL FINDINGS

Across five countries with complete LTC data, we found notable variations with Germany having the highest days of home-based services with relatively low costs, while Sweden incurred the highest overall expenditures. Comparisons of trajectories found that France had the highest use of inpatient rehabilitation. Germany was most likely to discharge hip fracture patients to home. Over 365 days, France averaged the highest number of days in institution with 104, Canada followed at 94, and Germany had just 87 days of institutional care on average.

CONCLUSION

In this comparison of LTC services following a hip fracture, we found international differences in total use of institutional and noninstitutional care, longevity, and total expenditures. There exist opportunities to organize postacute care differently to maximize independence and mitigate costs.

Trajectories of Frailty in the 5 Years Prior to Death Among U.S. Veterans Born 1927-1934

BACKGROUND

Electronic frailty indices (eFIs) are increasingly used to identify patients at risk for morbidity and mortality. Whether eFIs capture the spectrum of frailty change, including decline, stability, and improvement, is unknown.

METHODS

In a nationwide retrospective birth cohort of U.S. Veterans, a validated eFI, including 31 health deficits, was calculated annually using medical record and insurance claims data (2002-2012). K-means clustering was used to assign patients into frailty trajectories measured 5 years prior to death.

RESULTS

There were 214 250 veterans born between 1927 and 1934 (mean [SD] age at death = 79.4 [2.8] years, 99.2% male, 90.3% White) with an annual eFI in the 5 years before death. Nine frailty trajectories were identified. Those starting at nonfrail or prefrail had 2 stable trajectories (nonfrail to prefrail, n = 29 786 and stable prefrail, n = 28 499) and 2 rapidly increasing trajectories (prefrail to moderately frail, n = 28 244 and prefrail to severely frail, n = 22 596). Those who were mildly frail at baseline included 1 gradually increasing trajectory (mildly to moderately frail, n = 33 806) and 1 rapidly increasing trajectory (mildly to severely frail, n = 15 253). Trajectories that started at moderately or severely frail included 2 gradually increasing trajectories (moderately to severely frail, n = 27 662 and progressing severely frail, n = 14 478) and 1 recovering trajectory (moderately frail to mildly frail, n = 13 926).

CONCLUSIONS

Nine frailty trajectories, including 1 recovering trajectory, were identified in this cohort of older U.S. Veterans. Future work is needed to understand whether prevention and treatment strategies can improve frailty trajectories and contribute to compression of morbidity toward the end of life.

Evolution of health care utilization and expenditure during the year before death in 2015 among people with cancer: French snds-based cohort study

BACKGROUND

Cancer patients have one of the highest health care expenditures (HCE) at the end of life. However, the growth of HCE at the end of life remains poorly documented in the literature.

OBJECTIVE

To describe monthly reimbursed expenditure during the last year of life among cancer patients, by performing detailed analysis according to type of expenditure and the person's age.

METHOD

Data were derived from the Système national des données en santé (SNDS) [national health data system], which comprises information on ambulatory and hospital care. Analyses focused on general scheme beneficiaries (77% of the French population) treated for cancer who died in 2015.

RESULTS

Average reimbursed expenditure during the last year of life was €34,300 per person in 2015, including €21,100 (62%) for hospital expenditure. "Short-stays hospital" and "rehabilitation units" stays expenditure were €14,700 and €2000, respectively. Monthly expenditure increased regularly towards the end of life, increasing from 12 months before death €2000 to €5200 1 month before death. The highest levels of expenditure did not concern the oldest people, as average reimbursed expenditure was €50,300 for people 18-59 years versus €25,600 for people 80-90 years. Out-of-pocket payments varied only slightly according to age, but increased towards the end of life.

CONCLUSION

A marked growth of HCE was observed during the last 4 months of life, mainly driven by hospital expenditure, with a more marked growth for younger people.

Financial Protection in Health among the Elderly - A Global Stocktake

Universal Health Coverage is one of the key targets of the Sustainable Development Goals and it implies that everyone can access the healthcare they need without suffering financial hardship. In this paper, we use a large set of household surveys to examine if older populations are facing different degrees of financial hardship compared to younger populations. We find that while differences in average age structures between countries are not systematically associated with higher financial risk related to out-of-pocket health expenditures, there are large differences in financial hardship between younger and older households within countries. Households with more elderly members are more likely to face catastrophic and impoverishing out-of-pocket health payments compared to younger households, and this age gradient is stronger for the poorest segments of the population. Making progress toward Universal Health Coverage will require extension and improved targeting of benefit packages and financial protection to meet the health needs of older adults, and especially the poorest and most vulnerable segments of elderly populations.

[Healthcare expenditure and the impact of age: a detailed analysis for survivors and decedents]

BACKGROUND

Germany faces various socio-political challenges due to its ongoing ageing population. Significant increases in social security contributions are widely expected. The impact of ageing on healthcare expenditure is a controversial issue. Experts agree that costs for end-of-life care account for a significant part of total healthcare expenditures. For a meaningful forecast, detailed information on healthcare costs differentiated by survivors and decedents is necessary. Extensive data are hardly available for Germany. The aim of the analysis was therefore to describe healthcare costs in the statutory health insurance.

METHODS

The basis for the calculation is billing data from the statutory health insurance "AOK Niedersachsen" (Lower Saxony). Persons who survived or died in 2017 were included in the analysis. Average costs were standardised.

RESULTS

The data of 2.46 million survivors and 34,307 decedents were analysed. The average annual healthcare costs were 2756 € for survivors and 21,830 € for decedents in the last year of life. The average healthcare costs for survivors increase with age whereas costs for decedents are highest in younger age groups and decline with increasing age. A detailed analysis of end-of-life costs shows an exponential increase of costs in the last three years of life with the highest costs in the quarter before death (10,577 €).

DISCUSSION

The analysis gives a detailed overview on the structure of healthcare expenditure in the statutory health insurance and can serve as a basis for future forecasts regarding healthcare expenditure.

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

BACKGROUND

An accurate understanding of the current state of end-of-life care is important for healthcare planning. The objectives of this study were to examine the trajectories of end-of-life medical and long-term care expenditures and associated factors.

METHODS

This was a retrospective longitudinal study using a large-scale linked database of medical and long-term care claims-National Health Insurance, Advanced Elderly Medical Insurance, and long-term care insurance-covering Prefecture A in Japan. Patients aged ≥70 years who died between April 1, 2016, and March 31, 2017, were included (N = 16,084 patients; mean age = 85.1 ± 7.5 years; 7804 men (48.5%) and 8280 women (51.5%)). The outcome measures were medical expenditures (inpatient, outpatient, and prescription), long-term care expenditures, and total healthcare expenditures (the sum of medical and long-term care expenditures) during the 60 months before the date of death. We calculated each patient's monthly medical and long-term care expenditures for 60 months before the date of death and applied group-based trajectory modeling to identify distinct trajectories. Factors associated with spending trajectories were examined via multinomial logistic regression analyses. Explanatory variables included age, sex, diseases, and the medical services used.

RESULTS

We identified six distinct spending trajectories for the total healthcare expenditures: high persistent (45.6%), medium-to-high persistent (26.1%), early rise then high persistent (9.8%), late rise (6.4%), low persistent then very late rise (i.e., when spending starts increasing later than "late rise"; 6.4%), and progressive increase (5.7%). Factors associated with the high-persistent trajectory were chronic illnesses, various organ failures, neurodegenerative diseases, fractures, and tube feeding. The trajectory pattern of medical expenditures was similar to that of total healthcare expenditures; however, a different pattern was seen for long-term care expenditures.

CONCLUSIONS

Regarding combined medical and long-term care spending of the last 5 years, most patients belonged to a pattern in which the healthcare expenditures remained high, and a combination of multiple factors contributed to these patterns. This finding can offer healthcare providers a longer-term perspective on end-of-life care.

Valuing End-of-Life Care for Older People with Advanced Cancer: Is Dying at Home Important?

BACKGROUND

Most health care systems are facing the challenge of providing health services to support the increasing numbers of older people with chronic life-limiting conditions at the end of life. Many policies focus primarily on increasing the proportion of deaths at home.

OBJECTIVES

This study aims to investigate preferences for care throughout the latter stages of a life-limiting illness, particularly the importance of location of care, location of death, and the use of life-sustaining measures. It focuses on preferences for the care of an older person with advanced cancer in the last 3 weeks of life.

METHODS

A survey using discrete choice experiment (DCE) methods was completed online by a general population sample of 1548 Australians aged 45 years and over. The experiment included 12 attributes, and each respondent completed 11 choice sets. Analysis was by a mixed logit model and latent class analysis (LCA).

RESULTS

The most important attributes influencing care preferences were cost, patient anxiety, pain control, and carer stress (relative importance scores 0.21, 0.19, 0.14, and 0.14, respectively), with less importance given to place of care and place of death (relative importance scores 0.03 and 0.01). The model predicted that 42% would consider receiving most care in hospital better than at home (58%) holding the levels of other attributes constant across the alternatives, while 42% would consider death in hospital better than at home (58%). Three population segments with different preferences were identified by the LCA, the largest (46.5%) prioritised how the patient and carer felt as well as the pain control achieved, the next largest (28.1%) prioritised cost, and the smallest segment (25.4%) prioritised a single room when an inpatient.

CONCLUSIONS

This study shows that investment in services to support people at the end of life would be better targeted toward programmes that improve patient and carer wellbeing irrespective of the location of care and death.

Concordance of End-of-Life Care With End-of-Life Wishes in an Integrated Health Care System

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.

Trajectories of Long-Term Care Expenditure During the Last 5 Years of Life in Japan: A Nationwide Retrospective Cohort Study

OBJECTIVES

Despite the significant utilization of long-term care (LTC) services at the end of life, evidence on the trajectory of LTC expenditure in later life is scarce. This study aims to identify distinct trajectories of LTC expenditure in the last 5 years of life and to examine whether these trajectories differ according to cause of death.

DESIGN

A nationwide retrospective longitudinal cohort study based on linked data of National LTC Claims and the Japan's National Vital Statistic.

SETTING AND PARTICIPANTS

Participants comprised decedents aged 70 years or older and who died in 2017.

METHODS

We assessed 5 years of monthly LTC expenditure among participants and applied group-based trajectory model to identify distinct trajectories of LTC expenditure. Subsequently multinominal logistic regression analysis was performed to investigate how these trajectories vary according to cause of death.

RESULTS

Among 1,124,335 decedents, 4 distinct trajectories of LTC expenditure were identified: persistently low (58.5%), late increase (9.8%), progressive increase then late decrease (8.8%), and persistently high (22.9%). Approximately 80.7% of total LTC expenditure was spent by the persistently high group. After adjustment for age and sex; deaths due to age-related physical debility and dementia were associated with persistently high LTC expenditure.

CONCLUSIONS AND IMPLICATIONS

Ongoing discussions of LTC policy and reducing LTC expenditure may be more effective when emphasizing persistently high spenders. In addition, budget allocation for LTC at the end of life should be combined with data for health conditions.

Cost Savings Associated With Palliative Care Among Older Adults With Advanced Cancer

BACKGROUND

There is inconsistent evidence that palliative care intervention decreases total healthcare expenditure at end-of-life for oncology patients. This inconsistent evidence may result from small sample sizes at single institution studies and disparate characterization of costs across studies. Comprehensive studies in population-based datasets are needed to fully understand the impact of palliative care on total healthcare costs. This study analyzed the impact of palliative care on total healthcare costs in a nationally representative sample of advanced cancer patients.

METHODS

We conducted a matched cohort study among Medicare patients with metastatic lung, colorectal, breast and prostate cancers. We matched patients who received a palliative care consultation to similar patients who did not receive a palliative care consultation on factors related to both the receipt of palliative care and end of life costs. We compared direct costs between matched patients to determine the per-patient economic impact of a palliative care consultation.

RESULTS

Patients who received a palliative care consultation experienced an average per patient cost of $5,834 compared to $7,784 for usual care patients (25% decrease; p < 0.0001). Palliative care consultation within 7 days of death decreased healthcare costs by $451, while palliative care consultation more than 4 weeks from death decreased costs by $4,643.

CONCLUSION

This study demonstrates that palliative care has the capacity to substantially reduce healthcare expenditure among advanced cancer patients. Earlier palliative care consultation results in greater cost reductions than consultation in the last week of life.

Health care expenditure in the last five years of life is driven by morbidity, not age: A national study of spending trajectories in Danish decedents over age 65

BACKGROUND

The high level of medical spending at the end of life is well-documented, but whether there is any real potential for cost reductions there is still in question, and studies have tended to overlook the costs of care.

AIM

To identify the most common health care spending trajectories over the last five years of life among older Danes, as well as the determinants of following a given trajectory.

METHODS

We linked Danish health registries to obtain data on all health care expenditure (including hospital treatment, prescription drugs, primary care and costs of communal care) over the last five years of life for all Danish decedents above age 65 in the period 2013 through 2017. A latent class analysis identified the most common cost trajectories, which were then related to socio-economical characteristics and health status at five years before death.

RESULTS

Total health care expenditures in the last five years of life were largely independent of age and cause of death. Costs of home care and residential care increased steeply with age at death whereas hospital costs decreased correspondingly. We found four main spending trajectories among decedents: 3 percent followed a late-rise trajectory, 11 percent had accelerating costs, and two groups of 43 percent each followed moderately or consistently high trajectories. The main predictor of total expenditure was the number of chronic diseases.

INTERPRETATION

Spending at the end of life is largely determined by chronic disease, and age and cause of death only determine the distribution of expenses into care and cure.

Cost impact of introducing a treatment escalation/limitation plan during patients' last hospital admission before death

OBJECTIVE

A recent study found that the use of a treatment escalation/limitation plan (TELP) was associated with a significant reduction in non-beneficial interventions (NBIs) and harms in patients admitted acutely who subsequently died. We quantify the economic benefit of the use of a TELP.

DESIGN

NBIs were micro-costed. Mean costs for patients with a TELP were compared to patients without a TELP using generalized linear model regression, and results were extrapolated to the Scottish population.

SETTING

Medical, surgical and intensive care units of district general hospital in Scotland, UK.

PARTICIPANTS

Two hundred and eighty-seven consecutive patients who died over 3 months in 2017. Of these, death was 'expected' in 245 (85.4%) using Gold Standards Framework criteria.

INTERVENTION

Treatment escalation/limitation plan.

MAIN OUTCOME MEASURE

Between-group difference in estimated mean cost of NBIs.

RESULTS

The group with a TELP (n = 152) had a mean reduction in hospital costs due to NBIs of GB £220.29 (US $;281.97) compared to those without a TELP (n = 132) (95% confidence intervals GB £323.31 (US $413.84) to GB £117.27 (US $150.11), P = <0.001). Assuming that a TELP could be put in place for all expected deaths in Scottish hospitals, the potential annual saving would be GB £2.4 million (US $3.1 million) from having a TELP in place for all 'expected' deaths in hospital.

CONCLUSIONS

The use of a TELP in an acute hospital setting may result in a reduction in costs attributable to NBIs.

Improving Patient Preparedness and Confidence in Discussing Advance Directives for End-of-Life Care with Health Care Providers in the United States and Japan

BACKGROUND

The low completion rate of advance directives (ADs) has received attention in Japan and the United States, as policy makers and health care professionals face aging populations with multiple comorbidities. Among the barriers to AD planning, cultural values and attitudes appear to be particularly influential. A comparison of culturally distinct societies provides a deeper understanding of these barriers. Through such an approach, this study identifies strategies for increasing AD planning among late-middle-age Japanese and US individuals.

METHODS

After giving informed consent for the Institutional Review Board-approved study, Japanese and US respondents (45-65 y; 50% female) without ADs completed a language-appropriate online survey. Participants were asked to review a decision aid as part of a scenario-based physician consultation regarding artificial nutrition and hydration (ANH). Hypotheses were analyzed using multigroup structural equation modeling.

RESULTS

Important similarities were identified across the 2 groups. After reviewing the decision aid, both samples strongly preferred "no ANH." Respondents who strongly valued either self-reliance or interpersonal relationships experienced greater preparedness for AD planning. In both countries, greater decision preparedness and positive death attitude predicted greater confidence to discuss care options with a provider. Finally, cultural values predicted preference for family participation: respondents with a strong interdependent self-concept desired more family involvement, whereas high independents preferred less.

CONCLUSIONS

Findings indicate the importance of documenting care preferences and accounting for individual differences. To increase AD adoption, providers should identify patient segments likely to benefit most from the interventions. Targeting individuals in both countries who value self-reliance and interpersonal relationships appears to be a good place to begin. Such individuals can be identified clinically through administration of validated measures used in this study.

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)

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.

End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model

BACKGROUND

Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research.

PURPOSE

To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model.

METHOD

Walker and Avant's approach to concept analysis.

FINDINGS

End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences).

DISCUSSION

Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.

The Effect of Hospice on End-of-Life Costs for Terminal Medicare Patients With HIV

One-quarter of annual Medicare expenses in the traditional program (non-Medicare Advantage) are expended for 5% of Medicare enrollees, with much of this expenditure occurring in the last year of life. Hospice use may reduce end-of-life costs. However, evidence has been inconclusive due to sample selection and differences in insurance coverage for hospice. Claims data for HIV-positive Californians enrolled in Medicare who died in the period 2008 to 2010 were used to examine the relationship between hospice use and costs in the last 6 months of life. Logit estimates related hospice use to sickness levels and demographics. Inpatient and outpatient costs were analyzed separately. Logit regressions examined hospitalization probability. Robust regressions were used to examine the determinants of conditional inpatient costs and non-inpatient costs. Bootstrapped post-estimates were then used to determine the marginal probability of costs for the sample by hospice use. Hospice users have greater disease burden and are less likely to be African American. Controlling for disease burden, hospice users would have non-inpatient costs that were $14 771 greater than hospice non-users, but inpatient costs that were $20 522 lower. Thus, hospice reduces costs on net. Hospice is chosen by patients with more comorbidities. Controlling for these comorbidities, hospice use is associated with lower inpatient costs, greater non-inpatient costs and reduced end-of-life costs.

Ethical issues in geriatric cranial neurosurgery

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.

'More than one red herring'? Heterogeneous effects of ageing on health care utilisation

We study the effect of ageing, defined as an extra year of life, on health care utilisation. We disentangle the direct effect of ageing, from other alternative explanations such as the presence of comorbidities and endogenous time to death (TTD) that are argued to absorb the effect of ageing (so-called 'red herring' hypothesis). We exploit individual level end of life data from several European countries that record the use of medicine, outpatient and inpatient care and long-term care. Consistently with the 'red herring hypothesis', we find that corrected TTD estimates are significantly different from uncorrected ones, and their effect size exceeds that of an extra year of life, which in turn is moderated by individual comorbidities. Corrected estimates suggest an overall attenuated effect of ageing, which does not influence outpatient care utilisation. These results suggest the presence of 'more than one red herring' depending on the type of health care examined.

Decreased costs and retained QoL due to the 'PACE Steps to Success' intervention in LTCFs: cost-effectiveness analysis of a randomized controlled trial

BACKGROUND

The number of residents in long-term care facilities (LTCFs) in need of palliative care is growing in the Western world. Therefore, it is foreseen that significantly higher percentages of budgets will be spent on palliative care. However, cost-effectiveness analyses of palliative care interventions in these settings are lacking. Therefore, the objective of this paper was to assess the cost-effectiveness of the 'PACE Steps to Success' intervention. PACE (Palliative Care for Older People) is a 1-year palliative care programme aiming at integrating general palliative care into day-to-day routines in LTCFs, throughout seven EU countries.

METHODS

A cluster RCT was conducted. LTCFs were randomly assigned to intervention or usual care. LTCFs reported deaths of residents, about whom questionnaires were filled in retrospectively about resource use and quality of the last month of life. A health care perspective was adopted. Direct medical costs, QALYs based on the EQ-5D-5L and costs per quality increase measured with the QOD-LTC were outcome measures.

RESULTS

Although outcomes on the EQ-5D-5L remained the same, a significant increase on the QOD-LTC (3.19 points, p value 0.00) and significant cost-savings were achieved in the intervention group (€983.28, p value 0.020). The cost reduction mainly resulted from decreased hospitalization-related costs (€919.51, p value 0.018).

CONCLUSIONS

Costs decreased and QoL was retained due to the PACE Steps to Success intervention. Significant cost savings and improvement in quality of end of life (care) as measured with the QOD-LTC were achieved. A clinically relevant difference of almost 3 nights shorter hospitalizations in favour of the intervention group was found. This indicates that timely palliative care in the LTCF setting can prevent lengthy hospitalizations while retaining QoL. In line with earlier findings, we conclude that integrating general palliative care into daily routine in LTCFs can be cost-effective.

TRIAL REGISTRATION

ISRCTN14741671 .