Costs and Resource Use at End of Life among Medicare Beneficiaries

Healthcare at the end of life is multifaceted, encompassing patient preferences and values, healthcare provider practices, and concerns about appropriate use of resources. The cost of end-of-life care is substantial, with more than one quarter of Medicare spending occurring in the last year of life. One in 8 death certificates in the United States lists heart failure as the cause of death; >25% of Medicare beneficiaries die within 1 year of the incident diagnosis of heart failure, and 36% die within 1 year of hospitalization related to heart failure. To gain an understanding of the healthcare experiences of people who die from heart failure and the ways those experiences have evolved, researchers recently examined the use of healthcare resources in the last 6 months of life in an elderly cohort of Medicare beneficiaries with heart failure from 2000 through 2007. Results of the study were reported online in Archives of Internal Medicine [doi:10.1001/archinternmed.2010.371]. The retrospective cohort study utilized data on 229,543 Medicare beneficiaries with heart failure who died between January 1, 2000, and December 31, 2007. Beneficiaries with heart failure were identified using International Classification of Diseases, Ninth Revision, Clinical Modification, codes for heart failure on a single inpatient claim or on ≥3 carrier or outpatient claims. The date of incident diagnosis was defined as the earlier of the date of the earliest inpatient diagnosis or the date of the third outpatient or carrier diagnosis. The researchers examined resource use in the last 180 days of life, including all-cause hospitalizations, intensive care unit days, skilled nursing facility stays, home health, hospice, durable medical equipment, outpatient physician visits, and cardiac procedures. For the study cohort, mean age at death was 83 years; nearly 25% were >90 years of age at death. In 2000, 61% of beneficiaries had ≥4 comorbid conditions; in 2007, 73% had ≥4 comorbid conditions (P<.001). Approximately 80% of patients with heart failure were hospitalized in the last 6 months of life, a finding that was consistent throughout the study period. A higher percentage of patients had skilled nursing home stays in 2007 compared with 2000 (38.8% vs 33.4%; P<.002). Length of stay also increased over the study period, and use of hospice in the final 6 months of life increased from 19% to nearly 40% (P<.001). Total days of hospitalization increased from 36.5 days in 2000 to 44.0 days in 2007 (P<.001). Nearly 33% of patients received home health services, and the mean number of outpatient visits to a physician increased from 7.0 to 8.3 over the study period (P<.001). The rate of tests and procedures other than echocardiography was low and remained steady over the study period; the rate of use of echocardiography increased from 41.5% in 2000 to 51.3% in 2007 (P<.001). During the study period, the mean cost to Medicare per patient rose from $28,766 to $36,216 (a 26% increase), P<.001. The cost to Medicare for physician services in the last 6 months of life increased from $4319 to $5334 over the study period (a 24% increase), and the mean cost of hospice care per patient increased from $964 to $2594 (>50% increase). Although the use of the intensive care unit during terminal hospitalizations increased from 42.4% to 50.2% over the study period, the proportion of patients who died in the hospital declined from 40.2% to 35.2% (P<.001). The proportion of Medicare beneficiaries who died while receiving services covered by Medicare in a skilled nursing facility remained stable. The study found that increasing age was strongly and independently associated with lower costs; renal disease and chronic obstructive pulmonary disease were strong independent predictors of higher costs. The highest costs were among patients who died within 1 year of incident diagnosis. In conclusion, the researchers noted that in this study cohort, “healthcare resource use at the end of life increased over time with higher rates of intensive care and higher costs. However, the use of hospice services also increased markedly, representing a shift in patterns of care at the end of life.”