End-of-Life Costs among Patients with Heart Failure in Canada

In 2004-2005, heart failure (HF) was the fourth most expensive medical condition in hospital costs in Canada. The high cost of end-of-life (EOL) care has not been carefully examined despite the high mortality rates associated with HF. Researchers recently conducted a study to identify trends in resource use and costs during the last 6 months of life in a cohort of elderly patients with HF who died in the province of Alberta, Canada, between 2000 and 2006. Study results were reported in Archives of Internal Medicine [2011;171(3):211-217].

Patients were included if they met one of the following criteria: (1) at least 1 hospitalization with a diagnosis of HF in any diagnosis field; or (2) at least 3 outpatient or physician claims with a diagnosis of HF on different days in a consecutive 20-month period. The date of HF incidence was the date of the earliest diagnosis, the earliest emergency department diagnosis, or the third outpatient or physician claim diagnosis, whichever came first. Patients with an HF duration of >8 years were excluded. The researchers gathered data on the costs associated with all-cause hospitalizations, intensive care, emergency department visits, outpatient visits, physician office visits, and outpatient drugs in the 180 days before death for all patients ≥65 years of age who died between January 1, 2000, and December 31, 2006, in Alberta. They also examined overall costs and predictors of costs to the healthcare system.

Of the 37,103 patients ≥65 years of age with HF who died during the study period, 3959 were excluded from the study because the duration of their HF was >8 years. The final study population included 33,144 patients. Mean age at death was 83 years, and <40% of the patients had 4 chronic conditions in addition to HF at the time of death. The comorbidity burden increased during the study period: rates of dementia, diabetes mellitus, hypertension, and renal disease increased significantly. The percentage of patients with a least 1 hospitalization in the final 6 months of life was 84.0% in 2000, decreasing to 76.2% in 2006 (P<.001). The mean length of stay in the last 6 months of life was stable over the study period; intensive care unit stays accounted for less than one tenth of the total number of hospital days.

Over the course of the study, mean hospital costs increased from $21,995 in 2000 to $26,186 in 2006 (P<.001). The percentage of patients receiving outpatient care in the last 6 months of life increased from 52.8% in 2000 to 69.8% in 2006 (P<.001). For those receiving outpatient care, the mean number of visits to outpatient clinics increased from 6.4 in 2000 to 7.7 in 2006 (P<.001). Mean costs per patient increased for all services in the last 6 months of life. The largest relative increases were in outpatient costs (75%), followed by physician costs (49%), and drug costs (42%). Hospitalization costs accounted for the majority of costs in the last 6 months of life. Costs among patients who died in the hospital were more than double those for patients who did not die in the hospital. Multivariate analyses found an inverse relationship between age and EOL costs. All comorbid conditions were associated with significant increase in costs, with the exception of dementia; renal disease was associated with the highest costs. Compared with patients whose duration of HF was >1 year, 6-month costs were highest among those who died within 1 year of diagnosis. In summary, the researchers noted that “resource use in the last 6 months of life among patients with HF in Alberta is changing, with a reduction in hospitalizations, in-hospital deaths, and an increase in the use of outpatient services. However, EOL costs are substantial and continue to increase.”