Several new studies delve into the medical care delivered as people near the end of their lives with terminal diseases. Previous research has identified a significant portion of health spending occurring in the last year or so of a person’s life and significant variation in how care is delivered for this subset of patients. Two of the new studies, one from the US and one from Canada, looked at heart failure patients in the last six months of their lives and trends in care over a multi-year period. One looked at terminal prostate cancer patients’ use of hospice care. (Archives Studies-links)
The Canadian heart failure study covered patients who died in the years 2000-2006. There were about 33,000 in the final study population. Most of them had multiple chronic conditions in addition to heart failure and in 2006, 76% had at least one hospitalization in the last six months of life, compared to 84% in 2000. Over that time period, the use of outpatient care in the last six months of life increased; the number who died in the hospital decreased from 60% to 54% and all cost categories increased, from about $22,000 per patient to $26,200. The Canadian researchers concluded that Canada has inadequate hospice and other alternative sites of continuing care compared to the US and this causes substantial additional expenditures and lower quality of life for patients.
The US study covered about 230,000 Medicare beneficiaries who died between 2000 and 2007. The most notable finding was that use of hospice care increased from 19% of patients to almost 40%. Notwithstanding this, costs rose from $28,800 to $36,200, roughly a third more than spending on the same patients in Canada. The presence of comorbid conditions increased over the study period, but this could be due to coding changes, as hospitals have become more aggressive in identifying every possible comorbidity. The percent of patients dying in the hospital declined from 40% to 35%. Although hospice use increased dramatically, there was not a corresponding drop in hospitalization use. Notwithstanding negative judgments about the US health care system, it appears that patients with heart failure have better access to palliative care here and are less likely to die in a hospital.
The final study looked at use of hospice care in the US for terminal prostate cancer patients. Use of hospice was associated with less use of hospitalization and other high cost services, but the benefit was not fully realized because often the referral came too late. Because a substantial amount of overall health spending does occur near the end of a patient’s life, especially a high-cost patient, it is worth figuring out how to better manage the care of those patients. Overall, the research indicates that most people prefer palliative type care, which generally has lower costs and may even lead to longer survival times. Policymakers need to ignore “death panel” type rhetoric and encourage the use of end-of-life care that identifies and is consistent with patient desires and provides the best quality of life.