TY - JOUR T1 - Disability and decline in physical function associated with hospital use at end of life. JF - J Gen Intern Med Y1 - 2012 A1 - Amy Kelley A1 - Susan L Ettner A1 - R Sean Morrison A1 - Qingling Du A1 - Catherine A Sarkisian KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Chronic disease KW - Dementia KW - Disability Evaluation KW - Disabled Persons KW - Female KW - Frail Elderly KW - Geriatric Assessment KW - Hospitalization KW - Humans KW - Length of Stay KW - Longitudinal Studies KW - Male KW - Medicare KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

BACKGROUND: Hospital use near the end of life is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions.

OBJECTIVE: To concurrently examine regional and patient factors, including disability and functional decline, associated with end-of-life hospital use.

DESIGN/PARTICIPANTS: We sampled decedents aged 65 and older (n = 2,493) from the Health and Retirement Study (2000-2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last 6 months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI).

KEY RESULTS: Median hospital days was 7 (range = 0-183). 53% of respondents had functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47-9.05, depending on category). Dementia was associated with fewer days (-3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27).

CONCLUSIONS: Functional decline is significantly associated with end-of-life hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.

PB - 27 VL - 27 IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22382455?dopt=Abstract U2 - PMC3378753 U4 - Public Policy/Medicare/end of life/Functional decline/Functional decline/Hospital Care Intensity Index/Hospital Care Intensity Index/end-of-life ER - TY - JOUR T1 - Determinants of medical expenditures in the last 6 months of life. JF - Annals of Internal Medicine Y1 - 2011 A1 - Amy Kelley A1 - Susan L Ettner A1 - R Sean Morrison A1 - Qingling Du A1 - Neil S. Wenger A1 - Catherine A Sarkisian KW - Aged KW - Aged, 80 and over KW - Chronic disease KW - Ethnic Groups KW - Female KW - Health Expenditures KW - Humans KW - Income KW - Independent Living KW - Male KW - Medicare KW - Regression Analysis KW - Social Support KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

BACKGROUND: End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs.

OBJECTIVE: To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation.

DESIGN: Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics.

SETTING: United States, 2000 to 2006.

PARTICIPANTS: 2394 Health and Retirement Study decedents aged 65.5 years or older.

MEASUREMENTS: Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics.

RESULTS: Decline in function (rate ratio [RR], 1.64 [95% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for.

LIMITATION: The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation.

CONCLUSION: Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics.

PRIMARY FUNDING SOURCE: The Brookdale Foundation.

VL - 154 IS - 4 ER -