AIM: Use of healthcare resources drastically increases at end of HF patients' lives
Medicare beneficiaries with heart failure (HF) frequently utilize healthcare resources in the last six months of life, and use of medical resources and hospice has increased, particularly for intensive care, according to a study published online Oct. 11 in the Archives of Internal Medicine.

“Heart failure is a common cause of death among Medicare beneficiaries, but little is known about healthcare resource use at the end of life,” the authors wrote. Additionally, they reported that over a quarter of Medicare spending occurs in the last year of life.

To calculate healthcare resource use and costs for HF patients at the end of life, Kathleen T. Unroe, MD, of the Duke Clinical Research Institute in Durham, N.C., and colleagues utilized a 229,543 patient cohort of Medicare beneficiaries with HF who died between Jan. 1, 2000, and Dec. 31, 2007, to examine resource use in the last 180 days of life.

The researchers evaluated all-cause hospitalizations, intensive care unit days, skilled nursing facility stays, home health, hospice, durable medical equipment, outpatient physician visits and cardiac procedure rates, as well as overall Medicare costs.

The patients in the cohort had an average age of 83 years at death; one-quarter were above the age of 90. Additionally, the researchers found that the presence of comorbid conditions increased, with 61 percent having four or more conditions in 2000, and 73 percent in 2007.

Unroe and colleagues found that 80 percent of these patients were hospitalized in the last six months prior to death with days in intensive care increasing from 3.5 days to 4.6 days.

Additionally, the researchers found that hospice use had increased from 19 percent to almost 40 percent, and the number of days spent in hospice increased from 36.5 days to 44 days in 2000 to 2007, respectively. From 2000 to 2007, the mean cost of hospice care per patient more than doubled, from $964 to $2,594.

The mean costs to Medicare per patient rose by 26 percent from $28,766 to $36,216. After the researchers adjusted for age, sex, race, comorbid conditions and geographic region, these costs to Medicare rose by 11 percent.

The researchers reported that older age was independently associated with lower Medicare costs, while renal disease, chronic obstructive pulmonary disease and black race were strong independent predictors of higher costs to Medicare.

Unroe et al also reported that costs to Medicare of physician services increased by 24 percent, from $4,319 in 2000 to $5,334 in 2007.

While the number of patients who died in-hospital decreased from 40.2 percent to 35.2 percent, those admitted to the intensive care unit increased from 42.4 percent to 50.2 percent, from 2000 to 2007, respectively.

“Rates of inpatient hospitalization remained high, suggesting that the potential for hospice to prevent costly hospitalization has yet to be fully realized,” the authors wrote. “It remains unclear whether hospice services as a complement to or a substitution for usual acute care.”

The researchers speculated that the rising medical costs could be attributed to the increased use of medical tests and procedures in the elderly population. While rates of cardiac procedures such as CABG, pacemaker placement or ICD implantation remained steady, rates of echocardiography increased.

Additionally, the researchers said that “this analysis of resource use and costs associated with HF at the end of life has both clinical and policy implications,” and said that discussion of the goals of care should be considered an inpatient measure of quality for HF patients.

“Current measures endorsed by CMS include provision of instructions at discharge, assessment of left ventricular function, angiotensin-converting enzyme inhibitor or angiotensin receptor blockers at discharge, and smoking cessation counseling,” the authors concluded. “It will be critical to show that discussions of goals of care have the desired effects on patient-centered outcomes.”