Advance Care Planning Claims and Health Care Utilization Among Seriously Ill Patients Near the End of Life

Abstract

Importance: Although advance care planning is known to increase patient and caregiver satisfaction, its association with health care utilization is not well understood.

Objective: To examine the association between billed advance care planning encounters and subsequent health care utilization among seriously ill patients.

Design, setting, and participants: This retrospective cohort study conducted from October 1, 2015, to May 31, 2018, used a national commercial insurance claims database to retrieve data from 18 484 Medicare Advantage members 65 years or older who had a claim that contained a serious illness diagnosis.

Exposure: A claim that contained an advance care planning billing code between October 1, 2016, and November 30, 2017.

Main outcomes and measures: Receipt of intensive therapies, hospitalization, emergency department use, hospice use, costs, and death during the 6-month follow-up period.

Results: The final study sample included 18 484 seriously ill patients (mean [SD] age, 79.7 [7.9] years; 10 033 [54.3%] female), 864 (4.7%) of whom had a billed advanced care planning encounter between October 1, 2016, and November 30, 2017. In analyses adjusted for patient characteristics and a propensity score for advance care planning, the presence of a billed advance care planning encounter was associated with a higher likelihood of hospice enrollment (incidence rate ratio [IRR], 2.52; 95% CI, 2.22-2.86) and mortality (hazard ratio, 2.27; 95% CI, 1.79-2.88) compared with no billed advance care planning encounter. Although patients with billed advance care planning encounters were also more likely to be hospitalized (IRR, 1.37; 95% CI, 1.26-1.49), including in the intensive care unit (IRR, 1.25; 95% CI, 1.08-1.45), they were less likely to receive any intensive therapies (IRR, 0.85; 95% CI, 0.78-0.92), such as chemotherapy (IRR, 0.65; 95% CI, 0.55-0.78). Similar results were observed in a propensity score-matched analysis (99% matched) and in a decedent analysis of patients who died during the 6-month follow-up period.

Conclusions and relevance: Patients with billed advance care planning encounters were more likely than those without these encounters to receive hospice services and less likely to receive any intensive therapies, such as chemotherapy. However, they were also hospitalized more frequently than patients without billed advance care planning encounters. Although these findings were robust to multiple analytic methods, the results may be attributable to residual confounding because of a higher unmeasured severity of illness in the advance care planning group. Additional evidence appears to be needed to understand the effect of advance care planning on these outcomes.

Figure 1.. Patient Cohort Specification

All patients had a claim that contained a diagnosis code for a serious illness during the baseline period of October 1, 2015, to September 30, 2016. Patients with a billed advanced care planning (ACP) encounter during the intake period of October 1, 2016, to November 30, 2017, were included in the ACP group, whereas patients without a billed ACP encounter during the intake period were included in the no ACP group. The earliest date of ACP code use was assigned as the index date for patients in the ACP group. The pseudo-index date for patients in the no ACP group was calculated by adding an offset after their first serious illness diagnosis date that was derived from the distribution of days between the first serious illness diagnosis and first ACP code use in the ACP group. Outcomes were assessed in the 180 days after the index or pseudo-index date.

Figure 2.. Doubly Robust Analysis of Outcomes of Seriously Ill Patients With vs Without a Billed Advance Care Planning Encounter

A propensity score and all covariates listed in Table 1 were included in the regression analysis. Outcomes were measured during the 180-day follow-up period and included hospice enrollment; death; any hospitalization, including hospitalization with intensive care unit (ICU) admission and hospitalization without ICU admission; emergency department (ED) visit; and receipt of any intensive life support therapy, including intubation, gastrostomy tube placement, dialysis, artificial nutrition, and chemotherapy. Incidence rate ratios were not calculated for gastrostomy tube placement or death among decedents because no patients in the advance care planning group had a gastrostomy tube placed and all decedents in both groups died during the follow-up period. For all outcomes, incidence rate ratios were estimated, with the exception of mortality, for which a hazard ratio was estimated. Error bars indicate 95% CIs.