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Multicenter Study
. 2020 Jul;133(7):817-824.e1.
doi: 10.1016/j.amjmed.2019.11.024. Epub 2019 Dec 27.

End-of-Life Spending and Healthcare Utilization Among Older Adults with Chronic Obstructive Pulmonary Disease

Anand S Iyer  1 , Christine A Goodrich  2 , Mark T Dransfield  3 , Shama S Alam  2 , Cynthia J Brown  4 , C Seth Landefeld  5 , Marie A Bakitas  6 , Jeremiah R Brown  7
Affiliations
Multicenter Study

End-of-Life Spending and Healthcare Utilization Among Older Adults with Chronic Obstructive Pulmonary Disease

Anand S Iyer et al. Am J Med. 2020 Jul.

Abstract

Background: End-of-life spending and healthcare utilization among older adults with COPD have not been previously described.

Methods: We examined data on Medicare beneficiaries aged 65 years or older with chronic obstructive pulmonary disease (COPD) who died during the period of 2013-2014. End-of-life measures were retrospectively reviewed for 2 years prior to death. Hospital referral regions (HRRs) were categorized into quintiles of age-sex-race-adjusted overall spending during the last 2 years of life. Geographic quintile variation in spending and healthcare utilization was examined across the continuum.

Results: We investigated data on 146,240 decedents with COPD from 306 HRRs. Age-sex-race-adjusted overall spending per decedent during the last 2 years of life varied significantly nationwide ($61,271±$11,639 per decedent; range: $48,288±$3,665 to $79,453±$9,242). Inpatient care accounted for 40.2% of spending ($24,626±$6,192 per decedent). Overall, 82%±4% of decedents were admitted to the hospital for 13.7±3.1 days, and 55%±11% were admitted to an intensive care unit for 5.4±2.5 days. Compared with HRRs in the lowest spending quintile, HRRs in the highest spending quintile had a 1.5-fold longer hospital length of stay. Skilled nursing facilities accounted for 11.6% of spending ($7101±$2403 per decedent), and these facilities were utilized by 38%±7% of decedents for 18.7±4.9 days. Hospice accounted for 10.3% of spending ($6,307±$2,201 per decedent) and was utilized by 47%±9% of decedents for 39.7±14.8 days. Significant geographic variation in hospice utilization existed nationwide.

Conclusions: End-of-life spending and healthcare utilization among older adults with COPD varied substantially nationwide. Decedents with COPD frequently utilized acute care near the end of life. Hospice utilization was higher than expected, with significant geographic disparities.

Keywords: Chronic obstructive pulmonary disease; Cost, Healthcare utilization, Hospice, Palliative care.

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Conflict of interest statement

Conflicts of Interest: ASI is supported by an AHRQ K12 (K12HS023009) awarded to the Center for Outcomes and Effectiveness Research and Education (COERE) at the University of Alabama at Birmingham, and by a Palliative Research Enhancement Project (PREP) pilot award from the UAB Center for Palliative and Supportive Care. CJB is supported by a VA Rehabilitation R&D Scientific Merit Award. MTD is supported by grants from NIH (1K24HL140108), Department of Defense, American Lung Association, contracted clinical trials from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, PneumRx/BTG, Pulmonx, and reports consulting from AstraZeneca, GlaxoSmithKline, Mereo, PneumRx/BTG, and Quark. MAB is supported by NR013665–01A1, NR011871–01, PCORI PLC-1609–36381, PLC-1609–36714. CAG, SSA, CSL, and JEB have no conflicts to report.

Figures

Figure 1.
Figure 1.. Variation in Overall Medicare Spending Among Older Adults with COPD During the Last Two Years of Life.
(a) This map illustrates geographic variation across the US in Medicare spending per decedent during the last two years of life. HRRs are color-coded across quintiles of increasing spending. (b) This turnip plot demonstrates the distribution in mean overall spending per decedent within and across spending quintiles.
Figure 2.
Figure 2.. Variation in Categorical Spending Across Spending Quintiles for Older Adults with COPD.
This graph demonstrates the variation in mean spending per decedent across spending quintiles during the last two years of life for the following categories: a) Part B; b) skilled nursing facility; c) long-term care; d) home health agency; e) outpatient facility; and f) hospice.
Figure 3.
Figure 3.. Hospice Use During the Last Two Years of Life for Older Adults with COPD.
(a) This map illustrates the variation in hospice use in the last two years for older adults with COPD across the US. (b) This turnip plot demonstrates the variation in hospice use within and across spending quintiles.
See this image and copyright information in PMC

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