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

Anand S Iyer; Christine A Goodrich; Mark T Dransfield; Shama S Alam; Cynthia J Brown; C Seth Landefeld; Marie A Bakitas; Jeremiah R Brown

doi:10.1016/j.amjmed.2019.11.024

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

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

Authors

Anand S Iyer¹, Christine A Goodrich², Mark T Dransfield³, Shama S Alam², Cynthia J Brown⁴, C Seth Landefeld⁵, Marie A Bakitas⁶, Jeremiah R Brown⁷

Affiliations

¹ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Center for Outcomes and Effectiveness Research and Education, Department of Medicine University of Alabama at Birmingham, Birmingham, AL; Lung Health Center, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. Electronic address: aiyer@uabmc.edu.
² The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH.
³ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Lung Health Center, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Veterans Affairs Medical Center, Birmingham, AL.
⁴ Veterans Affairs Medical Center, Birmingham, AL; Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL.
⁵ Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL.
⁶ Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; School of Nursing, University of Alabama at Birmingham, Birmingham, AL.
⁷ Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Lebanon, NH; Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Lebanon, NH.

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.

Publication types

Multicenter Study
Research Support, N.I.H., Extramural
Research Support, U.S. Gov't, P.H.S.

MeSH terms

Aged
Cost-Benefit Analysis
Female
Health Expenditures / statistics & numerical data*
Humans
Male
Patient Acceptance of Health Care / statistics & numerical data*
Pulmonary Disease, Chronic Obstructive / economics
Pulmonary Disease, Chronic Obstructive / therapy*
Retrospective Studies
Terminal Care / economics*
United States

Abstract

Publication types

MeSH terms

Grants and funding