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12-10-2010 | Cardiology | Article

End-of-life costs for HF patients ‘spiraling upwards’



MedWire News: End-of-life costs for patients with heart failure (HF) are increasing in Canada and the USA, despite a shift from inpatient to outpatient care, two studies reveal.

One of the studies, results of which are published in the Archives of Internal Medicine, evaluated resource use in the last months of life among 33,144 individuals in Canada, aged 65 years and over and with a diagnosis of HF, who died between January 2000 and December 2006.

During the study period the patients' clinical characteristics changed, report Padma Kaul (University of Alberta, Edmonton, Canada) and colleagues. There were significant increases in rates of comorbid dementia, diabetes mellitus, hypertension, and renal disease, whereas rates of ischemic heart disease, stroke, and peripheral vascular disease fell significantly.

The proportion of patients who were hospitalized in the last 6 months of life fell from 84.0% in 2000 to 76.4% in 2006. The mean length of hospital stay was stable, at around 34 days, while mean hospitalization costs rose from Canadian $21,995 (€15,720) to Canadian $26,186 (€18,720).

Compensating for the reduction in inpatient care, patients who died in later years of the study were substantially more likely to receive outpatient care in the last 6 months of life than those who died in the earlier years (52.8% in 2000 rising to 69.8% in 2006).

The percentage of patients discharged to home care rose significantly, from 15% in 2000 to 18% in 2006, and the likelihood of dying in hospital fell from 60.4% to 54.0%. The authors comment: "Increasing the availability of alternative venues of care, such as long-term care and home care, may be effective in further reducing hospitalizations and containing costs."

In another paper, Kathleen Unroe (Duke Clinical Research Institute, Durham, North Carolina, USA) and colleagues studied resource use in the last 6 months of life for 229,543 US Medicare beneficiaries with HF who died between 2000 and 2007.

Around 80% of the patients were hospitalized in the last 6 months of life. Between 2000 and 2007, days in the intensive care unit increased from 3.5 to 4.6, hospice use increased from 19% to nearly 40% of patients and unadjusted average costs to Medicare per patient increased 26%, from US $28,766 (€20,620) to US $36,216 (€25,960). This was attenuated to an 11% rise after adjusting for age, gender, race, co-occurring medical conditions and region.

The trend of increasing hospice use marks a substantial change in end-of-life care, the authors note. "Some studies have found hospice care to be more cost-effective than nonhospice care, but we did not observe lower use of other services as the use of hospice increased," they write. "Rates of inpatient hospitalization remained high, suggesting that the potential for hospice to prevent costly hospitalizations has yet to be fully realized."

Rosemary Gibson, who led the Robert Wood Johnson Foundation initiative to improve end-of-life care, commented in a related editorial that healthcare use and associated costs appear to have "spiralled upward" since 2000. However, she questioned the assumption that providing more healthcare services responds to patients' wishes for the relief of suffering.

She said: "Only with the explicit goal of relieving the burden of illness, and relieving the burden of treatment, will healthcare systems fulfil their intended purpose of caring for the patient."

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