End-of-life care costs continue to climb upward
NEW YORK (Reuters Health) - Health care costs at the end of life show no signs of leveling off, according to new research from the United States and Canada published in the Archives of Internal Medicine.
But other trends over the past decade, including a sharp increase in use of hospice services, could point the way toward bringing these costs down while improving patient care, Dr. Jonathan Bergman of the University of California in Los Angeles, author of one of the studies, told Reuters Health.
"We end up spending about a third of our overall health care resources in the last year of life," Bergman said. "It represents a huge avenue for improvement."
Patients receiving hospice care typically forego life-saving or potentially curative treatments-like chemotherapy for cancer, for example-and instead receive treatment of their symptoms, as well as assistance with their spiritual and social needs. In order for Medicare to cover hospice, a doctor must certify that a patient has six months or less to live.
In his study, Bergman and his colleagues found that while hospice enrollment among dying prostate cancer patients jumped from around 30 percent in 1992 to over 60 percent in 2005, the timing of when they entered hospice didn't change. One-quarter of patients were in hospice for seven days or less, which is "too brief to maximize the benefit of enrollment," the researchers write. Another 10 percent outlived the six-month hospice care guideline.
Bergman and his team did find that hospice patients were about 20 percent less likely to receive high-intensity care, for example admission to the intensive care unit, two or more emergency department visits, or cardiopulmonary resuscitation. They also received fewer imaging tests, which are costly and are known to have no benefit for dying prostate cancer patients.
Evidence suggests that hospice care can cut health care costs, especially for cancer patients, Bergman and his team note, although they did not look at cost in their study.
Another study of dying heart failure patients found, however, that under the current U.S. system, more hospice didn't necessarily mean less spending.
In their study of nearly 230,000 Medicare patients who died of heart failure between 2000 and 2007, Dr. Kathleen T. Unroe of the Duke University School of Medicine in Durham, North Carolina, and her colleagues found that use of hospice "dramatically" increased, from 19 percent in 2000 to nearly 40 percent in 2007. But rates of hospitalization in the last six months of life held steady at around 80 percent.
And more people who were hospitalized spent time in an intensive care unit (ICU), up from 42 percent in 2000 to 50 percent in 2007. Average time in the ICU also increased, from 3.5 to nearly 5 days. Costs rose from about $28,000 per patient for their last six months of life in 2000 to $36,000 in 2007.
"While we are seeing increasing use of hospice, it doesn't seem to really be substituting for a lot of the institutional care, and there's a significant proportion of patients who are in hospice for a very short period," Unroe told Reuters Health. "When people are referred to hospice very late, it's difficult for hospice services to prevent hospitalization and for people really to get the full benefit."
A companion study found that costs for treating dying heart failure patients are on the rise in Canada as well, but not as fast, and likely for different reasons.
Dr. Padma Kaul of the University of Alberta in Edmonton and her colleagues found that while 84 percent of patients were hospitalized in 2000, 76 percent were in 2006. The likelihood of dying in the hospital also fell, from 60 percent to 54 percent. During the same period, costs for outpatient services increased by 75 percent. Overall costs for a dying heart failure patient's last six months of life were, in Canadian dollars, $25,069 in 2000 and nearly $28,000 in 2006.
In Alberta, Kaul noted, hospice services are far from adequate; some 20,000 continuing care and assisted living beds exist to serve the province of Alberta's 330,000 elderly. By providing more hospice beds, she added, the province could likely further reduce hospitalization of dying patients.
Neither Kaul nor Unroe found increases in the use of expensive, invasive heart failure treatments, such as implantable devices for improving the heart's pumping ability or restoring normal heart rhythms, which some health care experts had expected might be behind increases in treatment costs.
All three study authors agree that talking with patients about their wishes for end-of-life care early on is crucial for ensuring that patients get the care they want.
People may fear going into hospice because it requires them to acknowledge that they have six months or less to live, Unroe noted. "I think hospice is a wonderful benefit, but the rules and restrictions surrounding it do make it difficult for some physicians and patients to work with it."
Palliative care is another key option, and involves treating the symptoms of an illness, whether or not a person is terminally ill. "Palliative care is actually a much more broad set of services for people with chronic, incurable diseases who have difficult-to-manage symptoms," she explained, and as such is well-suited to patients with heart failure.
"This is a disease that can be unpredictable. People can live with heart failure for years, and other people will die more quickly," Unroe said.
"We might be able to do a better job with end of life care and cut costs not by rationing care but by making it more rational and treating each patient based on their original goals," Bergman said.
Right now, he added, "We do these expensive things that may not improve someone's quality of life or the quality of death, but we do it anyway."
In an editorial accompanying the study, Rosemary Gibson, who led the Robert Wood Johnson Foundation's efforts to improve end-of-life care, echoes the sentiment. "High-quality palliative care-provided in hospitals, nursing homes, at home, or in hospice-can help patients understand their illness and make informed decisions about their care, together with their families."
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