End-of-life Health-Care Utilization Patterns Among Chronically Ill Older Adults

Abstract

Patients with chronic illness are associated with high health-care utilization and this is exacerbated in the end of life, when healthcare utilization and costs are highest. Complex Care Management (CCM) is a model of care developed to reduce health-care utilization, while improving patient outcomes. We aimed to examine the relationship between health-care utilization patterns and patient characteristics over time in a sample of older adults enrolled in CCM over the last 2 years of life. Generalized estimating equation models were used. The sample (n ¼ 126) was 52% female with an average age of 85 years. Health-care utilization rose sharply in the last 3 months of life with at least one hospitalization for 67% of participants and an emergency department visit for 23% of participants. In the last 6 months of life, there was an average of 2.17 care transitions per participant. The odds of hospitalization increased by 27% with each time interval (P < .001). Participants demonstrated 11% greater odds of having a hospitalization for each additional comorbidity (P ¼ .05). A primary diagnosis of heart failure or coronary artery disease was associated with 21% greater odds of hospitalization over time compared to other primary diagnoses (P ¼ .017). Females had 70% greater odds of an emergency department visit compared to males (P ¼ .046). For each additional year of life, the odds of an emergency department visit increased by about 7% (P < .001). Findings suggest the need for further interventions targeting chronically ill older adults nearing end of life within CCM models.

Healthcare Resources Utilization throughout the Last Year of Life after Acute Myocardial Infarction

“…Our findings of significant increase in HRU prior to death, specifically of hospitalbased resources, are consistent with previous reports dealing with patients with various morbidities [8,[15][16][17]. Although a primary diagnosis of HF or coronary artery disease (CAD), during the last 2-years of life, has previously been reported to be associated with a greater odds of hospitalization over time compared to other primary diagnoses [9], to our knowledge, this is the first report focusing specifically on AMI survivors. Nevertheless, HRU and costs towards the end of life were meticulously investigated among patients with HF, which is often the result of CAD and an AMI [16,17].…”

“…Consistent with our findings, the following characteristics of patients with HF and other chronic illness were associated with greater resource utilization at the end of life: women, elderly (mostly "younger old" age-groups), and patients with greater comorbidity burden [8,9,11,16]. Other reports, however, have shown reduced utilization of hospitalcentered healthcare services in the last year of life among very old patients and those with dementia [11,18].…”

“…Nevertheless, these patients continue to be at increased risk for mortality and morbidity and hence utilize more healthcare services [5][6][7]. Multiple studies among patients with cardiac diseases (e.g., heart failure [HF] and congenital heart disease) demonstrate that health resource utilization (HRU) peaks in the last year of life, accounts for a substantial share of healthcare expenditure compared to other periods of life, and seems to be increasing over the last decade [8][9][10][11]. Furthermore, it has been previously estimated that one-quarter of all Medicare costs (US) goes to treating patients in their last year of life [12].…”

Can we determine burdensome transitions in the last year of life based on time of occurrence and frequency? An explanatory mixed-methods study

“…The sharp rise of transitions towards the end of life, especially hospitalizations, was congruent with international data (Aaltonen et al, 2010; Greenle et al, 2019). The amount of transitions reported indicates potential problems concerning continuity and quality of care.…”