Data from the Dartmouth Atlas show patients with chronic illness in their last two years of life account for about 32 percent of total Medicare spending, with much of that expense going toward physician and hospital fees associated with repeated hospitalizations.
Opportunities to reduce medical expenditures during the last 2 years of life are often looked upon as a way to reduce the cost of healthcare while actually improving the quality of life – and death. The rationale? So many of these expensive interventions are associated with a decline in patient experience and are not associated with an improvement in outcomes. Data from the Dartmouth Atlas demonstrate that in those parts of the country where the intensity of care is higher, the patient experience is lower.
A recent review and editorial looked at the variation in spending at the end of life and seek to understand what part of the variation is due to geographic variations (due to local factors such as patient or doctor culture, access to hospice, and the number of hospital beds per capita) and what part of the variation is due to patient specific characteristics.
The idea behind the study was to determine whether targeting particular patient groups might reduce inappropriate variations in care and reduce costs. The patient specific characteristics that are associated with high costs in end-of-life are: functional impairment and decline in function, having a nearby relative, or being black or Hispanic.
The functional decline measure offers an opportunity to start conversations with patients about their prognosis and desires for intervention by screening patient populations with various measures of functional status. Having a relative nearby clearly means families that are geographically close provide either direct care giving or at least support coordination of care and identification of patient wishes. So identifying patients who are declining in function who do not have a relative nearby provides an opportunity. Finally, the black and Hispanic factor is more difficult to understand. Causes may include: differential access to medical services, disparities in preventive care provider continuity, poor quality communication about end-of-life issues, or possibly patient preferences. Further research is needed.
So what does this research, and the rest of the literature suggest we do to improve end-of-life care? Identifying geographic factors gives us a chance to change resource use, such as fewer hospital beds and more hospice services. Identifying patient specific factors gives us the chance to find those that could benefit from a conversation. The quality of that conversation depends on clinicians learning and practicing more shared decision making and completing specific curricula of communication skills. Consulting palliative care physicians and geriatricians can enhance patient decision making. Our patients deserve a greater role in decisions. Caregivers need to find the patients at risk, and offer these resources. Society will benefit with better care and much lower cost.
Mark Novotny is Chief Medical Officer of Cooley Dickinson Hospital in Northampton, MA.
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