How Can We Get Better Value in End-of-Life Care?

Stanton R. Mehr
Published: Friday, Nov 09, 2012
Today’s healthcare controversies often lead to explosive debates. Few discussions in healthcare can be as incendiary as those concerning the care provided at the end of life. Addressing the real systemic problems seen during a patient’s last weeks is complicated by (1) erroneous, dire characterizations of health reform legislation resulting in “death panels”; (2) the latest evidence of the great health expenditures in the last weeks of life; and (3) questions about care quality in patients with terminal illness.

The philosophy of “keeping hope alive” despite the almost certain likelihood of near-term mortality fuels efforts to continue to try new active treatments right up until the end. On a population-wide basis, fiscal concerns and clinical facts show that this way of thinking cannot be supported for long.

High Costs and Variation in Services

The last year of life is associated with high health expenditures in the United States, and the costs are increasingly focused on patients’ last few months. According to a 2002 landmark study, the last month of life accounts for fully one-third of the health resources expended during the final 12 months.1

In another investigation of 230,000 Medicare patients who died as a result of congestive heart failure from 2000 to 2007, researchers found that the rate of hospitalization in the last 6 months of life was approximately 80%.2 In their study, published in 2011 in the Annals of Internal Medicine, 50% of the patients spent time in the hospital’s intensive care unit (ICU), and mean length of stay in the ICU increased as the study progressed. By 2007, ICU stays for these terminal patients reached nearly 5 days. This translated to an average cost per patient of $36,000 (in 2007).2

Complicating the issue is the variance in most healthcare costs from one geographic location to another. The same is true with end-of-life care. In 2008, the Dartmouth College group led by John Wennberg, MD,3 revealed that in patients with serious chronic diseases (including cancer) treated at one of 3000 hospitals, costs per patient in the last 2 years of life ranged from $53,432 (Mayo Clinic) to $105,000 (New York University Medical Center). Compared with lower-cost centers, the higher-cost institutions were associated with longer hospital stays, greater ICU use, more doctor and specialist visits, and greater use of other hospital-provided services. The researchers could find no difference in patient outcomes among the centers studied. They speculated that medical centers that received capitated payments or paid their physicians on a salary basis may be less likely to order unnecessary (or nonbeneficial) tests and procedures at the end of life.

Another study found that in-hospital end-of-life care was 65% greater in Los Angeles than in San Diego, and this was principally related to the more aggressive care observed in the Los Angeles institutions.4 The researchers found that “San Diego residents are significantly more likely to die with the assistance of hospice services and less likely to spend time in hospitals and intensive care units during the last 2 years of life.”

Dr. Diane Meier

Diane Meier, MD

Palliative Care, Hospice Care, and the End of Life

In patients with advanced metastatic disease, palliative therapy may be the only remaining option: Relieve the symptoms, ease the pain, and provide the best supportive care possible, with “the goal of improving quality of life for both the patient and the family,” said Diane Meier, MD, professor of geriatrics and palliative medicine at the Mount Sinai School of Medicine in New York City.

Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Dr Meier told Evidence-Based Oncology, “Palliative care is appropriate at any stage in a serious illness and can be provided together with curative treatment.” The Sidebar below provides some of the key recommendations from the American College of Physicians, which are backed by solid evidence.

The demand for palliative care has increased significantly, according to a 2012 national poll. The surveyors found that 71% believe that “It is more important to enhance the quality of life for seriously ill patients, even if it means a shorter life.”5

Ample evidence exists that hospice care plays a highly cost-effective role in end-of-life care. It seems that payers agree: “Commercial and government payers reimburse palliative care as in any other physician or advanced practice nurse services. For patients who are clearly dying, hospice is the most appropriate model of palliative care. It is covered by virtually all payers in the United States,” said Dr Meier.


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