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Due to greater attention to palliative or comfort care and use of hospice services, fewer Medicare patients die in an acute care hospital than in the past. However, those who do die while in the hospital are being treated more intensively and expensively, according to a study supported by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00028).
Between 1985 and 1999, the proportion of Medicare fee-for-service (FFS) patients dying in a hospital decreased from 44.4 percent to 39.3 percent. Yet the likelihood of being admitted to an intensive care unit (ICU) or undergoing an intensive procedure such as cardiopulmonary resuscitation (CPR) during the terminal hospitalization increased from 38 to 39.8 percent and from 17.8 to 30.3 percent, respectively.
Amber E. Barnato, M.D., M.P.H., of the University of Pittsburgh, and her colleagues used Medicare MedPAR files from 1985-1999 for 20 percent of all elderly FFS Medicare patients who died in the hospital and 5 percent of all survivors to calculate rates of ICU and intensive procedure use. Real inpatient expenditures for the Medicare FFS population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999. One-fourth of these expenditures were for people who died in the hospital. Net hospital expenditures for the dying might have been even higher if the shift toward hospice care had not occurred.
During this period, the proportion of Medicare patients with at least one ICU admission increased from 30.5 percent to 35 percent among decedents and from 5 to 7.1 percent among survivors; those undergoing one or more intensive procedures increased from 20.9 percent to 31 percent among decedents and from 5.8 to 8.5 percent among survivors. Most intensive procedures were performed in the more numerous survivors. Nevertheless, in 1999, 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of CPRs were in decedents.
See "Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life," by Dr. Barnato, Mark B. McClellan, M.D., Ph.D., Christopher R. Kagay, and Alan M. Garber, M.D., Ph.D., in the April 2004 Health Services Research 39(2), pp. 363-375.
Editor's Note: Another AHRQ-supported study on a related topic found that only 2 percent of elderly community-dwelling patients arrived at the hospital both terminally ill and cognitively impaired, suggesting the limited usefulness of advance care directives for this population compared with nursing home residents. For more details, see Dexter, P.R., Wolinsky, F.D., Gramelspacher, G.P., and others (2003, Fall). "Opportunities for advance directives to influence acute medical care." (AHRQ grant HS07632). Journal of Clinical Ethics 14(3), pp. 173-182.
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