End-of-life care patterns shift for patients with heart failure in both US and Canada

Health care in the last six months of life has become progressively more expensive for patients with heart failure both among Medicare beneficiaries in the United States and older adults in Canada, with a high rate of hospitalizations in the final six months of life in both countries, according to two reports posted online today that will be published in the February 14 print issue of Archives of Internal Medicine, one of the JAMA/Archives journals. A third report finds that more men dying of prostate cancer are receiving hospice care, but that the timing of hospice referral remains poor.

Heart failure is a common cause of death in both the United States and Canada, according to background information in the articles. The condition is listed on one in eight death certificates in the United States, and the five-year death rate among those hospitalized with heart failure is about 70 percent. "Provision of high-quality health care at the end of life poses challenges for both health care providers and policy makers," the authors write. "End-of-life care has many dimensions, including patient preferences and values, health care provider practices and concerns about the appropriate use of resources. Although most patients prefer to die at home, many die in hospitals or nursing homes. The cost of health care at the end of life is also substantial. More than one-quarter of Medicare spending occurs in the last year of life, a figure that has remained stable for several decades."

In one article, Kathleen T. Unroe, M.D., M.H.A., of Duke Clinical Research Institute, Durham, N.C., and colleagues studied 229,543 Medicare beneficiaries with heart failure who died between 2000 and 2007. They examined resource use in the last six months of life and calculated costs to Medicare.

Over the entire study period, about 80 percent of patients were hospitalized in the last six months of life. Between 2000 and 2007, days in the intensive care unit increased from 3.5 to 4.6, hospice use increased from 19 percent to nearly 40 percent of patients and unadjusted average costs to Medicare per patient increased 26 percent from $28,766 to $36,216. After adjusting for age, sex, race, co-occurring medical conditions and region, costs increased by 11 percent. Older patients tended to have lower costs, while those with kidney disease, lung disease or who were black were more likely to have higher costs.

The trend of increasing hospice use marks a substantial change in end-of-life care, the authors note. "Some studies have found hospice care to be more cost-effective than nonhospice care, but we did not observe lower use of other services as the use of hospice increased," they write. "Rates of inpatient hospitalization remained high, suggesting that the potential for hospice to prevent costly hospitalizations has yet to be fully realized."

In another article, Padma Kaul, Ph.D., of the University of Alberta, Edmonton, Alberta, Canada, and colleagues evaluated data from 33,144 patients in Canada who died of heart failure between 2000 and 2006. They also assessed resource use in the last six months of life along with costs to the national health care system, as Canada has a single-payer system with universal access.