Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life
Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life
复制标题
DOI：
10.1111/j.1475-6773.2004.00232.x
复制
发表时间：
2004-04-01
影响因子：
3.4
通讯作者：
Garber, AM
中科院分区：
文献类型：
--
作者：
Barnato, AE;McClellan, MB;Garber, AM
Objective.虽然越来越多的医疗保险受益人死在医院外，但在生命的最后一年，医疗保险总支出中用于护理的比例并没有下降。我们试图确定死亡者中医院治疗强度随时间不成比例的增加是否是导致临终支出持续增长的原因。1985-1999年医疗保险医疗提供者分析和审查（MedPAR）和分母文件。研究设计。我们对1985年至1999年间20%的老年按服务付费医疗保险死者和5%的所有幸存者的住院索赔进行了抽样，并计算了经年龄、种族和性别调整的人均住院支出以及重症监护室（ICU）和重症监护程序的使用率。我们使用死亡者与存活者的支出比率来确定死亡者的增长率是否超过存活者的增长率，使用存活者的增长率来控制治疗强度的长期趋势。数据收集。这些数据是由医疗保险和医疗补助服务中心收集的。医疗保险按服务收费人群的真实的住院费用增加了60%，从1985年的580亿美元增加到1999年的900亿美元，其中四分之一是由死者累积的。1985年至1999年期间，有一次或多次入住重症监护病房的受益人比例在死者中从30.5%增加到35.0%，在幸存者中从5.0%增加到7.1%;接受一次或多次强化手术的人在死者中从20.9%增加到31.0%，在幸存者中从5.8%增加到8.5%。在美国，大多数强化手术都是在更多的幸存者中进行的，尽管在1999年，50%的喂食管放置，60%的插管/气管造口术和75%的心肺复苏都是在死者中进行的。在医院死亡的受益人比例从44.4%下降到39.3%，但在终末期住院期间被送进ICU或接受强化治疗的可能性分别从38.0%和17.8%增加到39.8%和30.3%。1999年在医院死亡的五分之一的医疗保险受益人在其最终入院期间接受机械通气。1985年至1999年期间，所有按服务收费的受益人的住院治疗强度都有所增加，无论其存活状况如何。死亡者的人均住院费用、ICU入院和强化住院程序使用的绝对变化要高得多。相对变化是相似的，除了ICU入院，这在幸存者中增长更快。住院死亡率的长期下降并没有导致生命最后一年人均使用昂贵住院服务的减少。这可能意味着，如果没有发生向临终关怀的转变，在这段时间内，死亡的净医院支出可能会更高。
Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures.Data Source. The 1985-1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files.Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents out-paced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity.Data Collection. The data were collected by the Centers for Medicare and Medicaid Services.Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission.Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred.