Association of Advance Care Planning Visits With Intensity of Health Care for Medicare Beneficiaries With Serious Illness at the End of Life.
Association of Advance Care Planning Visits With Intensity of Health Care for Medicare Beneficiaries With Serious Illness at the End of Life.
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DOI：
10.1001/jamahealthforum.2021.1829
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发表时间：
2021-07
期刊：
影响因子：
--
通讯作者：
Manful A
中科院分区：
文献类型：
--
作者：
Weissman JS;Reich AJ;Prigerson HG;Gazarian P;Tjia J;Kim D;Rodgers P;Manful A
对于患有严重疾病的Medicare受益人，预先付费的护理计划（ACP）访视与生命末期（EOL）密集使用医疗保健服务有何关联？在这项队列研究中，对2017年和2018年死亡的955777名患有严重疾病的医疗保险受益人的索赔数据进行了研究，在死者的EOL过程中但在生命的最后一个月之前发生的ACP访问相对罕见。然而，它们的发生与较少密集使用EOL医疗保健服务有关。这项队列研究的结果表明，ACP与EOL医疗保健服务的使用强度较低相关。预先护理计划（ACP）的目的是最大限度地与临终（EOL）护理的一致性的偏好，并被认为会导致医疗保健服务的密集使用。医疗保险和医疗补助服务中心于2016年开始向临床医生报销与患者进行ACP讨论的费用。确定计费ACP访视是否与EOL时密集使用医疗保健服务相关。这项对重症患者的前瞻性患者水平队列分析包括2016年1月1日至12月31日期间符合严重疾病标准并于2017年1月1日至2018年12月31日期间死亡的医疗保险付费服务受益人。分析于2020年11月1日至2021年3月31日完成。使用的EOL医疗保健服务的五项指标（死亡后30天内住院、急诊科就诊和/或重症监护室住院;院内死亡;首次临终关怀账单的时间）和EOL支出的一项指标。对年龄、种族和民族、性别、Charlson Comorbid指数、Medicare-Medicaid双重资格和医院转诊区域（高、中或低）的支出进行了调整。主要暴露是接受分类为无、及时（死亡前>1个月）或延迟（死亡前≤1个月首次ACP访视）的ACP服务。在2016年符合严重疾病标准并于2017年或2018年死亡的955777名医疗保险受益人中，522737人（54.7%）为女性，764666人（80.0%）为75岁或以上，822684人（86.1%）为非西班牙裔白色人。在研究人群中，81131例（8.5%）接受了及时的ACP访视，另外22804例（2.4%）接受了晚期ACP访视。在多变量调整后，与未进行任何收费ACP访视的患者相比，及时进行ACP访视的患者在5项指标中的4项（包括院内死亡）上经历的强化EOL护理显著较少（调整的比值比[aOR]，0.85; 95% CI，0.84-0.87），住院（aOR，0.84; 95%CI，0.83-0.85）、入住重症监护室（aOR，0.87; 95%CI，0.85-0.88）和急诊科就诊（OR，0.83; 95%CI，0.82-0.84）。仅注意到晚期临终关怀使用或平均总EOL支出的微小或不显著差异。与无ACP的患者相比，晚期ACP患者经历了更多强化的EOL护理，包括院内死亡（aOR，1.22; 95% CI，1.19-1.26），住院（aOR，5.28; 95% CI，5.07-5.50），入住重症监护室（aOR，1.57; 95% CI，1.53-1.62）和急诊科就诊（aOR，3.87; 95% CI，3.72-4.02）。在这项针对美国医疗保险受益人的队列研究中，在严重疾病患者的EOL过程中使用ACP服务的情况相对少见，但如果发生在生命的最后一个月之前，则与EOL服务的使用强度较低相关。建议进一步研究影响临终关怀使用和支出的变量在EOL期间和晚期ACP的差异效应，以了解ACP在实现目标一致的护理的相对作用。这项队列研究检验了一个假设，即在患有严重疾病的医疗保险受益人中，预先付费的护理计划访视与较少密集使用临终医疗保健服务相关。
What is the association of a billed advance care planning (ACP) visit with intensive use of health care services at the end of life (EOL) for Medicare beneficiaries with serious illness? In this cohort study of claims data of 955 777 Medicare beneficiaries with serious illness who died in 2017 and 2018, billed ACP visits that occurred during the decedents’ EOL course but before the last month of life were relatively uncommon. However, their occurrence was associated with less intensive use of EOL health care services. The findings of this cohort study suggest that ACP is associated with less intensive use of EOL health care services. Advance care planning (ACP) is intended to maximize the concordance of preferences with end-of-life (EOL) care and is assumed to lead to less intensive use of health care services. The Centers for Medicare & Medicaid Services began reimbursing clinicians for ACP discussions with patients in 2016. To determine whether billed ACP visits are associated with intensive use of health care services at EOL. This prospective patient-level cohort analysis of seriously ill patients included Medicare fee-for-service beneficiaries who met criteria for serious illness from January 1 to December 31, 2016, and died from January 1, 2017, to December 31, 2018. Analyses were completed from November 1, 2020, to March 31, 2021. Five measures of EOL health care services used (inpatient admission, emergency department visit, and/or intensive care unit stay within 30 days of death; in-hospital death; and timing of first hospice bill) and a measure of EOL expenditures. Analyses were adjusted for age, race and ethnicity, sex, Charlson Comorbidity Index, Medicare-Medicaid dual eligibility, and expenditure by hospital referral region (high, medium, or low). The primary exposure was receipt of a billed ACP service classified as none, timely (>1 month before death), or late (first ACP visit ≤1 month before death). Of the 955 777 Medicare beneficiaries who met criteria for serious illness in 2016 and died in 2017 or 2018, 522 737 (54.7%) were women, 764 666 (80.0%) were 75 years or older, and 822 684 (86.1%) were non-Hispanic White individuals. Among the study population, 81 131 (8.5%) had a timely ACP visit, and an additional 22 804 (2.4%) had a late ACP visit. After multivariable adjustment, compared with patients without any billed ACP visit, patients with a timely ACP visit experienced significantly less intensive EOL care on 4 of 5 measures, including in-hospital death (adjusted odds ratio [aOR], 0.85; 95% CI, 0.84-0.87), hospital admission (aOR, 0.84; 95% CI, 0.83-0.85), intensive care unit admission (aOR, 0.87; 95% CI, 0.85-0.88), and emergency department visit (OR, 0.83; 95% CI, 0.82-0.84). Only small or insignificant differences in late hospice use or mean total EOL expenditures were noted. Compared with patients without ACP, patients with late ACP experienced more intensive EOL care, including in-hospital death (aOR, 1.22; 95% CI, 1.19-1.26), hospital admission (aOR, 5.28; 95% CI, 5.07-5.50), intensive care unit admission (aOR, 1.57; 95% CI, 1.53-1.62), and emergency department visit (aOR, 3.87; 95% CI, 3.72-4.02). In this cohort study of US Medicare beneficiaries, billed ACP services during the EOL course of patients with serious illness were relatively uncommon, but if they occurred before the last month of life, they were associated with less intensive use of EOL services. Further research on the variables affecting hospice use and expenditures in the EOL period and the differential effect of late ACP is recommended to understand the relative role of ACP in achieving goal-concordant care. This cohort study tests the hypothesis that having a billed advance care planning visit is associated with less intensive use of end-of-life health care services among Medicare beneficiaries with serious illness.
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