academyhealth 2007 gender differences in healthcare utilization at the end-of life andrea kronman,...
TRANSCRIPT
AcademyHealth 2007AcademyHealth 2007
Gender Differences in Gender Differences in Healthcare Utilization at the Healthcare Utilization at the
End-of LifeEnd-of Life
Andrea Kronman, MD MSc
Boston University BIRCWH Faculty ScholarWomen’s Health and Health Care Research Units
General Internal MedicineBoston University School of Medicine
Background Background Healthcare at the end-of-life Healthcare at the end-of-life
• Symptoms are under treatedSymptoms are under treated• Procedures are over usedProcedures are over used• 30% of Medicare revenues spent on 6% of beneficiaries30% of Medicare revenues spent on 6% of beneficiaries
MedicareMedicare Pressures to control costs and improve qualityPressures to control costs and improve quality Adequate hospitalization coverageAdequate hospitalization coverage Less adequate outpatient servicesLess adequate outpatient services Changes to Medicare likely to affect women moreChanges to Medicare likely to affect women more
Women, in contrast to menWomen, in contrast to men Live longer with more debilitating chronic illnessLive longer with more debilitating chronic illness Use more long-term and outpatient careUse more long-term and outpatient care Use more primary careUse more primary care
Adjusted for age, sex, race, Medicaid, nursing home use, comorbidity, geographic variation (HSA) *P< 0.05 **P< 0.001
Previous WorkPrevious WorkRelationship of previous primary care visits and
use of hospital services at the end of life
10
12
14
16
18
Hospital Days
Number of Primary Care Visits
0 1-2 3-5 6-8 > 9
TotalHospital
Days
**
**
**
**
*
Total Costs
$20,000
$21,000
$22,000
$23,000
$24,000
$25,000
$26,000
$27,000
$28,000
AcademyHealth 2007AcademyHealth 2007
Study QuestionsStudy Questions
1.1. Are there gender differences in utilization of Are there gender differences in utilization of health services at the end of life (EOL)?health services at the end of life (EOL)?
• Primary carePrimary care• Hospital servicesHospital services
2.2. Does the relationship between previous Does the relationship between previous primary care and end-of-life hospital use differ primary care and end-of-life hospital use differ for men and women?for men and women?
death
outcomespredictorscovariates
6 months (EOL)12 month (pre-period)
Study DesignRetrospective analysis of Medicare beneficiaries during their last 18 months of life
MethodsMethods
Study Sample• 78,353 Medicare beneficiaries• Random sample of beneficiaries• Minorities over-sampled• Exclusions: < 66 years old, in ESRD program,
non-continuous Medicare A/B
Predictors• Gender• Number of primary care visits
Outcome• Number of Hospital Days
Covariates• Age• Race• Medicaid receipt• Nursing home use• Comorbidity (DCG score)
Cluster Analysis • Fixed Effects Regression• Geographic Unit: Hospital Service Area (HSA)
Results Results Are there gender differences in use of health services
at the end of life?
Pre-period Characteristic
Total
N 78,356
%
Mean age (STD)
80.9 (8.1)
Race
White, % 40
Black, % 36
Hispanic, % 11
Other, % 14
Medicaid receipt, % 32
Nursing home use,% 13
Mean comorbidity risk score (STD)
2.2 (1.7)
Number of PC Visits %
0 38
1-2 22
3-5 19
6-8 10
>9 11
Pre-period Characteristic
Total
N 78,356
%
Mean age (STD)
80.9 (8.1)
Race
White, % 40
Black, % 36
Hispanic, % 11
Other, % 14
Medicaid receipt, % 32
Nursing home use,% 13
Mean comorbidity risk score (STD)
2.2 (1.7)
Number of PC Visits %
0 38
1-2 22
3-5 19
6-8 10
>9 11
Total Male Female
78,356 34,302 44,054
44 56
80.9 (8.1)
79.1 (7.6)
82.3 (8.2)
40 39 40
36 36 37
11 11 10
14 14 14
32 25 38
13 11 14
2.2 (1.7)
2.2 (1.7)
2.2 (1.7)
38 42 34
22 22 22
19 18 20
10 9 11
11 9 12
Total Male Female
78,356 34,302 44,054
44 56
80.9 (8.1)
79.1 (7.6)
82.3 (8.2)
40 39 40
36 36 37
11 11 10
14 14 14
32 25 38
13 11 14
2.2 (1.7)
2.2 (1.7)
2.2 (1.7)
38 42 34
22 22 22
19 18 20
10 9 11
11 9 12
Results Results Are there gender differences in use of health services
at the end of life?
Unadjusted End-Of-Life Utilization
Total Male Female
Mean total hospital days (STD)
15.1 (20.2)
15.3 (20.3)
15.0 (20.1)
Mean total costs, $ 1000 (STD)
24.8 (30.9)
25.4 (32.4)
24.4 (28.8)
Any hospital admission, % 74 74 74
Adjusted for age, sex, race, Medicaid, nursing home use, comorbidity, geographic variation (HSA) *P < .01
*
Primary Care Visits Associated With Fewer Hospital Days at End of Life
12.0
13.0
14.0
15.0
16.0
17.0
0 1-2 3-5 6-8 > 9
Number of Primary Care Visits
Ho
spit
al D
ays
male
female*
*
*
*
Results Results Does the relationship between previous primary care and
hospital use differ for men and women?
1. At the end-of-life, women had greater numbers of primary care visits
2. After a threshold of 3 – 5 primary care visits, more prior primary care visits were associated with less hospital use at the end of life Association is stronger for women
3. Men with 0 primary care visits were less likely to be admitted and had fewer hospital days
ConclusionsConclusions
LimitationsLimitations
Administrative data does not contain:Administrative data does not contain:• Clinical severityClinical severity• Patient preferencesPatient preferences• Content of the primary care visitsContent of the primary care visits• Nature of patient-provider interactionsNature of patient-provider interactions
Long term nursing residents not identifiedLong term nursing residents not identified• Nursing home use = Nursing home use =
Medicare skilled nursing facility (SNF) benefitMedicare skilled nursing facility (SNF) benefit
AcademyHealth 2007AcademyHealth 2007
ImplicationsImplications More access to primary care at the end of life More access to primary care at the end of life
may improve quality of life by decreasing may improve quality of life by decreasing hospital timehospital time Especially for womenEspecially for women
Validation of such findings could justify Validation of such findings could justify increased payment for primary care by increased payment for primary care by MedicareMedicare
Understanding gender differences in healthcare Understanding gender differences in healthcare utilization could increase efficiency of utilization could increase efficiency of healthcare delivery at the end of life healthcare delivery at the end of life
AcknowledgmentsAcknowledgments
Arlene S Ash1
Karen M Freund1
Emanuel J Emanuel2
1 Women’s Health and Health Care Research Units, General Internal Medicine, Boston University School of Medicine2 Dept. of Clinical Bioethics, The Clinical Center, National Institutes of Health, Bethesda, MD
This study was funded by the Office of Research on Women’s This study was funded by the Office of Research on Women’s Health (ORWH) K12-43444, with support from the Centers for Health (ORWH) K12-43444, with support from the Centers for
Medicare and Medicaid Services (CMS) and the National Medicare and Medicaid Services (CMS) and the National Cancer InstituteCancer Institute
AcademyHealth 2007AcademyHealth 2007
Financial Considerations 2001Financial Considerations 2001
Medicare spent an average of Medicare spent an average of $1,200 per day for hospital bed $1,200 per day for hospital bed $87 per level 4 primary care visit (2002)$87 per level 4 primary care visit (2002)
533,000 FFS Medicare beneficiaries died 533,000 FFS Medicare beneficiaries died in the hospitalin the hospital
Decreasing just 1 day in the hospital for Decreasing just 1 day in the hospital for each of these beneficiaries at the end of each of these beneficiaries at the end of life would have saved $648 million.life would have saved $648 million.
*P < 0.01
*
**
**
* *
Adjusted for age, race, comorbidity, Medicaid receipt, and nursing home useReference = Men with 0 primary care visits
*P < 0.01
Primary Care Visits Mediate Likelihood of Hospital Admission
0.5
1
1.5
0 1-2 3-5 6-8 > 9
Number of Primary Care Visits
Ad
just
ed
Od
ds
Rat
io
male
female
*
*
*
* *
Adjusted for age, race, comorbidity, Medicaid receipt, and nursing home usePrimary Care Visits measured during months 18 – 7 before deathHospital Days measured during the last 6 months of lifeReference = Men with 0 primary care visits
**
*P < 0.01
Primary Care Visits Mediate Likelihood of Hospital Admission
0.5
1
1.5
0 1-2 3-5 6-8 > 9
Number of Primary Care Visits
Ad
just
ed
Od
ds
Rat
io
male
female
*
*
*
* *
Adjusted for age, race, comorbidity, Medicaid receipt, and nursing home usePrimary Care Visits measured during months 18 – 7 before deathHospital Days measured during the last 6 months of lifeReference = Men with 0 primary care visits
**
Results 2Results 2Does the relationship between previous primary care and
hospital use differ for men and women?