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Published on: July 12, 2024
Advance Care Planning (ACP) in Medicare Beneficiaries with Heart Failure
Seuli Bose Brill1,2, Sean R Riley3,4,5, Laura Prater5
1Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, 2050 Kenny Road, Columbus, OH, 43215, USA. Seuli.Brill@osumc.edu.
Insights
Advance care planning for heart failure patients is infrequent but may reduce end-of-life healthcare costs. This study found lower total expenditures and inpatient use with advance care planning, alongside increased outpatient service utilization.
Area of Science:
- Gerontology
- Health Services Research
- Palliative Care
Background:
- Heart failure is a leading cause of death in the USA, associated with high end-of-life healthcare expenditures.
- Limited evidence exists on the impact of billed advance care planning (ACP) on healthcare utilization in heart failure patients.
- Large-scale claims data analysis is needed to inform policy and clinical practice regarding ACP in heart failure.
Purpose of the Study:
- To assess the association between billed advance care planning (ACP) and healthcare utilization in the last 30 days of life among Medicare beneficiaries with heart failure.
- To determine the impact of ACP on the type and quantity of end-of-life healthcare services utilized.
Main Methods:
- Retrospective cross-sectional cohort study utilizing Medicare fee-for-service claims from 2016 to 2020.
- Included 48,466 deceased patients diagnosed with heart failure.
- Examined billed ACP services in the last 12 months and 30 days of life as exposure, measuring end-of-life utilization and total expenditure across inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services.
Main Results:
- Advance care planning encounters were present in 4,406 of 48,466 patients (9.1%).
- Total end-of-life expenditure was 19% lower for patients with billed ACP encounters compared to those without.
- Patients with billed ACP showed higher odds of end-of-life outpatient utilization (2.65x) and increased outpatient expenditure (33% higher).
Conclusions:
- Billed advance care planning delivery is infrequent among heart failure patients.
- Prioritizing ACP for heart failure patients may decrease total end-of-life and inpatient expenditures.
- ACP may reduce costs by promoting the use of outpatient end-of-life services, including home healthcare and hospice.
Background:
Heart failure is a leading cause of death in the USA, contributing to high expenditures near the end of life. Evidence remains lacking on whether billed advance care planning changes patterns of end-of-life healthcare utilization among patients with heart failure. Large-scale claims evaluation assessing billed advance care planning and end-of-life hospitalizations among patients with heart failure can fill evidence gaps to inform health policy and clinical practice.
Objective:
Assess the association between billed advance care planning delivered and Medicare beneficiaries with heart failure upon the type and quantity of healthcare utilization in the last 30 days of life.
Design:
This retrospective cross-sectional cohort study used Medicare fee-for-service claims from 2016 to 2020.
Participants:
A total of 48,466 deceased patients diagnosed with heart failure on Medicare.
Main Measures:
Billed advance care planning services between the last 12 months and last 30 days of life will serve as the exposure. The outcomes are end-of-life healthcare utilization and total expenditure in inpatient, outpatient, hospice, skilled nursing facility, and home healthcare services.
Key Results:
In the final cohort of 48,466 patients (median [IQR] age, 83 [76-89] years; 24,838 [51.2%] women; median [IQR] Charlson Comorbidity Index score, 4 [2-5]), 4406 patients had an advance care planning encounter. Total end-of-life expenditure among patients with billed advance care planning encounters was 19% lower (95% CI, 0.77-0.84) compared to patients without. Patients with billed advance care planning encounters had 2.65 times higher odds (95% CI, 2.47-2.83) of end-of-life outpatient utilization with a 33% higher expected total outpatient expenditure (95% CI, 1.24-1.42) compared with patients without a billed advance care planning encounter.
Conclusions:
Billed advance care planning delivery to individuals with heart failure occurs infrequently. Prioritizing billed advance care planning delivery to these individuals may reduce total end-of-life expenditures and end-of-life inpatient expenditures through promoting use of outpatient end-of-life services, including home healthcare and hospice.
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