Gender Differences in
Healthcare Utilization at the
EndEnd-of Life
Background
Healthcare at the endend-ofof-life
•
•
•
Symptoms are under treated
Procedures are over used
30% of Medicare revenues spent on 6% of beneficiaries
Medicare
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Andrea Kronman, MD MSc
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Boston University BIRCWH Faculty Scholar
Women’s Health and Health Care Research Units
General Internal Medicine
Boston University School of Medicine
Pressures to control costs and improve quality
Adequate hospitalization coverage
Less adequate outpatient services
Changes to Medicare likely to affect women more
Women, in contrast to men
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AcademyHealth 2007
Live longer with more debilitating chronic illness
Use more longlong-term and outpatient care
Use more primary care
Previous Work
Study Questions
Relationship of previous primary care visits and
use of hospital services at the end of life
18
1.
$28,000
$27,000
16
*
**
$26,000
*
•
$25,000
•
**
Total 14
Hospital
Days
Are there gender differences in utilization of
health services at the end of life (EOL)?
Primary care
Hospital services
$24,000
**
*
Hospital Days
$23,000
12
Total Costs
2.
$22,000
$21,000
10
$20,000
0
1-2
3-5
6-8
Does the relationship between previous
primary care and endend-ofof-life hospital use differ
for men and women?
>9
Number of Primary Care Visits
Adjusted for age, sex, race, Medicaid, nursing home use, comorbidity, geographic variation (HSA)
*P< 0.05
**P< 0.001
Methods
Predictors
• Gender
• Number of primary care visits
Study Design
Retrospective analysis of Medicare beneficiaries during their
last 18 months of life
12 month (pre-period)
predictors
covariates
AcademyHealth 2007
6 months (EOL)
outcomes
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
death
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)
1
Results
Results
Are there gender differences in use of health services
at the end of life?
Are there gender differences in use of health services
at the end of life?
Pre-period
Characteristic
Male Female
N
%
Mean age
(STD),
R
Medicaid receipt, %
Nursing home use,%
Mean comorbidity risk score
(STD)
Number of PC Visits %
0
1-2
3-5
6-8
>9
34,302
44
79.1
(7.6)
44,054
56
82.3
(8.2)
25
11
2.2
(1.7)
38
14
2.2
(1.7)
42
22
18
9
9
34
22
20
11
12
13.0
male
female
*
*
Hospital Days
16.0
*
12.0
0
1-2
3-5
6-8
15.1
15.3
(20.2) (20.3)
24.8
25.4
(30.9) (32.4)
74
74
15.0
(20.1)
24.4
(28.8)
74
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
¾ Association is stronger for women
17.0
*
Mean total hospital days
(STD)
Mean total costs, $ 1000
(STD)
Any hospital admission, %
1. At the end-of-life, women had greater numbers
of primary care visits
Primary Care Visits Associated With Fewer
Hospital Days at End of Life
14.0
Total Male Female
Conclusions
Results
Does the relationship between previous primary care and
hospital use differ for men and women?
15.0
Unadjusted
End-Of-Life Utilization
3. Men with 0 primary care visits were less likely
to be admitted and had fewer hospital days
>9
Num ber of Prim ary Care Visits
*
Adjusted for age, sex, race, Medicaid, nursing home use, comorbidity, geographic variation (HSA)
*P < .01
Limitations
Administrative data does not contain:
•
•
•
•
Clinical severity
Patient preferences
Content of the primary care visits
Nature of patientpatient-provider interactions
Long term nursing residents not identified
•
Nursing home use =
Medicare skilled nursing facility (SNF) benefit
Implications
¾ More access to primary care
at the end of life
may improve quality of life by decreasing
hospital time
¾ Especially for women
¾ Validation of such findings could justify
increased payment for primary care by
Medicare
¾ Understanding gender differences in healthcare
utilization could increase efficiency of
healthcare delivery at the end of life
AcademyHealth 2007
2
Acknowledgments
Financial Considerations 2001
Arlene S Ash1
Karen M Freund1
Emanuel J Emanuel2
¾ Medicare spent an average of
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1
Women’s Health and Health Care Research Units, General
Internal Medicine, Boston University School of Medicine
2 Dept. of Clinical Bioethics, The Clinical Center, National
Institutes of Health, Bethesda, MD
This study was funded by the Office of Research on Women’
Women’s
Health (ORWH) K12K12-43444, with support from the Centers for
Medicare and Medicaid Services (CMS) and the National
Cancer Institute
$1,200 per day for hospital bed
$87 per level 4 primary care visit (2002)
¾ 533,000 FFS
Medicare beneficiaries died
in the hospital
¾ Decreasing just 1 day in the hospital for
each of these beneficiaries at the end of
life would have saved $648 million.
AcademyHealth 2007
Results 2
Does the relationship between previous primary care and
hospital use differ for men and women?
Primary Care Visits Mediate Likelihood of
*
*
Hospital
Admission
*
*
Adjusted
Odds Ratio
1.5
*
*
*
*
*
*
1
*
*
male
*
*
female
0.5
0
1-2
3-5
6-8
>9
Num ber of Prim ary Care Visits
Adjusted for age, race, comorbidity, Medicaid receipt, and nursing home use
Reference = Men with 0 primary care visits
*P < 0.01
3