Medication management of Behavioral Problems in Patients with End Stage Dementia.
Trends in End-of-Life Care among Patients with End-stage ... Care_Patient… · Trends in...
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Trends in End-of-Life Care among Patients with End-stage Renal Disease Yoshio N. Hall, MD, MS United States Renal Data System: Special Studies Center on Palliative and End of Life Care University of Washington – Stanford University
Transcript of Trends in End-of-Life Care among Patients with End-stage ... Care_Patient… · Trends in...
Trends in End-of-Life Care among Patients with End-stage Renal Disease
Yoshio N. Hall, MD, MS United States Renal Data System: Special Studies Center on Palliative and End of Life Care University of Washington – Stanford University
Disclosures
• Group Health Cooperative, Nephrology • American Kidney Fund, Board of Trustees • Clinical Journal of American Society of
Nephrology, Editorial Board • Grant Funding (University of Washington)
o NIH/NIDDK o Satellite Coplon Extramural grant program o American Kidney Fund
Rationale • Most patients receive
intensive care at the end of life that is primarily focused on life prolongation.
• End-of-life care is expensive, and costs are predominantly driven by inpatient services o 25% of Medicare expenditures
accounted for by 5% of recipients who die each year
Wong et al. JAMA Intern Med. 2012; Riley et al. Health Serv Res. 2010 Thomas et al. CJASN. 2013
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Objectives
• Examine trends in treatment practices and patterns of health care utilization during the final months of life among decedents with ESRD (2000—2012).
• Explore differences in trends by demographic characteristics.
• Identify potential opportunities to enhance EOL care planning for patients with ESRD in clinical practice.
Design & Data sources
DEATH
3 months
Case Study (Follow Back)
Fee-for-service Medicare A & B (primary payer) CMS 2746
Primary measures: 1. Frequency of hospital admission, length of stay 2. Admission to intensive care unit (ICU) 3. Use of hospice care 4. Dialysis discontinuation 5. Use of invasive procedures (ICD-9)
ESRD service date 1995 or later who died between 2000–2012
Medicare Institutional and Physician Supplier claims
Source: Public-use Standard Analysis Files (SAFs) 2014 version
PATIENTS MEDEVID RXHIST PAYHIST DEATH
{
Decendent Cohort
Variable 2000 2004 2008 2012 Age, mean, yrs 67.5 68.1 68.8 69.1 ≥75 years, % 35 37 38 37 Male, % 52 54 55 56 White, % 66 65 67 68 Black, % 28 28 27 27 Hispanic, % 8 10 11 12 Hemodialysis, % 86 89 89 88 Medicare A&B (last 90 days)
57 68 66 66
N=1,110,597
Median per person costs under Medicare Parts A & B in 2012 were $116,416 for the last year of life
Acute Hospital Admission Last 3 months of life
Median hospital length of stay
Median hospital length of stay = 17 days
Intensive Care Unit Admission
50 54 56 56 58 60 58 58
62 60 63 63 63
0
10
20
30
40
50
60
70
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
enta
ge o
f adm
itted
Calendar year
Receipt of intensive procedures
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
enta
ge
Calendar year
mechanical ventilation
*Intubation, mechanical ventilation, tracheostomy, CPR, feeding tube placement, or (par)enteral nutrition
Receipt of intensive procedures by age group
0
10
20
30
40
50
60
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
enta
ge
Calendar year
AGE 20-44 YEARS
AGE 45-64 YEARS
AGE 65-74 YEARS
AGE 75-84 YEARS
AGE ≥85 YEARS
*Intubation, mechanical ventilation, tracheostomy, CPR, feeding tube placement, or (par)enteral nutrition
Receipt of intensive procedures by race
0
5
10
15
20
25
30
35
40
45
50
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
enta
ge
Calendar Year
Native Amer. Asian BlackWhiteOther
*Intubation, mechanical ventilation, tracheostomy, CPR, feeding tube placement, or (par)enteral nutrition
Inpatient deaths
0
10
20
30
40
50
60
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
enta
ge
Calendar year
Inpatient deaths decreased from 47.3% in 2000 to 40.8% in 2012
Dialysis discontinuation prior to death
0
5
10
15
20
25
30
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
enta
ge
Median time from discontinuation to death as reported on the CMS Death Notification form was 6 days (IQR, 3, 12 days)
The percentage of decedents who discontinued dialysis before death increased from 19.3% in 2000 to 24.9% in 2012
Dialysis discontinuation: by age group
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
AGE 20-44 YEARS
AGE 45-64 YEARS
AGE 65-74 YEARS
AGE 75-84 YEARS
AGE ≥85 YEARS
Dialysis discontinuation before death was highest for patients aged 85+ years (34.2%) and lowest for those 20-44 years (10.9%)
Dialysis discontinuation by race
0
5
10
15
20
25
30
35
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
ent (
of e
ach
grou
p)
Native Amer.
Asian
Black
White
Other
Dialysis discontinuation before death was highest for Whites (27.3%) and lowest for patients of Other race (10.2%)
Hospice use at time of death The percentage of patients receiving hospice services at the time of death increased from 11.4% in 2000 to 25.4% in 2012
0
5
10
15
20
25
30
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Hospice use at death: by age group
0
5
10
15
20
25
30
35
40
45
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
enta
ge
Calendar year
AGE 20-44 YEARSAGE 45-64 YEARSAGE 65-74 YEARSAGE 75-84 YEARS
AGE ≥85 YEARS
Overall use of hospice services was highest for patients aged 85 years and older (28.9%) and lowest for those aged 20-44 years (7.0%)
Hospice use at death: by race
0
5
10
15
20
25
30
35
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Native Amer. Asian BlackWhiteOther
Overall use of hospice services was highest for Whites (22.4%) and lowest for those of Other race (7.5%)
Summary trends • Stable hospital admissions (83%) and length of
stay (median 17 days) • Increased frequency of ICU admissions (50% to
63%) • Increased intensive procedures (27% to 35%) • Reduced hospital deaths (47% to 41%) • Increased dialysis discontinuation (19% to 25%) • Increased use of hospice care at the time of
death (11% to 25%)
Advance Care Planning
Health and Retirement Study, a nationally-representative sample of older Americans found that more people are completing advance directives: from 47% in 2000 up to 72% in 2010
Prevalence of Advance Directives
Holley et al. (80 patients)
AJKD 1997
Sehgal et al. (65 nephrologists)
JAMA 1996
Kurella Tamura et al. (61 patients) NDT
2010
Completed an advance directive
35% 30% 38%
Prevalence of Advance Directives among Nursing Home Patients with ESRD is substantially lower than among patients with other life-limiting conditions (e.g., cancer, O2-depedent COPD, advanced dementia)
I do not understand the phrase, “systolic BP readings outside an individualized lower and upper systolic BP range would result in a breached alert”. Does this mean that the “breached alert” outcome was different for each patient?
Themes • Theme 1: Medical care for patients with advanced
kidney disease is complex and fragmented across settings, providers and over time
• Theme 2: Lack of a shared understanding and vision of ACP and its relationship with other aspects of care
• Theme 3: Unclear locus of responsibility and authority for ACP
• Theme 4: Lack of active collaboration and communication around ACP
Based on 32 providers at VA Puget Sound Healthcare System who care for patients with advanced kidney disease O’Hare et al. Clin J Amer Soc Nephrol., 2016 [in press]
http://www.usrds.org/2015/view/v2_14.aspx
End-of-life Care for Patients with End-Stage Renal Disease: 2000-2012
http://www.usrds.org/
USRDS Special Studies Center on Palliative and End-Of-Life Care
University of Washington
NIDDK
Palliative & EOL
Care SSC
USRDS
Manju Kurella-Tamura
NIH
Ann O’Hare
Sue Hailpern William Kreuter Linda Manahan
Laura Bender Yoshio Hall
Paul Hebert Ronit Katz
Randy Curtis Ruth Engelberg Danielle Lavalle
Lisa Vig
Sai Liu Maria Montez-Rath
Rajiv Saran Bruce Robinson Qi Li
Paul Eggers Kevin Abbott Larry Agodoa
University of Michigan Arbor Research
Stanford University
