Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, USA.
J Am Geriatr Soc. 2020 Sep;68(9):1947-1953. doi: 10.1111/jgs.16683. Epub 2020 Aug 27.
BACKGROUND/OBJECTIVE: The Centers for Medicare & Medicaid Services (CMS) reimburses clinicians for advance care planning (ACP) discussions with Medicare patients. The objective of the study was to examine the association of CMS-billed ACP visits with end-of-life (EOL) healthcare utilization.
Patient-level analyses of claims for the random 20% Medicare fee-for-service (FFS) sample of decedents in 2017. To account for multiple comparisons, Bonferroni adjusted P value <.008 was considered statistically significant.
Nationally representative sample of Medicare FFS beneficiaries.
A total of 237,989 Medicare FFS beneficiaries who died in 2017 and included those with and without a billed ACP visit during 2016-17.
The key exposure variable was receipt of first billed ACP (none, >1 month before death).
Six measures of EOL healthcare utilization or intensity (inpatient admission, emergency department [ED] visit, intensive care unit [ICU] stay, and expenditures within 30 days of death, in-hospital death, and first hospice within 3 days of death). Analyses was adjusted for age, race, sex, Charlson Comorbidity Index, expenditure by Dartmouth hospital referral region (high, medium, or low), and dual eligibility.
Overall, 6.3% (14,986) of the sample had at least one billed ACP visit. After multivariable adjustment, patients with an ACP visit experienced significantly less intensive EOL care on four of six measures: hospitalization (odds ratio [OR] = .77; 95% confidence interval [CI] = .74-.79), ED visit (OR = .77; 95% CI = .75-.80), or ICU stay (OR = .78; 95% CI = .74-.81) within a month of death; and they were less likely to die in the hospital (OR = .79; 95% CI = .76-.82). There were no differences in the rate of late hospice enrollment (OR = .97; 95% CI = .92-1.01; P = .119) or mean expenditures ($242.50; 95% CI = -$103.63 to $588.61; P = .169).
Billed ACP visits were relatively uncommon among Medicare FFS decedents, but their occurrence was associated with less intensive EOL utilization. Further research on the variables affecting hospice use and expenditures in the EOL period is recommended to understand the relative role of ACP.
背景/目的：医疗保险和医疗补助服务中心（CMS）为与医疗保险患者进行预先护理计划（ACP）讨论的临床医生报销费用。本研究的目的是研究 CMS 计费的 ACP 就诊与临终医疗保健利用之间的关联。
对 2017 年随机抽取的 20%的 Medicare 按服务项目付费（FFS）样本中死者的患者水平进行分析。为了考虑到多次比较，Bonferroni 调整后的 P 值<.008 被认为具有统计学意义。
全国性的 Medicare FFS 受益人群样本。
共有 237989 名 Medicare FFS 受益人在 2017 年死亡，包括在 2016-17 年期间接受过和未接受过计费 ACP 就诊的患者。
关键暴露变量是首次接受计费的 ACP（无，死亡前>1 个月）。
临终医疗保健利用或强度的六个指标（住院入院、急诊部 [ED] 就诊、重症监护病房 [ICU] 入住、死亡后 30 天内的支出、院内死亡和死亡后 3 天内首次入住临终关怀）。分析调整了年龄、种族、性别、Charlson 合并症指数、达特茅斯医院转诊区域（高、中、低）的支出以及双重资格。
总体而言，样本中 6.3%（14986 人）至少接受过一次计费 ACP 就诊。经过多变量调整后，接受 ACP 就诊的患者在六个指标中的四个指标上的临终护理强度显著降低：住院（比值比 [OR] = .77；95%置信区间 [CI] = .74-.79）、ED 就诊（OR = .77；95% CI = .75-.80）或 ICU 入住（OR = .78；95% CI = .74-.81）在死亡一个月内；并且他们在医院死亡的可能性较低（OR = .79；95% CI = .76-.82）。晚期临终关怀入院率（OR = .97；95% CI = .92-1.01；P = .119）或平均支出（$242.50；95% CI = -$103.63 至 $588.61；P = .169）无差异。
在 Medicare FFS 死者中，计费的 ACP 就诊相对较少见，但它们的发生与临终护理利用强度降低有关。建议进一步研究影响临终期间临终关怀使用和支出的变量，以了解 ACP 的相对作用。
