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Functional Status and Medicare Costs in the Last 6 Months of LIfe

A large proportion of healh care costs is incurred towards the end of life. However, very little is known about how patient characteristics impact of end of life costs.

A recent study in the Annals of Internal Medicine by Dr. Amy Kelley a Geriatrician in the Mount Sinai Department of Geriatrics and Palliative Medicine is a major advance in our understanding of costs of care at the end of life. This study provides the best data yet available about how patient characteristics impact Medicare expenditures in the last 6 months of life. The study examined these costs in decedents in the landmark Health and Retirement Study.

The most important finding of this study is the tremendous importance of functional status as a determinant of end of life medical costs. Kelley showed that both the degree of functional impairment and the slope of functional decline were strong determinants of medical costs. In particular:

  • Decedents who needed no help with activities of daily living in the last 3 months of life had the lowest costs
  • Those who had moderate functional impairment (need for help in 1 to 3 activities of daily living) though the last year of life had end of life Medicare expenditures that were 20% higher than those who needed no ADL help.
  • Those who started out with good function (no need for help in activities of daily living 1 year prior to death) but has severe functional deficits in the last 3 months of life (need for help wiht 4 or more activities of daily living) had end of life Medicare expenditures that were 64% higher than those who needed no ADL help.
This study proves that functional impairment is a crucial determinant of end of life health costs. It strongly suggests that we need to pay at least as much attention to patients' functional status as we pay to their diagnoses. As noted by the authors:

"Healthcare reforms may have a greater effect on improving care and reducing costs if they prioritize patient-centered rather than single disease oriented models of care. These efforts should include high-quality primary care and well-coordinated care for these complicated and functionally impaired patients."

by: Ken Covinsky


Patrice Villars said…
This is another great example of the important intersection between geriatrics and palliative care. Health care costs would very likely be lowered. Elderly patients and their families would be much better served if all older adults with decreasing functional status had automatic and easily accessible palliative care.
hyperhydrosis said…
The most important finding of this study is the tremendous importance of functional status as a determinant of end of life medical costs. Health care costs would very likely be lowered.
Good article summarizing study results. Because of the scope of Medicare, it might be difficult to determine topics such as a patients' functionality.
Dan Matlock said…
This was a super article by Amy Kelly wt al.

A huge challenge in this disucssion is finding a distinction between appropriate and inappropriate variations in end-of-life spending. That is, for years, Dartmouth has demonstrated wide variation in end-of-life spending by region. This article showed that this variation remained significant even after adjustment for a host of patient variables. This strengthens the arguement that regional variations are "inappropriate" as they don't relate to patient variability.

This is another extremely important contribution of this article as the Dartmouth Atlas has received so much criticism for their inability to adjust for patient variability.
Dr. Rob said…
This was a very detailed and concise article on the functionality of patients toward the end of their life. It was eye opening.

I recently came across a study published in Topics in Clinical Chiropractic, The study consisted of randomized clinical trial data and found chiropractic geriatric patients "less likely to have been hospitalized, less likely to have used a nursing home, more likely to report a better health status, more likely to exercise vigorously, and more likely to be mobile in the community."

This study suggests that chiropractic may aid in the functionality of geriatrics towards the end of their life.

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