The latest wave of data confirming that end-of-life care is an outsized driver of healthcare costs comes with one caveat from the chair of SHM’s research committee.
“It’s not always obvious you’re providing end-of-life care when you’re providing it,” says David Meltzer, MD, PhD, FHM, FACP, chief of the section of hospital medicine and associate professor in the Department of Medicine and the Graduate School of Public Policy Studies at the University of Chicago. “You have to be really careful not to conflate age and proximity to death.”
Dr. Meltzer was one of the lead investigators who helped develop the university’s Curriculum for the Hospitalized Aging Medical Patient (CHAMP) and has studied the costs of healthcare delivery to the elderly. He cautions hospitalists against couching cost calculations in terms of the age of their patient census—and reviewing instead what would improve a patient’s quality of life.
“There are times when it’s appropriate to discuss the goals of care,” Dr. Meltzer says. “I doubt the answer to that question is defined by age.”
Accordingly, a statistical brief released last month by the federal Agency of Healthcare Research and Quality (AHRQ) focused on cost drivers, not age. The data show the inpatient death rate in 2007 was 1.9%. “However, these hospital stays ending in death were responsible for 5.2% ($20 billion) of all hospital inpatient costs,” the brief concluded. In what is probably no surprise to hospitalists, much of that cost is traced to length of stay, which averaged 8.8 days for patients who died and 4.5 days for those who lived. The data is for 2007, the latest year available.
To counter rising costs, Dr. Meltzer recommends:
- Review a patient’s condition holistically, looking past age;
- Have an upfront discussion with the patient about what their expectations of care are. Avoid excess care that is not in line with the patient’s wishes; and
- Talk with hospital administration to ensure that your HM group has a say in care decisions, effectively giving hospitalists an opportunity to act as a change agent.
“It’s not so much measuring against cost; it’s measuring against the patient’s preferences,” Dr. Meltzer says. “Ultimately, the physician is the patient’s agent.”