Abstract
Measuring health care utilization and costs before death has the potential to initiate health care improvement. To examine population-level trends in health care utilization and expenditures in the 2 years before death in Canada's single-payer health system. This population-based cohort included 966 436 deaths among adult residents of Ontario, Canada, from January 2005 to December 2015, linked to health administrative and census data. Data for deaths from 2005 to 2013 were analyzed from November 1, 2016, through January 31, 2017. Analyses were updated from May 1, 2019, to June 15, 2019, to include deaths from 2014 and 2015. Sociodemographic exposures included age, sex, and neighborhood income quintiles, which were obtained by linking decedents' postal codes to census data. Aggregated Diagnosis Groups were used as a general health service morbidity-resource measure. Health care services accessed for the last 2 years of life, including acute hospitalization episodes of care, intensive care unit visits, and emergency department visits. Total health care costs were calculated using a person-centered costing approach. The association of area-level income with high resource use 1 year before death was analyzed with Poisson regression analysis, controlling for age, sex, and Aggregated Diagnosis Groups. Among 966 436 decedents (483 038 [50.0%] men; mean [SD] age, 76.4 [14.96] years; 231 634 [24.0%] living in the lowest neighborhood income quintile), health care expenditures increased in the last 2 years of life during the study period (CAD$5.12 billion [US $3.83 billion] in 2005 vs CAD$7.84 billion [US $5.86 billion] in 2015). In the year before death, 758 770 decedents (78.5%) had at least 1 hospitalization episode of care, 266 987 (27.6%) had at least 1 intensive care unit admission, and 856 026 (88.6%) had at least 1 emergency department visit. Overall, deaths in hospital decreased from 37 984 (45.6%) in 2005 to 39 474 (41.5%) in 2015. Utilization in the last 2 years, 1 year, 180 days, and 30 days of life varied by resource utilization gradients. For example, the proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life (top 5%, 45 535 [94.2%]; top 6%-50%, 401 022 [92.2%]; bottom 50%, 409 469 [84.7%]) and 1 year of life (top 5%, 43 007 [89.0%]; top 6%-50%, 381 732 [87.8%]; bottom 50%, 380 859 [78.8%]); however, in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%]). No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile (rate ratio, 1.02; 95% CI, 0.99-1.05) after adjusting for relevant covariates. In this study, health care use and spending in the last 2 years of life in Ontario were high. These findings highlight a trend in hospital-centered care before death in a single-payer health system.
Highlights
The proportion of individuals visiting the emergency department was slightly higher among the top 5% of health care users compared with other utilization groups in the last 2 years of life and 1 year of life; in the last 30 days of life, more than half of individuals in the top 6% to top 50% (223 262 [51.3%]) and bottom 50% (288 480 [59.7%]) visited an emergency department, compared with approximately one-third of individuals in the top 5% (16 916 [35.0%])
No meaningful associations were observed in high resource use between individuals in the highest income quintile compared with the lowest income quintile after adjusting for relevant covariates
A large proportion of these costs are incurred toward the end of life, with multiple studies demonstrating that health care utilization in the final months of life accounts for a substantial share of health care expenditures in comparison with other points in an individual’s life
Summary
Similar to those in other high-income countries, health care utilization and costs in Canada are expected to increase because of an expanding and aging population. A large proportion of these costs are incurred toward the end of life, with multiple studies demonstrating that health care utilization in the final months of life accounts for a substantial share of health care expenditures in comparison with other points in an individual’s life. In addition, most spending is concentrated in small groups of the population, who are characterized as high-cost users. Studies have shown that high-intensity medical care at the end of life can produce poor outcomes, can be associated with poor quality of life, and may conflict with patient preferences. To meet the growing needs of an aging population, a deeper understanding of the determinants and patterns of health care utilization and costs prior to death is required.Most studies examining health care utilization prior to death have focused on a single aspect of care (eg, palliative services) or were specific to a particular cause of death. To our knowledge, few studies have examined health care use and costs at a population level and across an array of health sectors. Despite its potential to inform health care service delivery and improvement, evidence on health care utilization and cost patterns before death in a Canadian context is limited. Similar to those in other high-income countries, health care utilization and costs in Canada are expected to increase because of an expanding and aging population.. To meet the growing needs of an aging population, a deeper understanding of the determinants and patterns of health care utilization and costs prior to death is required. Despite its potential to inform health care service delivery and improvement, evidence on health care utilization and cost patterns before death in a Canadian context is limited. Using comprehensive multilinked mortality files, we analyzed population-level trends in health care utilization and expenditures prior to death in Ontario’s single-payer health system by looking at overall trends for more than a decade and by gradients of cost (ie, patients in the top 5%, top 6%-50%, and bottom 50% of health care costs)
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