Gender Differences in Healthcare Utilization at the End-of Life

1. Gender Differences in Healthcare Utilization at the End-of Life Andrea Kronman, MD MSc Boston University BIRCWH Faculty Scholar Women’s Health and Health Care Research Units General Internal Medicine Boston University School of Medicine AcademyHealth 2007

2. Background Healthcare at the end-of-life • Symptoms are under treated • Procedures are over used • 30% of Medicare revenues spent on 6% of beneficiaries Medicare • Pressures to control costs and improve quality • Adequate hospitalization coverage • Less adequate outpatient services • Changes to Medicare likely to affect women more Women, in contrast to men • Live longer with more debilitating chronic illness • Use more long-term and outpatient care • Use more primary care

3. 18 $28,000 $27,000 * ** * 16 $26,000 ** Total Hospital Days $25,000 * ** 14 $24,000 Total Costs Hospital Days $23,000 12 $22,000 $21,000 10 $20,000 0 1-2 3-5 6-8 > 9 Number of Primary Care Visits Previous Work Relationship of previous primary care visits and use of hospital services at the end of life Adjusted for age, sex, race, Medicaid, nursing home use, comorbidity, geographic variation (HSA) *P< 0.05 **P< 0.001

4. Study Questions • Are there gender differences in utilization of health services at the end of life (EOL)? • Primary care • Hospital services • Does the relationship between previous primary care and end-of-life hospital use differ for men and women? AcademyHealth 2007

5. 12 month (pre-period) 6 months (EOL) death outcomes predictors covariates Methods • Study Design • Retrospective analysis of Medicare beneficiaries during their last 18 months of life • Study Sample • 78,353 Medicare beneficiaries • Random sample of beneficiaries • Minorities over-sampled • Exclusions: < 66 years old, in ESRD program, non-continuous Medicare A/B

6. Predictors • Gender • Number of primary care visits • Outcome • Number of Hospital Days • Covariates • Age • Race • Medicaid receipt • Nursing home use • Comorbidity (DCG score) • Cluster Analysis • Fixed Effects Regression • Geographic Unit: Hospital Service Area (HSA)

7. Results Are there gender differences in use of health services at the end of life?

8. Results Are there gender differences in use of health services at the end of life?

9. Results Does the relationship between previous primary care and hospital use differ for men and women? * * * * * Adjusted for age, sex, race, Medicaid, nursing home use, comorbidity, geographic variation (HSA) *P < .01

10. Conclusions • At the end-of-life, women had greater numbers of primary care visits • After a threshold of 3 – 5 primary care visits, more prior primary care visits were associated with less hospital use at the end of life • Association is stronger for women • Men with 0 primary care visits were less likely to be admitted and had fewer hospital days

11. Limitations Administrative data does not contain: • Clinical severity • Patient preferences • Content of the primary care visits • Nature of patient-provider interactions Long term nursing residents not identified • Nursing home use = Medicare skilled nursing facility (SNF) benefit

12. Implications • More access to primary care at the end of life may improve quality of life by decreasing hospital time • Especially for women • Validation of such findings could justify increased payment for primary care by Medicare • Understanding gender differences in healthcare utilization could increase efficiency of healthcare delivery at the end of life AcademyHealth 2007

13. Acknowledgments Arlene S Ash1 Karen M Freund1 Emanuel J Emanuel2 1 Women’s Health and Health Care Research Units, General Internal Medicine, Boston University School of Medicine 2 Dept. of Clinical Bioethics, The Clinical Center, National Institutes of Health, Bethesda, MD This study was funded by the Office of Research on Women’s Health (ORWH) K12-43444, with support from the Centers for Medicare and Medicaid Services (CMS) and the National Cancer Institute

14. Financial Considerations 2001 • Medicare spent an average of • $1,200 per day for hospital bed • $87 per level 4 primary care visit (2002) • 533,000 FFS Medicare beneficiaries died in the hospital • Decreasing just 1 day in the hospital for each of these beneficiaries at the end of life would have saved $648 million. AcademyHealth 2007

15. Results 2 Does the relationship between previous primary care and hospital use differ for men and women? * * * * * * * Adjusted for age, race, comorbidity, Medicaid receipt, and nursing home use Reference = Men with 0 primary care visits *P < 0.01