Advance care planning (ACP) is increasingly considered a crucial component of quality end-of-life-care ― and one that may lower healthcare costs by avoiding aggressive interventions that patients don’t want. But a large cohort study of seriously ill Medicare Advantage beneficiaries suggests that for those nearing the end of life, ACP may not be associated with a reduction in healthcare use.
In a study published online in JAMA Network Open on November 1, researchers from the University of Pennsylvania’s Perelman School of Medicine in Philadelphia report that billed ACP encounters are more frequently associated with hospitalization, hospice care, and death, though they are less frequently associated with intensive therapies, such as chemotherapy.
Deepshikha Charan Ashana, MD, MBA, a clinical fellow at Perelman, and associates analyzed a cohort of 18,484 seriously ill Medicare Advantage patients whose mean age was 79.7 years (54.3% women). From October 2106 through November 2017, 864 beneficiaries had a billed ACP visit, and 17,620 beneficiaries had no billed ACP visit. The researchers found that an ACP claim was associated with the following:
a higher likelihood of hospice enrollment in the 6 months after the index ACP visit (incidence rate ratio [IRR], 2.52);
higher mortality (hazard ratio, 2.27) in the 6 months after the index ACP visit;
a greater likelihood of hospitalization (IRR, 1.37);
a greater likelihood of admission to the intensive care unit (IRR, 1.25); and
a lesser likelihood of receiving any intensive therapies (IRR, 0.85) and especially chemotherapy (IRR, 0.65).
Serious illnesses included chronic obstructive pulmonary disease, fibrotic lung disease, malignancy, and heart failure. ACP-visit patients were slightly older (mean age, 81.4 years vs 79.6 years) and had more comorbidities (mean Deyo-Charlson Comorbidity Index, 6.0 vs 4.6). Serious illnesses were similar in number in both groups — 1.4 vs 1.3. For ACP claimants, the mean number of encounters per patient was 1.2 to a maximum of 4. More than half of ACP services were provided by primary care physicians (41.1%) and nonphysicians, such as nurse practitioners (20.7%).
A propensity score–matched analysis (99% matched) and decedent analysis of patients who died during the 6-month follow-up period yielded similar results.
In other findings, patients with ACP claims utilized more healthcare during the previous year than patients without ACP claims. They had more hospital admissions (mean, 2 vs 0.9); more emergency department visits (mean, 1 vs 0.8); and higher median total medical costs ($31,044 vs $9565).
Compared with the overall sample, the 606 patients who died during the 6-month follow-up period were older and had more comorbidities, hospital admissions, and medical expenditures than those who survived. Decedents were also more likely than all seriously ill patients to have a billed ACP encounter (14.2% vs 4.7%).
According to the authors, the greater use of hospice services by those with ACP visits may indicate a preference for palliative care over restorative care; that possibility is supported by the lower likelihood of their receiving aggressive treatment. The study, however, was not able to determine the impact of billed ACP encounters on these preferences. Another possible explanation is that patients with ACP visits were sicker than those without such visits, but this was not captured in the primary analysis.
The authors indicate that the seeming inconsistency between the ACP-visit group’s more frequent hospitalization but less frequent receipt of aggressive therapies could be attributable to a difference in care during hospital stays for patients with ACP claims in comparison to patients without ACP claims.
“For example, seriously ill patients who are hospitalized for symptom management or further clarification of goals of care during an acute deterioration in their health may not receive the intensive therapies that would otherwise be medically indicated,” they write. “If this hypothesis is confirmed in future studies, it would suggest that end-of-life hospital and ICU utilization may be patient centered in some cases.”
They cite the need for randomized clinical trials to evaluate the causal effect of ACP on these patient outcomes.
According to an invited commentary, end-of-life ACP is being increasingly recommended on the assumption that if patients are informed about options, many will choose less aggressive care than they would otherwise receive. “Driving the urgency of these conversations is the concern that much of the care that is currently provided toward the end of life may be overly aggressive and thus misaligned with patients’ values,” write anesthesiologists May Hua, MD, of Columbia University, New York City, and Hannah Wunsch, MD, of the University of Toronto, Canada.
They further point out that misaligned care may increase the burden of symptoms and contribute to a worse quality of death and low-value care for the health system.
Hua and Wunsch caution about the potential for misclassification of the ACP visit exposure and residual confounding by indication, inasmuch as patients who received ACP were more likely to die during the follow-up period. “Given these concerns, the authors were appropriately conservative in their conclusions, suggesting that their findings highlighted the need for further experimental studies to determine a causal relationship between ACP and patients’ outcomes,” they write.
Nevertheless, they add, because matching delivered care to the care desired by patients is the aim of ACP intervention, the analysis “highlights existing opportunities to better refine our thinking about what constitutes goal-concordant care.” Instead of viewing healthcare utilization as an outcome in which more care is always poor-quality care, a better taxonomy of quality care might offer options that best reflect the value of care to patients and families. “Given the difficult choices that patients and families face at the end of life, it is perhaps only fitting that our approach to this issue begins to mirror that complexity,” they write.
The project was funded by grants from the National Heart, Lung, and Blood Institute. Ashana reports receiving grants from the National Heart, Lung, and Blood Institute during the study. Several coauthors report employment or stock ownership in private-sector companies. Hua reports grants from the National Institute on Aging and the American Federation for Aging Research.