1. AcademyHealth 2007 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

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

3. Adjusted for age, sex, race, Medicaid, nursing home use, comorbidity, geographic variation (HSA) *P< 0.05 **P< 0.001 Previous Work Relationship of previous primary care visits and use of hospital services at the end of life 10 12 14 16 18 Hospital Days Number of Primary Care Visits 01-23-56-8> 9 Total Hospital Days ** * * * Total Costs $20,000 $21,000 $22,000 $23,000 $24,000 $25,000 $26,000 $27,000 $28,000

4. AcademyHealth 2007 Study Questions 1. Are there gender differences in utilization of health services at the end of life (EOL)? Primary care Primary care Hospital services Hospital services 2. Does the relationship between previous primary care and end-of-life hospital use differ for men and women?

5. death outcomes predictors covariates 6 months (EOL)12 month (pre-period) Study Design Retrospective analysis of Medicare beneficiaries during their last 18 months of life Methods 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. Adjusted for age, sex, race, Medicaid, nursing home use, comorbidity, geographic variation (HSA) *P <.01 * * * * * Results Does the relationship between previous primary care and hospital use differ for men and women?

10. 1.At the end-of-life, women had greater numbers of primary care visits 2.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 3.Men with 0 primary care visits were less likely to be admitted and had fewer hospital days Conclusions

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

12. AcademyHealth 2007 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

13. Acknowledgments Arlene S Ash 1 Karen M Freund 1 Emanuel J Emanuel 2 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. AcademyHealth 2007 Financial Considerations 2001  Medicare spent an average of $1,200 per day for hospital bed $1,200 per day for hospital bed $87 per level 4 primary care visit (2002) $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.

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