Quality and Costs of End-of-Life Care: The Need for Transparency and Accountability

摘要: Increasing attention to the quality of end-of-life care for seriously ill, dying adults has included evaluation site death, place care, and health transitions1 with an important concern being whether these patterns especially receipt aggressive is consistent patient preferences improved life. Choices involving other aspects such as hospice are complex decisions that involve patients, their families, physicians. However, elegantly stated by Levine using metaphor “Goldilocks Three Bears,”2 current dilemma involves timing referral it too late, early, or just right. In this issue JAMA, Obermeyer colleagues3 report findings from study examining utilization expenditures patients poor-prognosis cancers during last year The authors used coarsened exact matching create 18 165 pairs Medicare beneficiaries who were similar, based on available data fromMedicare claims, but differed in theywere enrolled hospice. Patients received vs matched control not receiving hospice, had lower ratesofhospitalizations (42%vs65%), intensive admissions (15%vs 36%), invasive procedures (27%vs 51%), well total over life ($62 819 $71 517), a relative savings nearly $9000 per chose Although et al provides information adds evidence regarding cancer, several caveats should be considered. An threat validity cross-sectional, retrospective was unobserved difference may explain observed cost savings. Rightfully, acknowledge limitations, restriction population exclusion managed non-Medicare reliance only claims-based risk adjustments. Despite raise policy issues. A key if saves money, promote increased access? Perhaps even larger role costs driving US ill those at close right measures currently place. While majority programs high quality, there significant minority which emerging concerns, increasing rates live discharges, home visited professional staff days life, for-profit less likely provide discretionary noncore services than nonprofit programs.4-7 Dying vulnerable often impoverished, frail, older, cognitively impaired.8 As both private insurers change financial incentives inhealth fromdoing “more” “less,” need transparency accountability. error having incorrect substandard serious focuses solely expenditures. This isoneof themost lessons fromthe failed implementation Liverpool Care Pathway United Kingdom.9 Thedemise theLiverpool Pathway, program theoriginal intentof guiding theholistic careofdyingpersons anacute carehospital, must heeded. reported 2013 independent review Pathway,9 National Health Systems Trust adopted Pathway. Total approximately £30 million (approximatelyUS $48million) reportedlywaspaid 3-year period trusts formeeting targeted rate persons Pathway.10 payment led perception placed pathway enhance institution’s wellbeing, rather patient. Transparency accountabilitywere lacking. Public fueledbypress reports bereaved relativeswhobelieved lovedone’s death hastened artificial hydration nutrition stopped without informed consent demise recommended review.9 States, despite progress accountability, opportunities improvement, noted June 2014Medicare Payment Advisory Commission (MedPAC) report.11 Currently, overly rely process some concerns ceiling effects, poor correlation outcome measures. MedPAC considering population-based Medicare’s 3 models.11 recommendation Related article page 1888 Opinion