Trends in Integration Between Physician Organizations and Pharmacies for Self-Administered Drugs.

Importance: Increasing integration across medical services may have important implications for health care quality and spending. One major but poorly understood dimension of integration is between physician organizations and pharmacies for self-administered drugs or in-house pharmacies. Objective: To describe trends in the use of in-house pharmacies, associated physician organization characteristics, and associated drug prices. Design, Setting, and Participants: A cross-sectional study was conducted from calendar years 2011 to 2019. Participants included 20% of beneficiaries enrolled in fee-for-service Medicare Parts A, B, and D. Data analysis was performed from September 15, 2020, to December 20, 2023. Exposures: Prescriptions filled by in-house pharmacies. Main Outcomes and Measures: The share of Medicare Part D spending filled by in-house pharmacies by drug class, costliness, and specialty was evaluated. Growth in the number of physician organizations and physicians in organizations with in-house pharmacies was measured in 5 specialties: medical oncology, urology, infectious disease, gastroenterology, and rheumatology. Characteristics of physician organizations with in-house pharmacies and drug prices at in-house vs other pharmacies are described. Results: Among 8 020 652 patients (median age, 72 [IQR, 66-81] years; 4 570 114 [57.0%] women), there was substantial growth in the share of Medicare Part D spending on high-cost drugs filled at in-house pharmacies from 2011 to 2019, including oral anticancer treatments (from 10% to 34%), antivirals (from 12% to 20%), and immunosuppressants (from 2% to 9%). By 2019, 63% of medical oncologists, 20% of urologists, 29% of infectious disease specialists, 21% of gastroenterologists, and 22% of rheumatologists were in organizations with specialty-relevant in-house pharmacies. Larger organizations had a greater likelihood of having an in-house pharmacy (0.75 percentage point increase [95% CI, 0.56-0.94] per each additional physician), as did organizations owning hospitals enrolled in the 340B Drug Discount Program (10.91 percentage point increased likelihood [95% CI, 6.33-15.48]). Point-of-sale prices for high-cost drugs were 1.76% [95% CI, 1.66%-1.87%] lower at in-house vs other pharmacies. Conclusions and Relevance: In this cross-sectional study of physician organization-operated pharmacies, in-house pharmacies were increasingly used from 2011 to 2019, especially for high-cost drugs, potentially associated with organizations' financial incentives. In-house pharmacies offered high-cost drugs at lower prices, in contrast to findings of integration in other contexts, but their growth highlights a need to understand implications for patient care.

Organization of Cancer Specialists in US Physician Practices and Health Systems.

PURPOSE: To describe the supply of cancer specialists, the organization of cancer care within versus outside of health systems, and the distance to multispecialty cancer centers. METHODS: Using the 2018 Health Systems and Provider Database from the National Bureau of Economic Research and 2018 Medicare data, we identified 46,341 unique physicians providing cancer care. We stratified physicians by discipline (adult/pediatric medical oncologists, radiation oncologists, surgical/gynecologic oncologists, other surgeons performing cancer surgeries, or palliative care physicians), system type (National Cancer Institute [NCI] Cancer Center system, non-NCI academic system, nonacademic system, or nonsystem/independent practice), practice size, and composition (single disciplinary oncology, multidisciplinary oncology, or multispecialty). We computed the density of cancer specialists by county and calculated distances to the nearest NCI Cancer Center. RESULTS: More than half of all cancer specialists (57.8%) practiced in health systems, but 55.0% of cancer-related visits occurred in independent practices. Most system-based physicians were in large practices with more than 100 physicians, while those in independent practices were in smaller practices. Practices in NCI Cancer Center systems (95.2%), non-NCI academic systems (95.0%), and nonacademic systems (94.3%) were primarily multispecialty, while fewer independent practices (44.8%) were. Cancer specialist density was sparse in many rural areas, where the median travel distance to an NCI Cancer Center was 98.7 miles. Distances to NCI Cancer Centers were shorter for individuals living in high-income areas than in low-income areas, even for individuals in suburban and urban areas. CONCLUSION: Although many cancer specialists practiced in multispecialty health systems, many also worked in smaller-sized independent practices where most patients were treated. Access to cancer specialists and cancer centers was limited in many areas, particularly in rural and low-income areas.

Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life.

PURPOSE: To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms. METHODS: Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS. RESULTS: Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, -4.3 percentage points, 95% CI, -4.8 to -3.6; Hispanic, -3.6 percentage points, 95% CI, -4.4 to -2.9) and long-acting opioids (Black, -3.1 percentage points, 95% CI, -3.6 to -2.8; Hispanic, -2.2 percentage points, 95% CI, -2.7 to -1.7). They also received lower daily doses (Black, -10.5 MMED, 95% CI, -12.8 to -8.2; Hispanic, -9.1 MMED, 95% CI, -12.1 to -6.1) and lower total doses (Black, -210 MMEs, 95% CI, -293 to -207; Hispanic, -179 MMEs, 95% CI, -217 to -142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities. CONCLUSION: There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.

US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life.

PURPOSE: Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer. METHODS: Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end-of-life (EOL), defined as the 30 days before death or hospice enrollment. We used administrative claims to evaluate trends in pain-related emergency department (ED) visits near EOL. RESULTS: Between 2007 and 2017, the proportion of decedents with poor prognosis cancers receiving ≥ 1 opioid prescription near EOL declined 15.5% (relative percent difference [RPD]), from 42.0% (95% CI, 41.4 to 42.7) to 35.5% (95% CI, 34.9 to 36.0) and the proportion receiving ≥ 1 long-acting opioid prescription declined 36.5% (RPD), from 18.1% (95% CI, 17.6 to 18.6) to 11.5% (95% CI, 11.1 to 11.9). Among decedents receiving opioids near EOL, the mean daily dose fell 24.5%, from 85.6 MMED (95% CI, 82.9 to 88.3) to 64.6 (95% CI, 62.7 to 66.6) MMED. Overall, the total amount of opioids prescribed per decedent near EOL (averaged across those who did and did not receive an opioid) fell 38.0%, from 1,075 morphine milligram equivalents per decedent (95% CI, 1,042 to 1,109) to 666 morphine milligram equivalents per decedent (95% CI, 646 to 686). Simultaneously, the proportion of patients with pain-related ED visits increased 50.8% (RPD), from 13.2% (95% CI, 12.7 to 13.6) to 19.9% (95% CI, 19.4 to 20.4). Sensitivity analyses demonstrated similar declines in opioid utilization in the 60 and 90 days before death or hospice, and suggested that trends in opioid access were not confounded by secular trends in hospice utilization. CONCLUSION: Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening.

Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015.

Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and -7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.

Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement.

BACKGROUND: Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect. METHODS: We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population. RESULTS: There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains. CONCLUSION: Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities. LEVEL OF EVIDENCE: Economic analysis, level II.

Early death after discharge from emergency departments: analysis of national US insurance claims data.

OBJECTIVE:  To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients. DESIGN:  Retrospective cohort study. SETTING:  Claims data from the US Medicare program, covering visits to an emergency department, 2007-12. PARTICIPANTS:  Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded. MAIN OUTCOME MEASURE:  Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients. RESULTS:  Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)-3.4 times higher than hospitals in the highest fifth (0.08%)-despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7). CONCLUSIONS:  Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.

Surgeon specialization and operative mortality in United States: retrospective analysis.

OBJECTIVE:  To measure the association between a surgeon's degree of specialization in a specific procedure and patient mortality. DESIGN:  Retrospective analysis of Medicare data. SETTING:  US patients aged 66 or older enrolled in traditional fee for service Medicare. PARTICIPANTS:  25 152 US surgeons who performed one of eight procedures (carotid endarterectomy, coronary artery bypass grafting, valve replacement, abdominal aortic aneurysm repair, lung resection, cystectomy, pancreatic resection, or esophagectomy) on 695 987 patients in 2008-13. MAIN OUTCOME MEASURE:  Relative risk reduction in risk adjusted and volume adjusted 30 day operative mortality between surgeons in the bottom quarter and top quarter of surgeon specialization (defined as the number of times the surgeon performed the specific procedure divided by his/her total operative volume across all procedures). RESULTS:  For all four cardiovascular procedures and two out of four cancer resections, a surgeon's degree of specialization was a significant predictor of operative mortality independent of the number of times he or she performed that procedure: carotid endarterectomy (relative risk reduction between bottom and top quarter of surgeons 28%, 95% confidence interval 0% to 48%); coronary artery bypass grafting (15%, 4% to 25%); valve replacement (46%, 37% to 53%); abdominal aortic aneurysm repair (42%, 29% to 53%); lung resection (28%, 5% to 46%); and cystectomy (41%, 8% to 63%). In five procedures (carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy), the relative risk reduction from surgeon specialization was greater than that from surgeon volume for that specific procedure. Furthermore, surgeon specialization accounted for 9% (coronary artery bypass grafting) to 100% (cystectomy) of the relative risk reduction otherwise attributable to volume in that specific procedure. CONCLUSION:  For several common procedures, surgeon specialization was an important predictor of operative mortality independent of volume in that specific procedure. When selecting a surgeon, patients, referring physicians, and administrators assigning operative workload may want to consider a surgeon's procedure specific volume as well as the degree to which a surgeon specializes in that procedure.

Economic Approaches to Estimating Benefits of Regulations Affecting Addictive Goods.

The question of how to evaluate lost consumer surplus in benefit-cost analyses has been contentious. There are clear health benefits of regulations that curb consumption of goods with health risks, such as tobacco products and foods high in fats, calories, sugar, and sodium. Yet, if regulations cause consumers to give up goods they like, the health benefits they experience may be offset by some utility loss, which benefit-cost analyses of regulations need to take into account. This paper lays out the complications of measuring benefits of regulations aiming to curb consumption of addictive and habitual goods, rooted in the fact that consumers' observed demand for such goods may not be in line with their true preferences. Focusing on the important case of tobacco products, the paper describes four possible approaches for estimating benefits when consumers' preferences may not be aligned with their behavior, and identifies one as having the best feasibility for use in applied benefit-cost analyses in the near term.

Emergency Care Use and the Medicare Hospice Benefit for Individuals with Cancer with a Poor Prognosis.

OBJECTIVES: To compare patterns of emergency department (ED) use and inpatient admission rates for elderly adults with cancer with a poor prognosis who enrolled in hospice to those of similar individuals who did not. DESIGN: Matched case-control study. SETTING: Nationally representative sample of Medicare fee-for-service beneficiaries with cancer with a poor prognosis who died in 2011. PARTICIPANTS: Beneficiaries in hospice matched to individuals not in hospice on time from diagnosis of cancer with a poor prognosis to death, region, age, and sex. MEASUREMENTS: Comparison of ED use and inpatient admission rates before and after hospice enrollment for beneficiaries in hospice and controls. RESULTS: Of 272,832 matched beneficiaries, 81% visited the ED in the last 6 months of life. At baseline, daily ED use and admission rates were not significantly different between beneficiaries in and not in hospice. By the week before death, nonhospice controls averaged 69.6 ED visits/1,000 beneficiary-days, versus 7.6 for beneficiaries in hospice (rate ratio (RR) = 9.7, 95% confidence interval (CI) = 9.3-10.0). Inpatient admission rates in the last week of life were 63% for nonhospice controls and 42% for beneficiaries in hospice (RR = 1.51, 95% CI = 1.45-1.57). Of all beneficiaries in hospice, 28% enrolled during inpatient stays originating in EDs; they accounted for 35.7% (95% CI = 35.4-36.0%) of all hospice stays of less than 1 month and 13.9% (95% CI = 13.6-14.2%) of stays longer than 1 month. CONCLUSION: Most Medicare beneficiaries with cancer with a poor prognosis visited EDs at the end of life. Hospice enrollment was associated with lower ED use and admission rates. Many individuals enrolled in hospice during inpatient stays that followed ED visits, a phenomenon linked to shorter hospice stays. These findings must be interpreted carefully given potential unmeasured confounders in matching.

ACO model should encourage efficient care delivery.

The independent Office of the Actuary for CMS certified that the Pioneer ACO model has met the stringent criteria for expansion to a larger population. Significant savings have accrued and quality targets have been met, so the program as a whole appears to be working. Ironically, 13 of the initial 32 enrollees have left. We attribute this to the design of the ACO models which inadequately support efficient care delivery. Using Bellin-ThedaCare Healthcare Partners as an example, we will focus on correctible flaws in four core elements of the ACO payment model: finance spending and targets, attribution, and quality performance.

Physician Characteristics Strongly Predict Patient Enrollment In Hospice.

Individual physicians are widely believed to play a large role in patients' decisions about end-of-life care, but little empirical evidence supports this view. We developed a novel method for measuring the relationship between physician characteristics and hospice enrollment, in a nationally representative sample of Medicare patients. We focused on patients who died with a diagnosis of poor-prognosis cancer in the period 2006-11, for whom palliative treatment and hospice would be considered the standard of care. We found that the proportion of a physician's patients who were enrolled in hospice was a strong predictor of whether or not that physician's other patients would enroll in hospice. The magnitude of this association was larger than that of other known predictors of hospice enrollment that we examined, including patients' medical comorbidity, age, race, and sex. Patients cared for by medical oncologists and those cared for in not-for-profit hospitals were significantly more likely than other patients to enroll in hospice. These findings suggest that physician characteristics are among the strongest predictors of whether a patient receives hospice care-which mounting evidence indicates can improve care quality and reduce costs. Interventions geared toward physicians, both by specialty and by previous history of patients' hospice enrollment, may help optimize appropriate hospice use.

Vitamin D deficiency in minority populations.

OBJECTIVE: Black and Hispanic individuals synthesize less vitamin D per unit of sun exposure than white individuals. The relationship between UV radiation and vitamin D insufficiency in minorities has not been well explored. DESIGN: Prospective cohort study. SETTING: Using the National Health and Nutrition Examination Survey, we obtained serum vitamin D levels for non-Hispanic Whites, Hispanics and non-Hispanic Blacks aged ≥18 years from 2000-2006. We linked these data with the average monthly solar UV index by census tract and data on sun exposure, vitamin D supplementation, health and demographics. We used multivariable regression analyses to assess vitamin D deficiency (<15 ng/ml) and insufficiency (<20 ng/ml) in January (when the UV index was lowest) by race/ethnicity and geography. SUBJECTS: Adults (n 14,319) aged ≥18 years. RESULTS: A 1-point increase in the UV index was associated with a 0·51 ng/ml increase in vitamin D (95% CI 0·35, 0·67 ng/ml; P<0·001). Non-Hispanic Black race and Hispanic ethnicity were associated with a 7·47 and 3·41 ng/ml decrease in vitamin D, respectively (both P<0·001). In January, an estimated 65·4% of non-Hispanic Blacks were deficient in vitamin D, compared with 28·9% of Hispanics and 14·0% of non-Hispanic Whites. An estimated 84·2% of non-Hispanic Blacks were insufficient in vitamin D v. 56·3% of Hispanics and 34·8% of non-Hispanic Whites. More non-Hispanic Blacks were estimated to be deficient in vitamin D in January in the highest UV index quartile than were non-Hispanic Whites in the lowest UV index quartile (60·2% v. 25·7%). CONCLUSIONS: Wintertime vitamin D insufficiency is pervasive among minority populations, and not uncommon among non-Hispanic Whites.

When does education matter? The protective effect of education for cohorts graduating in bad times.

Using Eurobarometer data, we document large variation across European countries in education gradients in income, self-reported health, life satisfaction, obesity, smoking and drinking. While this variation has been documented previously, the reasons why the effect of education on income, health and health behaviors varies is not well understood. We build on previous literature documenting that cohorts graduating in bad times have lower wages and poorer health for many years after graduation, compared to those graduating in good times. We investigate whether more educated individuals suffer smaller income and health losses as a result of poor labor market conditions upon labor market entry. We confirm that a higher unemployment rate at graduation is associated with lower income, lower life satisfaction, greater obesity, more smoking and drinking later in life. Further, education plays a protective role for these outcomes, especially when unemployment rates are high: the losses associated with poor labor market outcomes are substantially lower for more educated individuals. Variation in unemployment rates upon graduation can potentially explain a large fraction of the variance in gradients across different countries.

Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer.

IMPORTANCE: More patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health care utilization and costs have hampered efforts to promote it. OBJECTIVE: To compare utilization and costs of health care for patients with poor-prognosis cancers enrolled in hospice vs similar patients without hospice care. DESIGN, SETTING, AND PARTICIPANTS: Matched cohort study of patients in hospice and nonhospice care using a nationally representative 20% sample of Medicare fee-for-service beneficiaries who died in 2011. Patients with poor-prognosis cancers (eg, brain, pancreatic, metastatic malignancies) enrolled in hospice before death were matched to similar patients who died without hospice care. EXPOSURES: Period between hospice enrollment and death for hospice beneficiaries, and the equivalent period of nonhospice care before death for matched nonhospice patients. MAIN OUTCOMES AND MEASURES: Health care utilization including hospitalizations and procedures, place of death, cost trajectories before and after hospice start, and cumulative costs, all during the last year of life. RESULTS: Among 86,851 patients with poor-prognosis cancers, median time from first poor-prognosis diagnosis to death was 13 months (interquartile range [IQR], 3-34), and 51,924 patients (60%) entered hospice before death. Matching yielded a cohort balanced on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization, with 18,165 patients in the hospice group and 18,165 in the nonhospice group. After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. After exposure, nonhospice beneficiaries had significantly more hospitalizations (65% [95% CI, 64%-66%], vs hospice with 42% [95% CI, 42%-43%]; risk ratio, 1.5 [95% CI, 1.5-1.6]), intensive care (36% [95% CI, 35%-37%], vs hospice with 15% [95% CI, 14%-15%]; risk ratio, 2.4 [95% CI, 2.3-2.5]), and invasive procedures (51% [95% CI, 50%-52%], vs hospice with 27% [95% CI, 26%-27%]; risk ratio, 1.9 [95% CI, 1.9-2.0]), largely for acute conditions not directly related to cancer; and 74% (95% CI, 74%-75%) of nonhospice beneficiaries died in hospitals and nursing facilities compared with 14% (95% CI, 14%-15%) of hospice beneficiaries. Costs for hospice and nonhospice beneficiaries were not significantly different at baseline, but diverged after hospice start. Total costs over the last year of life were $71,517 (95% CI, $70,543-72,490) for nonhospice and $62,819 (95% CI, $62,082-63,557) for hospice, a statistically significant difference of $8697 (95% CI, $7560-$9835). CONCLUSIONS AND RELEVANCE: In this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care vs not (control), had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.

US trends in quality-adjusted life expectancy from 1987 to 2008: combining national surveys to more broadly track the health of the nation.

OBJECTIVES: We used data from multiple national health surveys to systematically track the health of the US adult population. METHODS: We estimated trends in quality-adjusted life expectancy (QALE) from 1987 to 2008 by using national mortality data combined with data on symptoms and impairments from the National Medical Expenditure Survey (1987), National Health Interview Survey (1987, 1994-1995, 1996), Medical Expenditure Panel Survey (1992, 1996, 2000-2008), National Nursing Home Survey (1985, 1995, and 1999), and Medicare Current Beneficiary Survey (1992, 1994-2008). We decomposed QALE into changes in life expectancy, impairments, symptoms, and smoking and body mass index. RESULTS: Years of QALE increased overall and for all demographic groups-men, women, Whites, and Blacks-despite being slowed by increases in obesity and a rising prevalence of some symptoms and impairments. Overall QALE gains were large: 2.4 years at age 25 years and 1.7 years at age 65 years. CONCLUSIONS: Understanding and consistently tracking the drivers of QALE change is central to informed policymaking. Harmonizing data from multiple national surveys is an important step in building this infrastructure.