Influence of age on Medicare expenditures and medical care in the last year of life.

CONTEXT: Expenditures for Medicare beneficiaries in the last year of life decrease with increasing age. The cause of this phenomenon is uncertain. OBJECTIVES: To examine this pattern in detail and evaluate whether decreases in aggressiveness of medical care explain the phenomenon. DESIGN, SETTING, AND PATIENTS: Analysis of sample Medicare data for beneficiaries aged 65 years or older from Massachusetts (n = 34 131) and California (n = 19 064) who died in 1996. MAIN OUTCOME MEASURE: Medical expenditures during the last year of life, analyzed by age group, sex, race, place and cause of death, comorbidity, and use of hospital services. RESULTS: For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admissions and by markedly decreasing use of cardiac catheterization, dialysis, ventilators, and pulmonary artery monitors, regardless of cause of death. Decrease in the cost of hospital services accounts for approximately 80% of the decrease in Medicare expenditures with age in both states. CONCLUSIONS: Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.

Intensive care unit use and mortality in the elderly.

OBJECTIVE: To examine utilization and outcomes of intensive care unit (ICU) use for the elderly in the United States. DESIGN: We used 1992 data from the Health Care Financing Administration to examine ICU utilization and mortality by age and admission reason for hospitalizations of elderly Medicare beneficiaries. MAIN RESULTS: Use of the ICU was least likely for the oldest elderly overall (85+ years, 21.1% of admissions involved ICU; 75-84 years, 27.9%; 65-74 years, 29.7%), but more likely during surgical admissions. Eighty-three percent of the Medicare patients who received intensive care survived at least 90 days. Of the oldest elderly, 74% survived. Even among the 10% most expensive ICU hospitalizations, 77% of all patients and 62% of those 85 years and older survived at least 90 days. CONCLUSIONS: The likelihood of ICU use among these elderly decreased with age, especially among those 85 years or older. Diagnostic mix importantly influenced ICU use by age. The great majority of the elderly, including those 85 years and older and those receiving the most expensive ICU care, survived at least 90 days.

Patterns of use of common major procedures in medical care of older adults.

OBJECTIVES: We analyzed Medicare data to determine the influence of age, mortality during the study year, and high individual Medicare costs on the frequency of hospitalization for the most common major procedures and for general medical diagnoses. METHODS: We used 1992 Medicare data to classify the most frequent diagnosis related groups (DRGs), representing one-half of all admissions, as procedural or general medical. We studied the frequency of hospitalization for the most common procedures (bowel surgery, cardiovascular procedures, hip and femur surgery) and for general medical care in the entire Medicare population, in persons aged 65 to 74, 75 to 84, and 85 or older, in those who died, and in the 5% of persons whose annual Medicare costs were the highest. RESULTS: In the entire population, common procedures accounted for 21% of the most frequent DRGs. Among those who died, the procedures were performed in only 8% of admissions. In the 5% of persons with the highest Medicare costs, 28% of admissions involved procedures. Admissions for cardiovascular procedures and for cancer chemotherapy decreased with age and were infrequent in persons 85 years and older. Hip and femur procedures increased with age and accounted for 70% of the common procedures in persons 85 years and older. CONCLUSIONS: The most common major procedures account for a minority of hospitalizations of persons more than age 65, of persons 85 and older, of those who died, and of persons with the highest Medicare expenditures. Most hospitalizations are for general medical care. Major procedures appear to be used with restraint in the very old and in persons in their last year of life.

A survey of changes in the proportions of ambulatory training in internal medicine clerkships and residencies from 1986-87 to 1996-97.

PURPOSE: To determine changes from 1986-87 to 1996-97 in the proportions of time devoted to education in ambulatory settings within clerkships and internal medicine residencies. METHOD: In 1997, a questionnaire was sent to the departments of internal medicine of all 125 U.S. medical schools. The response rate was 73%. RESULTS: Training in ambulatory settings increased greatly over the decade. The percentages of time in ambulatory settings increased for clerkships from 6% to 28%, and for residencies from 14% to 30%. In 1986-87, two thirds of clerkships provided no ambulatory training; by 1996-97, only 5% were exclusively inpatient. In 1986-87, 56% of residencies devoted 10% or less of their time to ambulatory education. By 1996-97, no residency program was in this category, while 87% devoted at least 20% of their time to ambulatory training. All programs used hospital clinics for ambulatory education; more than half used private physicians' offices, while fewer used health centers, home care services, and HMOs. Problems in expanding ambulatory training included inadequate numbers of sites or patient volumes (58% of programs), insufficient instructors (55%), and costs. CONCLUSION: There has been a major increase in the proportions of time devoted to ambulatory education in clerkships and residencies. Significant problems impede the reported desire of program directors further to increase these proportions.

Measuring, managing, and improving the quality of end-stage renal disease care.

As the federal end-stage renal disease (ESRD) program enters its third decade, it continues to grow both in terms of patient enrollment and cost. High visibility as well as patient, physician, and societal concerns regarding ESRD treatment outcomes and expenditures make the development of improved and expanded quality assurance and improvement (QA/QI) mechanisms for the ESRD program vital. The purpose of a QA/QI program is to identify and apply techniques for assessing and improving ESRD care quality to achieve the best possible outcome for all patients who can benefit medically, within the expenditure constraints set by society. Current QA knowledge and methods are reviewed in this article and are judged to be useful but of limited value. Limitations of current quality assessment tools, provider resistance, and inadequate governmental support are substantial barriers to implementation of a QA program. An ESRD QA/QI program should develop improved QA tools at the same time that available tools are cautiously put to work. Such a program would be based in individual treatment units, using existing network and US Renal Data System structures and a new national ESRD QA committee for support and oversight. As additional ESRD QA data become available, providers would incorporate the new information into decision making at all levels to enhance patient outcome. Substantial financial support from the government will be needed to implement such a quality program. A comprehensive ESRD QA program could serve as a model for QA for the national health care system.

Regulation of renal rK1-kallikrein in spontaneously hypertensive rats.

Urinary and renal rK1-kallikrein was studied in spontaneously hypertensive rats (SHR) and their normotensive controls (WKY). It was demonstrated that the antiserum used for kallikrein radioimmunoassay (RIA) reacts with rK1- but not with rK7-protein. The specificity of the kininogenase assay was tested: rK7 had only 8% of the activity of rK1. Urinary kallikrein excretion by RIA was reduced by about two thirds in 5-week-old SHR compared WKY (11.5 versus 37.1 micrograms/24 h). On the contrary, the kidney content of rK1-kallikrein by RIA was increased by 40% in these rats (11.6 versus 8.4 ng/mg protein). The increase in kidney rK1 was confirmed by kininogenase assays. The same pattern of reduced urinary and increased renal rK1-kallikrein was observed in 8-week-old SHR rats. Kidney rK1-kallikrein mRNA tended to be lower (0.10 > p > 0.05) in SHR compared to WKY rats, suggesting that the increased kidney rK1 content is not due to increased rK1 synthesis. We hypothesize that the combination of high kidney content and low urinary excretion may be due to a defective mechanism for secretion of rK1 into the urine by tubular epithelial cells.

Endotoxin inhibits contraction of vascular smooth muscle in vitro.

Decreased responsiveness of the vasculature to vasoconstrictors has been implicated in the pathogenesis of endotoxic shock, yet the mechanism of diminished responsiveness has not been determined. In these studies, exposure of rat aortic rings to purified Escherichia coli lipopolysaccharide (endotoxin) in vitro inhibited subsequent contractions caused by vasoconstrictors. Contractions caused by the alpha-adrenoceptor agonist phenylephrine, as well as those induced by potassium depolarization, were depressed by endotoxin. The effect of endotoxin on vascular contractions was delayed. Phenylephrine-induced contractions were not decreased during a 1-h exposure to endotoxin (10 micrograms/ml), but they were markedly decreased when tested several hours after the exposure period. A large part of the inhibition caused by a 1-h exposure to endotoxin was endothelium dependent. In contrast, endotoxin inhibited contractions equally in rings with or without endothelium exposed to endotoxin for a longer period (3 h). The inhibitory effect of endotoxin was not affected by indomethacin, but it was eliminated in aortic rings treated with the protein synthesis inhibitor cycloheximide. These studies indicate that endotoxin potently inhibits vascular contraction in vitro. The effect of endotoxin is apparently independent of prostanoids but may involve protein synthesis and effects on both vascular smooth muscle and endothelial cells.