title: Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study.
abstract: Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD.
  
  
  
  We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients.
  
  
  
  During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care.
  
  
  
  Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.
authors.affiliation: Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Bradley
authors.initials: B
authors.lastname: Chen
authors.affiliation: Department of Public Health Sciences & Epidemiology, University of Hawaii at Manoa, 1960 East-West Road, Biomed D204, Honolulu, HI, USA.|François-Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, USA.|Center for Global Development, Washington, D.C., USA.
authors.forename: Victoria Y
authors.initials: VY
authors.lastname: Fan
authors.affiliation: Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.|Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Yiing-Jenq
authors.initials: YJ
authors.lastname: Chou
authors.affiliation: Big Data Center, China Medical University Hospital, Taichung, Taiwan. chinchik@gmail.com.|Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, 13F.-2, No.101, Kaixuan Rd., East Dist, Tainan City, Taiwan. chinchik@gmail.com.
authors.forename: Chin-Chi
authors.initials: CC
authors.lastname: Kuo
mesh_terms: D000368:Aged; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D017048:Health Care Costs; D005102:Health Expenditures; D006291:Health Policy; D017051:Hospice Care; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000191:economics / Q000706:statistics & numerical data; D051436:Renal Insufficiency, Chronic / Q000191:economics* / Q000628:therapy; D012121:Respiration, Artificial / Q000191:economics / Q000706:statistics & numerical data; D012151:Resuscitation / Q000191:economics / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000191:economics / Q000706:statistics & numerical data; D013624:Taiwan; D013727:Terminal Care / Q000191:economics*
keywords: Chronic kidney disease; Elderly; End-of-life care; Health care costs; Intensive procedures