Care of Chronic Illness in Last Two Years of Life

More than 90 million Americans live with at least one chronic illness, and seven out of ten Americans die from chronic disease. Among the Medicare population, the toll is even greater: about nine out of ten deaths are associated with just nine chronic illnesses, including congestive heart failure, chronic lung disease, cancer, coronary artery disease, renal failure, peripheral vascular disease, diabetes, chronic liver disease, and dementia. As chronic disease progresses, the amount of care delivered and the costs associated with this care increase dramatically. Patients with chronic illness in their last two years of life account for about 32% of total Medicare spending, with much of it going toward physician and hospital fees (Medicare Part A and Part B) associated with repeated hospitalizations.

Our emphasis on this period of life is partially motivated by our interest in developing measures of efficiency and performance that minimize the chance that variation in the care delivered in different regions and by different hospitals can be explained by differences in the severity of patients’ illnesses. By looking at care delivered during fixed intervals of time prior to death, we can say with assurance that the prognosis of all the patients in the cohort is identical -- all were dead after the interval of observation. By further adjusting for differences in age, sex, race, and primary chronic illness, we believe that we have developed fair measures of the relative intensity of care provided to equally ill patients -- comparisons for which differences among patients are an unlikely explanation.

The primary database is derived from eight CMS research files for traditional (fee-for-service) Medicare: the Denominator file (which provides information on all Medicare beneficiaries’ demographic data, eligibility status and date of death) and files that contain records of Medicare claims: the MedPAR file, the Inpatient file, the Physician/Supplier Part B file, the Outpatient file, and the Home Health Agency, Hospice, and Durable Medical Equipment files.

The measures are for two study populations, one based on assignment of decedents to the hospital they most frequently used in the last two years of life, and the other on place of residence at time of death. To allow for two years of follow-back for all patients, the populations are restricted to those whose age on the date of death was 67 to 99 years, and to those having full Part A and Part B entitlement throughout the last two years of life. Persons enrolled in managed care organizations were excluded from the analyses. Blank cells indicate that a hospital did not have a sufficient study population (400 deaths during the five-year study period) to measure Part B and outpatient events. Hospital and regional event measures based on a count of fewer than 11 patients are also not displayed for reasons of patient confidentiality. These cells are marked "na." Click here to read about changes in methods between the 2001-05 and 2003-07 analyses.


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The Dartmouth Atlas of Health Care is based at The Dartmouth Institute for Health Policy and Clinical Practice and is supported by a coalition of funders led by the Robert Wood Johnson Foundation, including the WellPoint Foundation, the United Health Foundation, the California HealthCare Foundation, and the Charles H. Hood Foundation.