Cardiovascular Risk Profile Earlier in Life and Medicare Costs in the Last Year of Life

Article (PDF Available)inArchives of Internal Medicine 165(9):1028-34 · June 2005with56 Reads
DOI: 10.1001/archinte.165.9.1028 · Source: PubMed
Abstract
Health care costs are generally highest in the year before death, and much attention has been directed toward reducing costs for end-of-life care. However, it is unknown whether cardiovascular risk profile earlier in life influences health care costs in the last year of life. This study addresses this question. Prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6582 participants (40% women), aged 33 to 64 years at baseline examination (1967-1973), who died at ages 66 to 99 years. Medicare billing records (1984-2002) were used to obtain cardiovascular disease-related and total charges (adjusted to year 2002 dollars) for inpatient and outpatient services during the last year of life. Participants were classified as having favorable levels of all major cardiovascular risk factors (low risk), that is, serum cholesterol level lower than 200 mg/dL (<5.2 mmol/L), blood pressure 120/80 mm Hg or lower and no antihypertensive medication, body mass index (calculated as weight in kilograms divided by the square of height in meters) lower than 25, no current smoking, no diabetes, and no electrocardiographic abnormalities, or unfavorable levels of any 1 only, any 2 only, any 3 only, or 4 or more of these risk factors. In the last year of life, average Medicare charges were lowest for low-risk persons. For example, cardiovascular disease-related and total charges were lower by 10,367 dollars and 15,318 dollars compared with those with 4 or more unfavorable risk factors; the fewer the unfavorable risk factors, the lower the Medicare charges (P for trends <.001). Analyses by sex showed similar patterns. Favorable cardiovascular risk profile earlier in life is associated with lower Medicare charges at the end of life.

Figures

ORIGINAL INVESTIGATION
Cardiovascular Risk Profile Earlier in Life
and Medicare Costs in the Last Year of Life
Martha L. Daviglus, MD, PhD; Kiang Liu, PhD; Amber Pirzada, MD; Lijing L. Yan, PhD; Daniel B. Garside, BS;
Philip Greenland, MD; Larry M. Manheim, PhD; Alan R. Dyer, PhD; Renwei Wang, MD; James Lubitz, MPH;
Willard G. Manning, PhD; James F. Fries, MD; Jeremiah Stamler, MD
Background: Health care costs are generally highest in
the year before death, and much attention has been di-
rected toward reducing costs for end-of-life care. How-
ever, it is unknown whether cardiovascular risk profile
earlier in life influences health care costs in the last year
of life. This study addresses this question.
Methods: Prospective cohort of adults from the Chi-
cago Heart Association Detection Project in Industry in-
cluded 6582 participants (40% women), aged 33 to 64
years at baseline examination (1967-1973), who died at
ages 66 to 99 years. Medicare billing records (1984-
2002) were used to obtain cardiovascular disease–
related and total charges (adjusted to year 2002 dollars)
for inpatient and outpatient services during the last year
of life. Participants were classified as having favorable lev-
els of all major cardiovascular risk factors (low risk), that
is, serum cholesterol level lower than 200 mg/dL (5.2
mmol/L), blood pressure 120/80 mm Hg or lower and
no antihypertensive medication, body mass index (cal-
culated as weight in kilograms divided by the square of
height in meters) lower than 25, no current smoking, no
diabetes, and no electrocardiographic abnormalities, or
unfavorable levels of any 1 only, any 2 only, any 3 only,
or 4 or more of these risk factors.
Results: In the last year of life, average Medicare charges
were lowest for low-risk persons. For example, cardio-
vascular disease–related and total charges were lower by
$10 367 and $15 318 compared with those with 4 or more
unfavorable risk factors; the fewer the unfavorable risk
factors, the lower the Medicare charges (P for trends
.001). Analyses by sex showed similar patterns.
Conclusion: Favorable cardiovascular risk profile ear-
lier in life is associated with lower Medicare charges at
the end of life.
Arch Intern Med. 2005;165:1028-1034
H
EALTH CARE COSTS ARE
generally highest at the
end of life; a dispropor-
tionately large percent-
age of all Medicare expen-
ditures is for the year prior to death.
1-3
While
decedents comprise approximately 5% of
all Medicare beneficiaries, expenses in the
last year of life account for up to 31% of total
Medicare expenditures.
1-3
Moreover, each
year cardiovascular disease (CVD) ac-
counts for almost 39% of all deaths in the
United States.
4
With the proportion of
Americans 65 years and older increasing
rapidly, Medicare spending at the end of life
is an important issue.
Much attention has been directed
toward reducing costs for end-of-life
care,
5-8
but little research has focused on
identifying factors related to lower health
care utilization as a means of cost con-
tainment. It has been shown that the
benefits of having favorable levels of all
major CVD risk factors (ie, low risk in
young adulthood and middle age)
encompass not only lower age-specific
risk of mortality
9,10
but also favorable
economic impact on average annual
Medicare charges.
11
However, previous
studies on health care costs incurred at
the end of life are limited mostly to the
effects of sociodemographic factors.
3,12-14
To our knowledge, no data exist on
whether the benefits of low CVD risk
profile at younger ages extend to lower
Medicare expenditures in the last year of
life, reflecting lower disease and disabil-
ity even in the period before death. We
address this question with data from the
Chicago Heart Association Detection
Project in Industry (CHA) study on men
and women aged 32 to 64 years at base-
line in 1967 through 1973, who died at
ages 66 to 99 years and had Medicare
coverage for at least 1 year in 1984
through 2002.
Author Affiliations: Departments
of Preventive Medicine
(Drs Daviglus, Liu, Pirzada, Yan,
Greenland, Dyer, Wang, and
Stamler and Mr Garside), and
Medicine, Division of Geriatrics
(Drs Daviglus and Liu), and the
Institute for Health Services
Resear ch and Policy Studies
(Dr Manheim), Feinberg School
of Medicine, Northwestern Uni-
versity, Chicago, Ill; Department
of Health Economics and Man-
agement, Guanghua School of
Management, Peking University,
Beijing, China (Dr Yan);
National Center for Health
Statistics, Centers for Disease
Control and Prevention, Hyatts-
ville, Md (Mr Lubitz); Harris
School of Public Policy Studies,
University of Chicago, Chicago
(Dr Manning); and Department
of Medicine, Stanford University
School of Medicine, Palo Alto,
Calif (Dr Fries).
Financial Disclosure: None.
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METHODS
BASELINE EXAMINATION
AND MORTALITY FOLLOW-UP
During 1967 through 1973, the CHA study screened 39 522 men
and women 18 years or older employed by 84 Chicago-area or-
ganizations. Standardized methods were used.
15
Briefly, trained
staff measured height, weight, supine blood pressure, and se-
rum cholesterol.
16
Participants completed a questionnaire about
demographic characteristics, smoking history, medical diag-
noses, and treatment. Resting electrocardiograms (ECGs) were
classified as showing major, minor, or no abnormalities.
17,18
With
use of data from the National Death Index,
19
vital status was
ascertained through 2002 (average, 32 years follow-up). The
study protocol has received periodic institutional review board
approval. Appropriate administrative and physical safeguards
were established to protect confidentiality of the data.
MEDICARE CHARGES DATA
Medicare fee-for-service claims data were obtained from the Cen-
ters for Medicare and Medicaid Services for participants aged
65 and older who were eligible for Medicare benefits from 1984
(the first year data were available for research use) through 2002.
Centers for Medicare and Medicaid Services data for each par-
ticipant were cross-referenced by social security number, sex,
and birth date. Records include—for each medical service billed
to Medicare—date of service, total charges, diagnostic-related
group, primary diagnosis, and up to 9 other diagnoses coded
according to the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM). Claims related to
inpatient, skilled nursing facility, and outpatient hospital-
related care were available for 1984 through 2002; physician
visit claims (part B), durable medical equipment, home health
agency, and hospice claims for 1992 through 2002.
ELIGIBILITY AND STUDY COHORT
Persons with a history of myocardial infarction and major ECG
abnormality at baseline were excluded because data from these
individuals could not only skew costs but also obscure the re-
lationship of baseline risk profile with subsequent CVD-
related expenditures. Among 23 926 participants aged 32 to 64
years at baseline, free of myocardial infarction and major ECG
abnormalities, 9860 deaths occurred through 2002. Of these,
6921 decedents aged 66 to 99 years with at least 1 full year of
Medicare coverage during 1984 through 2002 were eligible for
this study. Of these decedents, 383 were excluded owing to miss-
ing data on risk factors and other variables used in the models.
One decedent with total charges exceeding $2 million (almost
double the next highest amount—clearly an outlier) was also
excluded. Thus, the study cohort includes 6582 decedents
(40.4% women).
CARDIOVASCULAR RISK GROUPS
Participants were classified according to baseline CVD risk sta-
tus as low risk, that is, having favorable levels of all major risk
factors: blood pressure 120/80 mm Hg or lower and not receiv-
ing antihypertensive medication,
20
serum cholesterol level lower
than 200 mg/dL (5.2 mmol/L),
21
body mass index (BMI; cal-
culated as weight in kilograms divided by the square of height
in meters) lower than 25.0,
22
not currently smoking, no diag-
nosed diabetes, and no minor ECG abnormalities.
9-11
Individu-
als not at low risk were grouped as having any 1 only, any 2
only, any 3 only, or 4 or more of the risk factors unfavorable,
that is, blood pressure higher than 120/80 mm Hg or receiving
antihypertensive medication, serum cholesterol level 200 mg/dL
or higher (5.2 mmol/L) or receiving cholesterol-lowering medi-
cation, BMI 25.0 or greater, currently smoking, diagnosed dia-
betes, and presence of minor ECG abnormalities.
STATISTICAL ANALYSIS
Medicare claims were used to estimate health care spending.
For each beneficiary, hospital-related charges (1984-2002) or
charges from all types of services covered by Medicare (1992-
2002) in the 1-year period before date of death were summed.
Charges related to CVD were defined as those for health care
services with primary discharge diagnosis coded as ICD-9-CM
390 through 459.
Baseline characteristics were compared across risk groups.
Either
2
(for categorical variables) or F tests (for continuous
variables) were used to detect statistically significant differ-
ences. Mean CVD-related and total charges in the year before
death were computed for each risk stratum by the general lin-
ear model method, with adjustment for sex, race, education,
and age at death because Medicare expenditures in the last year
of life tend to be lower at older ages.
12,13
Given the skewed na-
ture of charge data, a modified Cox regression procedure
11
was
used to assess statistical significance. This approach assumes
a semiparametric model for associations of medical costs with
cardiovascular risk strata and other factors. In this approach,
health care charges are first inverted by subtracting each per-
son’s charge from the maximal charge. Inverted charges are then
substituted for survival time in the Cox model so that people
with the highest charges are treated as having the shortest sur-
vival times and those with no charges are considered censored
at the maximal charge (equivalent to the longest survival time).
With this method linear trends across risk factor groups are
assessed using an ordinal variable with values 1 to 5 in Cox
regressions.
To account for inflation, all charges were adjusted to year
2002 dollars with use of the hospital and related services com-
ponent of the Consumer Price Index.
23
This correction also helps
to control for changes in costs stemming from advances in medi-
cal technology over time. To estimate costs, annual cost-to-
charge ratios for hospital patient care services obtained from
the Medicare Payment Advisory Commission were applied to
each year’s Medicare charges.
24
Cost-charge ratios from 1984
through 2002 ranged from 0.800 to 0.413. Sensitivity analyses
substituting estimated costs for charges were conducted. In ad-
dition, analyses were performed excluding beneficiaries en-
rolled in managed care plans.
Analyses were also repeated for the subsample of dece-
dents (n=4876) with data on charges from all types of claims
(1992-2002) and for subcohorts of decedents without minor
ECG abnormalities and diabetes at baseline (n=5827 with hos-
pital-related charges; n=4378 with charges for all types of ser-
vices). All analyses were conducted using SAS statistical soft-
ware version 8.02 (SAS Institute Inc, Cary, NC).
RESULTS
BASELINE CHARACTERISTICS
By definition, risk groups differed in average blood pres-
sure, serum cholesterol level, BMI, and prevalence of
smoking, diabetes, and minor ECG abnormalities
(
Table 1). Low-risk decedents were also younger and
more educated.
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AGE AT DEATH AND MEDICARE CHARGES
On average, persons with 4 or more risk factors died at a
younger age compared with others (
Table 2). Average
health care charges for inpatient and outpatient care in the
last year of life were lowest for low-risk individuals com-
pared with persons with unfavorable levels of any 1 or more
risk factors (Table 2). For example, CVD and total charges
for low-risk individuals were less by $10 367 and $15 318
compared with those with 4 or more risk factors; the fewer
the unfavorable risk factors, the lower the Medicare charges
(P for trends .001). Results for men and women sepa-
rately were consistent with those for the total sample; P for
trends ranged from .009 to .001 (
Figure).
For the subcohort with charge data on all types of ser-
vices covered by Medicare (n= 4876), patterns of associa-
tions were generally similar, that is, lower CVD and total
average Medicare charges in the last year of life for low-
risk persons compared with others (
Table 3). For ex-
ample, CVD-related and total charges for low-risk dece-
dents were lower by $14 684 and $8868 compared with
those with 4 or more risk factors (P for trends .001 and
.01, respectively). Analyses by sex using charge data on all
types of services showed similar patterns (data not shown).
Table 1. Baseline Characteristics of Study Participants (1967-1973)*
Characteristic
Baseline Risk Status†
Low Risk
(n = 108)
Not Low Risk
Any 1 Risk
Factor Only
(n = 609)
Any 2 Risk
Factors Only
(n = 1944)
Any 3 Risk
Factors Only
(n = 2606)
4 Risk Factors
(n = 1315)
Age, y 50.5 (7.2) 51.4 (7.3) 52.8 (7.0) 53.1 (6.6) 51.6‡ (6.8)
Women 49.1 52.4 45.7 39.0 29.4‡
Race, white 94.4 94.9 94.4 94.4 91.7‡
Education, y 13.3 (2.8) 12.6 (2.6) 12.3 (2.6) 12.2 (2.6) 11.9‡ (2.5)
In the risk definition
Systolic BP, mm Hg 114.9 (6.4) 126.5 (16.5) 139.0 (20.2) 146.1 (19.5) 149.3 (18.6)
Diastolic BP, mm Hg 70.4 (6.4) 75.9 (10.1) 81.7 (11.6) 85.5 (11.4) 87.2 (11.3)
Hypertension Rx 0 2.5 6.7 9.6 9.0
Serum Chol, mg/dL 175.8 (17.1) 193.2 (32.9) 205.8 (38.2) 227.0 (36.5) 234.2 (32.7)
BMI 22.6 (1.7) 23.3 (2.7) 25.4 (4.1) 27.5 (4.1) 28.8 (3.5)
Minor ECG abnormalities 0 1.0 2.3 5.8 25.3
Currently smoking 0 19.4 28.5 40.0 83.3
Diabetes mellitus 0 0.2 1.3 2.8 11.0
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); BP, blood pressure; Chol, Cholesterol;
ECG, electrocardiogram; Rx, prescription.
SI conversion factor: To convert Chol to millimoles per liter, multiply by 0.0259.
*Data are given as percentage of patients or mean (SD) value unless otherwise specified.
†With exclusions of persons with prior myocardial infarction or major ECG abnormalities, participants were classified as low risk (Chol level 200 mg/dL [5.2
mmol/L], BP 120/80 mm Hg and no antihypertensive medication, BMI 25, no minor ECG abnormalities, no current smoking, and no diabetes) or as having
any 1 only, any 2 only, any 3 only, or 4 or more of the above risk factors unfavorable.
P.01 from F (continuous variables) or
2
tests (categorical variables) for overall group differences (for sex, race, baseline age, and education). No tests were
performed for all other factors because they were included in the definition of baseline risk status.
Table 2. Adjusted* Mean Medicare Hospital-Related† Charges in the Last Year of Life (1984-2002)
by Baseline (1967-1973) Risk Status
Baseline Risk Status‡
No. of Persons
(N = 6582)
Age at Death,
Mean (SD), y CVD§ Charges,§ $ Total Charges, $
Low risk 108 78.1 (7.9) 8151 42 801
Not low risk
Any 1 risk factor only 609 77.4 (7.5) 11 642 55 517
Any 2 risk factors only 1944 77.9 (7.1) 12 608 51 702
Any 3 risk factors only 2606 77.9 (7.0) 14 863 54 457
4 Risk factors 1315 75.7 (6.6) 18 518 58 119
P for trend .001 .001 .001
*Cardiovascular (CVD)-related and total charges were adjusted for age at death, race, sex, and education.
†Hospital-related charges are for inpatient, skilled nursing facility, and outpatient care.
‡For abbreviations and risk definitions, see footnotes to Table 1.
§Charges from claims with a primary diagnosis of CVD based on International Classification of Diseases, Ninth Revision, Clinical Modification codes 390
through 459.
P.05 for comparison with the low-risk group based on linear model (age at death) or a modified Cox regression method (charges).
P values for trend based on a modified Cox regression method with “risk status” as an ordinal variable with values from 1 to 5.
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Exclusion of beneficiaries enrolled in managed care plans
(ranging from 1.7% in 1991 to 7.4% in 2002) had little im-
pact on the observed relationship of risk status with Medi-
care charges (P for trends ranged from .03 to .001).
With dollar amounts lower for estimated Medicare costs,
differences in health care costs across risk groups were simi-
lar to those with Medicare charges. For example, adjusted
total average annual costs for low-risk persons and those
with 4 or more risk factors were $23 235 and $34 453, a
relative difference of 48.3%, similar to that seen with charges
(35.8%) (data not shown). For decedents without minor
ECG abnormalities and diabetes at baseline, favorable lev-
els of all 4 cardiovascular risk factors (serum cholesterol,
blood pressure, BMI, and no smoking) were also associ-
ated with lower Medicare charges in the last year of life com-
pared with those with unfavorable levels of these risk fac-
tors (P for trends .004) (data not shown).
Charges in the last year of life for hospital inpatient
and outpatient care (
Table 4) and for all types of ser-
vices covered by Medicare (Table 5) were stratified by
sex, age at death, race, and education. In concordance
with published data,
1,3
Medicare expenditures in the last
year of life were generally lower for CHA participants who
died after age 75 years
1
compared with younger dece-
dents (ie, age 70-74 years) and higher among blacks.
3
COMMENT
Among both men and women, we found a significant graded
positive association between cardiovascular risk profile in
young adulthood or middle age and CVD-related and total
Medicare charges in the last year of life. In general, cardio-
vascular and total end-of-life health care expenditures for
hospital-related services were lowest for low-risk persons
and increased with number of unfavorable risk factors. Simi-
lar results were observed in analyses by sex and for expen-
ditures from all types of Medicare-covered services.
High health care costs incurred by persons at the end
of life have generated concern as an important contribu-
tor to rising medical expenditures by older persons,
25,26
and
almost one third of Medicare costs is incurred in the last
year of life.
1-3
With most persons—including those at high
risk for CVD—surviving past age 65 years,
27
and the pro-
jected increase in the proportion of the population 65 years
and older from 12% in 2000 to 20% by 2050,
28
absolute
number of deaths in older persons and total dollars spent
on care at the end of life are bound to increase, with im-
portant implications for future Medicare expenditures.
Approaches to control costs at the end of life have in-
cluded use of advanced directives and establishment of
hospital guidelines to identify and reduce unnecessary
care.
5-8
However, some argue that cost savings from such
health care practices are unlikely to be substantial, for
example, an estimated 6% for Medicare and 3% for total
health care spending at the end of life.
29
Major cardio-
vascular risk factors measured in young adulthood and
middle age strongly predict cardiovascular and all-
cause mortality long-term.
9,10
In addition, CVD risk pro-
file at younger ages predicts morbidity and health-
related quality of life in older age.
30,31
Furthermore, both
cumulative disability and disability in the 1 to 2 years be-
fore death are lower in persons previously with low or
moderate risk (based on levels of smoking, BMI, and ex-
ercise) compared with high-risk individuals.
32,33
Unfortunately, low-risk individuals comprised only a
small minority (10%) of the CHA population at base-
line. Low-risk status was similarly rare in the National Health
and Nutrition Examination Surveys (NHANES) and con-
tinues to be uncommon among adult Americans. Data from
NHANES for US adults aged 18 to 79 years, with low-risk
defined as BP lower than 120/80 mm Hg, cholesterol level
lower than 200 mg/dL (5.2 mmol/L), and not smoking
(among nondiabetic persons without history of myocar-
dial infarction), show low-risk population rates of 6% in
1971 through 1975, 8% in 1976 through 1980, and 17%
in both 1988 through 1994 and 1999 through 2000.
34
While genetic makeup undoubtedly influences the pro-
pensity to be at low risk, extensive data have shown that
in populations with little or no CVD, adoption of adverse
lifestyles results in increase of BMI, blood pressure, cho-
lesterol level, and diagnosed diabetes.
35
Owing to ad-
vances in medicine and increases in life expectancy, higher
proportions of persons with adverse risk factors earlier in
life survive to experience their deleterious consequences
in older age, including disease, disability, and higher health
care costs. Our findings suggest that preventive measures
at younger ages, that is, adherence to a healthy lifestyle,
including a healthy diet, regular physical activity, and ab-
stinence from smoking, can lead to a healthier older popu-
lation with less disability and greater ability to function in-
dependently, hence potentially lowering costs for care at
70
000
50
000
60
000
40
000
30
000
20
000
10
000
0
Men
P
<.001
Women
P
<.001
Men
P
=
.002
Women
P
=
.009
Hospital Related Charges, $
Low Risk Any
1 RF Only
Any 2 RFs
Any 3 RFs
4 RFs
CVD Charges Total Charges
Figure. Adjusted mean Medicare hospital-related charges in the last year of
life (1984-2002) by baseline (1967-1973) risk status for 3920 men and 2662
women. Adjusted for age at death, race, and baseline education.
Hospital-related charges are for inpatient, skilled nursing facility, and
outpatient care. Cardiovacular disease (CVD)-related charges include only
charges from claims with primary diagnoses codes 390 through 459,
International Classifications of Diseases, Ninth Revision, Clinical
Modification. With exclusions of persons with prior myocardial infarction or
major electrocardiographic abnormalities, participants were classified as low
risk (cholesterol level 200 mg/dL [5.2 mmol/L], blood pressure 120/80
mm Hg and no antihypertensive medication, body mass index [calculated as
weight in kilograms divided by the square of height in meters] 25, no
minor electrocardiograpic abnormalities, no current smoking, and no
diabetes), or as having any 1 only, any 2 only, any 3 only, or 4 or more of the
above risk factors (RFs) unfavorable. P values for trend across 5 risk strata
were based on a modified Cox regression method with risk status as an
ordinal variable with values from 1 to 5.
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older ages, even in the year immediately preceding death.
Not only do low-risk individuals have less disease and dis-
ability,
30-33
our results suggest that they also experience lower
acceleration in the functional decline common before death,
which is reflected by their lower costs in the last year of
life, lending further credence to the compression of mor-
bidity hypothesis.
36
Few studies have linked health habits or CVD bio-
medical risk factors to health care costs among older per-
sons, and in general risks were measured only a few years
before costs were incurred.
37,38
Nonsmoking, higher ex-
ercise level, and other healthy habits were associated with
lower medical costs
37
; elevated levels of cardiovascular
risk factors (ie, systolic blood pressure, serum choles-
terol level, and smoking) were related to higher annual
Medicare costs.
38
A previous report on 13 796 CHA par-
ticipants showed that total and CVD- and cancer-
related average annual Medicare charges over an 11-
year period were much lower for persons with favorable
risk status in middle age than for others (eg, for low-
risk men and women, total average annual Medicare
charges were lower by $1615 and $1885; CVD-related
charges lower by $979 and $556, respectively).
11
Recent
findings on 2013 CHA participants (baseline ages 36-52
years) also suggest that compared with persons with 1
or more adverse risk factors, those without cardiovascu-
lar risk factors in middle age incurred lower cumulative
Medicare expenditures from age 65 years to the point of
death or to advanced ages, despite greater longevity.
39
Research on health care costs at the end of life has been
limited mostly to the effects of sociodemographic factors
(eg, age, sex, and race),
3,12-14
various medical conditions,
14
or functional status and disability assessed mostly in the
period just before death.
40
Among 261 decedents drawn
from patients attending a fee-for-service group practice, total
medical expenses in the last year of life did not differ greatly
by functional status; hospital costs were lower, and nurs-
ing home and home health care costs were higher with
Table 3. Adjusted* Mean Medicare Charges for All Types of Services Covered by Medicare†
in the Last Year of Life (1992-2002) by Baseline (1967-1973) Risk Status
Baseline Risk Status‡
No. of Persons
(n = 4876)
Age at Death,
Mean (SD), y CVD Charges,‡ $ Total Charges, $
Low risk 94 78.9 (7.6) 11 643 86 908
Not low risk
Any 1 risk factor only 496 78.5 (7.5) 1796 89 810
Any 2 risk factors only 1470 79.2 (7.1) 20 179 90 951
Any 3 risk factors only 1941 79.4 (6.9) 23 603 94 868
4 Risk factors 875 77.2§ (6.9) 26 327 95 776
P for trend .001 .001 .01
Abbreviations: For abbreviations and risk definitions, see footnotes to Table 1.
*Cardiovascular (CVD)-related and total charges were adjusted for age at death, race, sex, and education.
†All types of services include claims from inpatient, outpatient, hospice, home health care, skilled nursing facility, physician visits, and durable medical
equipment.
‡Charges from claims with a primary diagnosis of CVD based on International Classification of Diseases, Ninth Revision, Clinical Modification codes 390
through 459.
§P.05 for comparison with the low-risk group based on linear model (age at death) or a modified Cox regression method (charges).
P values for trend based on a modified Cox regression method with “risk status” as an ordinal variable with values from 1 to 5.
Table 4. Mean Medicare Hospital-Related* Charges in the Last Year of Life (1984-2002) by Sex, Age at Death, Race, and Education
Variable
Men
Women Men and Women
No.
CVD
Charges, $
Total
Charges, $ No.
CVD
Charges, $
Total
Charges, $ No.
CVD
Charges, $
Total
Charges, $
Sex 3920 15 105 56 344 2662 13 656 51 245 6582 14 519 54 281
Age at death, y
66-69 707 13 681 53 083 341 13 399 60 785 1048 13 589 55 589
70-74 928 17 674 66 192 459 16 251 65 318 1387 17 203 65 903
75 2285 14 503 53 353 1862 13 063 46 028 4147 13 856 50 034
Race
White 3681 15 019 55 851 2502 13 497 50 294 6183 14 403 53 602
Black 197 13 954 60 958 137 17 907 68 318 334 15 576 63 977
Education, y
12 1152 14 558 54 049 896 15 706 54 053 2048 15 060 54 050
12 1251 15 231 57 817 1234 12 251 49 215 2485 13 751 53 545
13-15 650 17 165 61 632 353 14 665 54 290 1003 16 285 59 048
16 867 14 107 53 303 179 11 092 45 177 1046 13 591 51 912
Abbreviation: CVD, cardiovascular disease.
*Hospital-related charges are for inpatient, skilled nursing facility, and outpatient care.
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poorer functional status.
40
To our knowledge, the impact
of risk status earlier in life on health care costs incurred in
the last year of life has not been previously examined.
The current findings extend our previous report on
health care costs
11
and demonstrate that CVD risk pro-
file at younger ages also relates to Medicare expendi-
tures in the year prior to death. Associations persisted
when decedents with minor ECG abnormalities or dia-
betes at baseline were excluded and with adjustment for
age at death, a major factor influencing end-of-life medi-
cal costs.
12,13
Furthermore, the present study also in-
cludes BMI in the risk definition; this is of great public
health importance because prevalence of overweight and
obesity—a major independent CVD risk factor
41
—has in-
creased markedly in the United States during the last few
decades and continues to rise.
42,43
For the CHA cohort, only 1 set of cardiovascular risk
factor measurements was made, with no interim assess-
ments of risk factors. Lack of repeat measures would likely
lead to underestimation of the impact of baseline risk sta-
tus, that is, bias results toward the null. Diet and physical
activity were not assessed; therefore, it is not possible to
determine the relation of these behaviors with end-of-life
expenditures. Another limitation is lack of data on use of
health services not covered by Medicare, most impor-
tantly, long-term nursing home care and prescription drugs.
Among CHA participants 65 and older, adverse levels of
cardiovascular risk factors measured earlier in life were as-
sociated with lower mental, social, and physical function-
ing in older age and higher use of prescription drugs.
30
Thus,
potential bias from this limitation is likely to be toward un-
derestimation of health care costs of unfavorable risk fac-
tors levels. Data on out-of-pocket payments are not in-
cluded either; however, these constitute only a small
proportion of total expenditures. In addition, Medicare data
do not capture expenditures for decedents younger than
65 years. Nevertheless, the changing demographics of the
US population (ie, increasing numbers of older persons)
and the fact that most Americans (67%) die at 65 years or
older
44
and that Medicare spends more than $220 billion
per year in the health care of enrollees
45
warrants the study
of costs incurred by older decedents. Finally, the use of only
fee-for-service Medicare data may lead to underestimates
of actual total health care expenditures because health care
costs incurred outside the Medicare system are not ac-
counted for. However, Medicare is the largest single source
of health care spending in the United States, and exclu-
sion of beneficiaries enrolled in managed care plans did not
alter the observed positive relationship between risk pro-
file and Medicare charges.
In conclusion, these data indicate that persons with
favorable levels of all major cardiovascular risk factors
in young adulthood or middle age have lower health care
costs in the last year of life. Among those with unfavor-
able risk factors, the fewer the risk factors, the lower the
Medicare expenditures in the year before death. Cur-
rent treatments (including drug treatment and lifestyle
modifications) to control adverse levels of cardiovascu-
lar risk factors, while effective, do not typically reduce
morbidity and mortality to levels observed in low-risk
individuals.
46,47
Our findings underscore the impor-
tance of a comprehensive national public health policy
emphasizing concurrent primary prevention of all ma-
jor cardiovascular risk factors from early life on as an im-
portant strategic priority for controlling health care costs
in older ages and at the end of life.
Accepted for Publication: December 9, 2004.
Correspondence: Martha L. Daviglus, MD, PhD, Depart-
ment of Preventive Medicine, Feinberg School of Medi-
cine, Northwestern University, 680 N Lake Shore Dr, Suite
1102, Chicago, IL 60611 (daviglus@northwestern.edu).
Funding/Support: This research was supported by grants
from the National Heart, Lung, and Blood Institute (R01
HL62684 and R01 HL21010); the Chicago Health Re-
search Foundation; and private donors.
Table 5. Mean Medicare Charges for All Types of Services Covered by Medicare*
in the Last Year of Life (1992-2002) by Sex, Age at Death, Race, and Education
Variable
Men
Women Men and Women
No.
CVD
Charges, $
Total
Charges, $ No.
CVD
Charges, $
Total
Charges, $ No.
CVD
Charges, $
Total
Charges, $
Sex 2798 23 130 97 100 2078 21 085 87 907 4876 22 259 93 182
Age at death, y
66-69 381 14 914 81 788 171 23 810 109 788 552 17 670 90 462
70-74 579 24 569 105 635 303 22 786 101 040 882 23 956 104 057
75 1838 24 380 97 585 1604 20 474 83 094 3442 22 559 90 832
Race
White 2629 23 243 96 979 1950 20 804 86 296 4579 22 205 92 430
Black 133 20 731 101 259 113 27 016 119 232 246 23 618 109 515
Education, y
12 767 22 105 86 985 678 24 134 90 744 1445 23 057 88 749
12 885 23 454 101 496 970 19 001 85 412 1855 21 125 93 086
13-15 478 24 487 105 729 282 21 931 92 024 760 23 539 100 644
16 668 22 906 96 713 148 19 168 83 424 816 22 228 94 303
Abbreviation: CVD, cardiovascular disease
*All types of services include claims from inpatient, outpatient, hospice, home health care, skilled nursing facility, physician visits, and durable medical
equipment.
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Acknowledgment: We are indebted to the officers and
employees of the Chicago companies and organizations
whose invaluable cooperation and assistance made this
study possible; to the staff members and volunteers in-
volved in the Chicago Heart Association Detection Project
in Industry; and to our colleagues who contributed to this
important endeavor (an extensive list of colleagues is given
in Cardiology. 1993;82:191-222).
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    • "It has been found that whites and females have higher health care expenses in general than others, but lower levels close to death (Hogan et al., 2001; Shugarman et al., 2009). This stands in contrast to the finding that higher expenses are incurred in the last year of life for people with a higher cardiovascular risk profile earlier in life (Daviglus et al., 2005 ). To summarize, it remains unclear how large the variation is in the costs of dying, and what socio-demographic factors are contributors to variation. "
    [Show abstract] [Hide abstract] ABSTRACT: The health care costs of population ageing are for an important part attributable to higher mortality rates in combination with high costs of dying. This paper answers three questions that remain unanswered regarding the costs of dying: (1) contributions of different health services to the costs of dying; (2) variation in the costs of dying; and (3) the influence of preceding health care expenses on the costs of dying. We retrieved data on 61,495 Dutch subjects aged 65 and older from July 2007 through 2010 from a regional health care insurer. We included all deceased subjects of whom health care expenses were known for 26 months prior to death (n=2,833). Costs of dying were defined as health care expenses made in the last six months before death. Lorenz curves, generalized linear models and a two-part model were used for our analyses. (1) The average costs of dying are €25,919. Medical care contributes to 57% of this total, and long-term care 43%. The costs of dying mainly relate to hospital care (40%). (2) In the costs of dying, 75% is attributable to the costliest half of the population. For medical care, this distribution figure is 86%, and for long-term care 92%. Age and preceding expenses are significant determinants of this variation in the costs of dying. (3) Overall, higher preceding health care expenses are associated with higher costs of dying, indicating that the costs of dying are higher for those with a longer patient history. To summarize, there is not a large variation in the costs of dying, but there are large differences in the nature of these costs. Before death, the oldest old utilize more long-term care while their younger counterparts visit hospitals more often. To curb the health care costs of population ageing, a further understanding of the costs of dying is crucial.
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    • "Research shows that middle-age individuals with a low CVD risk profile, defined as the levels of established modifiable CVD risk factors, [5] have dramatically lower mortality rates, greater longevity, and substantially lower rates and risks for CVD events in comparison to individuals without a lowrisk profile [5][8]. Furthermore, a low risk profile in middle age is associated with higher quality of life and lower Medicare charges in advanced age [6],[9],[10]. There is substantial epidemiological evidence that shows that a person's risk for cardiovascular disease will be dramatically lower if he or she can maintain optimal levels of risk factors until middle age. "
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    • "This demographic shift has resulted in importance being placed on health status trends for older people and how these trends may change in future, due to the anticipated increase in demand for health and social care ser- vices [4]. More recently, longer life expectancy has led to discussion of the likely quality of life associated with these additional years [5,6]. 'Quality of ageing' is rapidly becoming one of the most important social, political and health priorities of the early 21st century. "
    [Show abstract] [Hide abstract] ABSTRACT: Social isolation affects a significant proportion of older people and is associated with poor health outcomes. The current evidence base regarding the effectiveness of interventions targeting social isolation is poor, and the potential utility of mentoring for this purpose has not previously been rigorously evaluated. The purpose of this study was to examine the effectiveness of a community-based mentoring service for improving mental health, social engagement and physical health for socially isolated older people. This prospective controlled trial compared a sample of mentoring service clients (intervention group) with a matched control group recruited through general practice. One hundred and ninety five participants from each group were matched on mental wellbeing and social activity scores. Assessments were conducted at baseline and at six month follow-up. The primary outcome was the Short Form Health Survey v2 (SF-12) mental health component score (MCS). Secondary outcomes included the SF-12 physical health component score (PCS), EuroQol EQ-5D, Geriatric Depression Score (GDS-10), social activity, social support and morbidities. We found no evidence that mentoring was beneficial across a wide range of participant outcomes measuring health status, social activity and depression. No statistically significant between-group differences were observed at follow-up in the primary outcome (p = 0.48) and in most secondary outcomes. Identifying suitable matched pairs of intervention and control group participants proved challenging. The results of this trial provide no substantial evidence supporting the use of community mentoring as an effective means of alleviating social isolation in older people. Further evidence is needed on the effectiveness of community-based interventions targeting social isolation. When using non-randomised designs, there are considerable challenges in the recruitment of suitable matches from a community sample. SCIE Research Register for Social Care 105923.
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