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February 14, 2011, Vol 171, No. 3, Pages 190-269

Editorial

Resource Use in the Last 6 Months of LifeWhat Does It Mean for Patients?

Abstract Full Text
Arch Intern Med. 2011;171(3):194-195. doi:10.1001/archinternmed.2010.360
Original Investigation

Resource Use in the Last 6 Months of Life Among Medicare Beneficiaries With Heart Failure, 2000-2007

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Arch Intern Med. 2011;171(3):196-203. doi:10.1001/archinternmed.2010.371
BackgroundHeart failure is a common cause of death among Medicare beneficiaries, but little is known about health care resource use at the end of life.MethodsIn a retrospective cohort study of 229 543 Medicare beneficiaries with heart failure who died between January 1, 2000, and December 31, 2007, we examined resource use in the last 180 days of life, including all-cause hospitalizations, intensive care unit days, skilled nursing facility stays, home health, hospice, durable medical equipment, outpatient physician visits, and cardiac procedures. We calculated overall costs to Medicare and predictors of costs.ResultsApproximately 80% of patients were hospitalized in the last 6 months of life; days in intensive care increased from 3.5 to 4.6 (P < .001). Use of hospice increased from 19% to nearly 40% of patients (P < .001). Unadjusted mean costs to Medicare per patient rose 26% from $28 766 to $36 216 (P < .001). After adjustment for age, sex, race, comorbid conditions, and geographic region, costs increased by 11% (cost ratio, 1.11; 95% confidence interval, 1.10-1.13). Increasing age was strongly and independently associated with lower costs. Renal disease, chronic obstructive pulmonary disease, and black race were independent predictors of higher costs.ConclusionsAmong Medicare beneficiaries with heart failure, health care resource use at the end of life increased over time with higher rates of intensive care and higher costs. However, the use of hospice services also increased markedly, representing a shift in patterns of care at the end of life.

Resource Use in the Last 6 Months of Life Among Patients With Heart Failure in Canada

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Arch Intern Med. 2011;171(3):211-217. doi:10.1001/archinternmed.2010.365
BackgroundHeart failure (HF) is a debilitating and chronic condition associated with significant morbidity and mortality. However, much less is known about end-of-life (EOL) costs among patients with HF.MethodsTo examine trends in resource use and costs during the last 6 months of life among elderly patients with HF, we evaluated data regarding all patients 65 years or older with HF who died between January 1, 2000, to December 31, 2006, in Alberta, Canada, and examined costs associated with all-cause hospitalizations, intensive care, emergency department visits, outpatient visits, physician office visits, and outpatient drugs in the 180 days before death. Overall costs and predictors of costs to the health care system were also examined.ResultsThe study population included 33 144 patients with HF who died. The mean age at death was 83 years. The clinical profile of patients changed during the study period, with an increasing comorbidity burden over time. Between 2000 and 2006, the percentage of patients hospitalized during the last 6 months of life decreased from 84% to 76% (P < .01); and the percentage dying in hospital decreased from 60% to 54% (P < .01). In 2006, the average EOL cost was $27 983 in Canadian dollars. In multivariate analyses, increasing age was inversely associated with EOL costs and comorbid conditions were associated with higher costs.ConclusionsResource use in the last 6 months of life among patients with HF in Alberta is changing, with a reduction in hospitalizations, in-hospital deaths, and an increase in the use of outpatient services. However, EOL costs are substantial and continue to increase.

Cost-Utility of Aspirin and Proton Pump Inhibitors for Primary Prevention

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Arch Intern Med. 2011;171(3):218-225. doi:10.1001/archinternmed.2010.525

The Magnitude of Acute Serum Creatinine Increase After Cardiac Surgery and the Risk of Chronic Kidney Disease, Progression of Kidney Disease, and Death

Abstract Full Text
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Arch Intern Med. 2011;171(3):226-233. doi:10.1001/archinternmed.2010.514

Effect of Cardiac Rehabilitation Referral Strategies on Utilization RatesA Prospective, Controlled Study

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Arch Intern Med. 2011;171(3):235-241. doi:10.1001/archinternmed.2010.501

Incidence and Transmission Patterns of Acute Hepatitis C in the United States, 1982-2006

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Arch Intern Med. 2011;171(3):242-248. doi:10.1001/archinternmed.2010.511

Lack of Follow-up After Fecal Occult Blood Testing in Older AdultsInappropriate Screening or Failure to Follow Up?

Abstract Full Text
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Arch Intern Med. 2011;171(3):249-256. doi:10.1001/archinternmed.2010.372
BackgroundIt is unclear whether lack of follow-up after screening fecal occult blood testing (FOBT) in older adults is due to screening patients whose comorbidity or preferences do not permit follow-up vs failure to complete follow-up in healthy patients.MethodsA prospective cohort study of 2410 patients 70 years or older screened with FOBT was conducted at 4 Veteran Affairs (VA) medical centers from January 1 to December 31, 2001. The main outcome measure was receipt of follow-up within 1 year of FOBT based on national VA and Medicare data. For patients with positive FOBT results, age and Charlson comorbidity scores were evaluated as potential predictors of receiving a complete colon evaluation (colonoscopy or sigmoidoscopy plus barium enema), and medical records were reviewed to determine reasons for lack of follow-up.ResultsA total of 212 patients (9%) had positive FOBT results; 42% received a complete colon evaluation within 1 year. Age and comorbidity were not associated with receipt of a complete follow-up, which was similar among patients 70 to 74 years old with a Charlson score of 0 compared with patients 80 years or older with a Charlson score of 1 or higher (48% vs 41%; P = .28). The VA site, number of positive FOBT cards, and number of VA outpatient visits were predictors. Of 122 patients who did not receive a complete follow-up within 1 year, 38% had documentation that comorbidity or preferences did not permit follow-up, and over the next 5 years 76% never received a complete follow-up.ConclusionsWhile follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of follow-up. Efforts to improve follow-up should address the full chain of decision making, including decisions to screen and decisions to follow up.
Invited Commentary
Challenges in Clinical Electrocardiography

Factitious Ventricular Tachyarrhythmia Outbreak

Abstract Full Text
Arch Intern Med. 2011;171(3):191-191. doi:10.1001/archinternmed.2010.537

Factitious Ventricular Tachyarrhythmia Outbreak—Discussion

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Arch Intern Med. 2011;171(3):192-192. doi:10.1001/archinternmed.2010.538
Images From Our Readers

Bikers resting on a beach

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Arch Intern Med. 2011;171(3):193-193. doi:10.1001/archinternmed.2010.545

Artist's depiction of Lyme disease

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Arch Intern Med. 2011;171(3):256-256. doi:10.1001/archinternmed.2010.544
In This Issue of Archives of Internal Medicine

Archives of Internal Medicine

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Arch Intern Med. 2011;171(3):190-190. doi:10.1001/archinternmed.2010.523
ONLINE FIRST

Hospice Use and High-Intensity Care in Men Dying of Prostate Cancer

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Arch Intern Med. 2011;171(3):204-210. doi:10.1001/archinternmed.2010.394
Commentary

Future Directions in Industry Funding of Continuing Medical Education

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Arch Intern Med. 2011;171(3):257-258. doi:10.1001/archinternmed.2010.498
Research Letters

Atovaquone-Proguanil Use in Early Pregnancy and the Risk of Birth Defects

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Arch Intern Med. 2011;171(3):259-260. doi:10.1001/archinternmed.2010.521

Use of Neuroimaging in US Emergency Departments

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Arch Intern Med. 2011;171(3):260-262. doi:10.1001/archinternmed.2010.520

Invited Commentary—Emergency Department Neuroimaging: Are We Using our Heads?Comment on “Use of Neuroimaging in US Emergency Departments”

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Arch Intern Med. 2011;171(3):262-264. doi:10.1001/archinternmed.2010.519
Editor's Correspondence

Cardiac Function in 5-Year Survivors of Childhood Cancer

Abstract Full Text
Arch Intern Med. 2011;171(3):264-264. doi:10.1001/archinternmed.2010.533

Cardiac Function in 5-Year Survivors of Childhood Cancer—Reply

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Arch Intern Med. 2011;171(3):264-265. doi:10.1001/archinternmed.2010.534

Vitamin D Supplementation and Fracture Risk

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Arch Intern Med. 2011;171(3):265-265. doi:10.1001/archinternmed.2010.531

Vitamin D Supplementation and Fracture Risk—Reply

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Arch Intern Med. 2011;171(3):265-266. doi:10.1001/archinternmed.2010.532

Vitamin D Efficacy and Safety

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Arch Intern Med. 2011;171(3):266-266. doi:10.1001/archinternmed.2010.528

Investigating Factors of Decline in Cognitive Function or Dementia

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Arch Intern Med. 2011;171(3):266-267. doi:10.1001/archinternmed.2010.529

Investigating Factors of Decline in Cognitive Function or Dementia—Reply

Abstract Full Text
Arch Intern Med. 2011;171(3):267-267. doi:10.1001/archinternmed.2010.530
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