Claudia Geue is a health economist at the University of Glasgow with a special interest in the pattern of healthcare utilisation and associated expenditure at the end of life. In this blog she discusses her recent Age & Ageing paper on healthcare costs.
We know that the last months of life are characterised by high healthcare costs, in particular when we look at the costs for hospital admissions. What is less clear though is the question whether there are any geographic variations in costs at the end of life.
Scotland was well suited for our analysis with approximately 21% of its population living in rural or remote areas, so it is important to provide appropriate and equitable care across all geographical regions. A number of studies have described differences in morbidity and mortality between geographical areas, mainly related to the distance to the nearest hospital for emergency admissions, such as acute myocardial infarction (AMI) and stroke. Thinking about rurality and related costs at the end of life, we could imagine two scenarios unfolding: i) increased costs for hospital care due to remoteness and related challenges (e.g. difficulties in discharge planning), or ii) reduced costs in the context of increased early mortality (e.g. patients are not hospitalised in time to get emergency care). Both situations are important but the healthcare and policy implications would be very different. The aim of our study was therefore to investigate whether geographic inequalities in mortality would translate into differences in costs incurred at the end of life.
To define our sample we used a five percent random sample of decedents in Scotland over a 15 year period and these were linked to all inpatient admissions during that time. We then identified the ten most frequent admission reasons to hospital for the last episode before death and looked at cost differences for these ten morbidities in each of our eight geographic areas. We found that after we adjust for age, sex, remaining time to death, socio-economic deprivation and geographic location, costs in very remote rural areas were generally higher than costs in large, urban areas. This was particularly apparent for AMI, stroke, and fracture of femur. After looking at the main driver of these costs, it emerged that patients in remote, rural areas tend to have longer stays at hospital.
Overall, we conclude that an increased risk of mortality for patients being admitted to hospital from rural areas, does not seem to lead to reduced costs due to non-admission. On the contrary, once patients are admitted to hospital, those living in remote areas incurred on average higher costs than those from large urban areas. We think that this clearly highlights the difficulties that rural areas face when discharging patients at the end of life in areas where there might be a lack of end-of-life support facilities, which tend to be more frequently available in larger urban areas.