Objectives: (1) To compare the number of hospital days used by survivors with those by persons in their last, second last, and third last year of life in relation to age; (2) to analyse lifelong hospital utilisation in relation to life expectancy. Design: Cohort study using a 10% sample (stratified by age and sex) of persons insured by one sickness fund. Setting: Germany, 1989Germany, -1995. Subjects: 69 847 survivors (with a minimum of three more years to live), 1385 persons in last, 1368 in second last, and 1333 in third last year of life. Results: The number of days spent in hospital in the last year of life was lowest for the young (24.2 days under age 25) and the old (23.2 days at age 85+) and was greatest at ages 55-64 (40.6 days). The ratio of days to survivors was highest at age 35-44 (31.0) and fell continously thereafter to 4.3 at age 85+. Similar patterns were seen for hospital days in the second and third year before death, except that peaks were at 35-44 years (22.5 and 13.7 days respectively). Calculated lifelong number of hospital days increased with age from 54.8 (death at age 20) to 201.0 (age 90). Numbers of hospital days per year of life, averaged over the entire lifespan, were stable at 2.0-2.2 for deaths between age 50 and 90 (and up to 2.7 at age 20). Conclusions: Lifelong hospital utilisation for persons who die at 50 or later is directly proportional to the number of years lived. These data contradict results from cross sectional studies that suggest an exponential rise in health care costs as longevity increases. They have important implications for projections of future health care expenditure.T he belief that health care costs rise steeply with age is considered "common knowledge" by most clinicians, politicians, health care researchers, and lay people alike. Demographic changes leading to an aging population, a consequent rise in chronic diseases, and technological advances are considered by many to form a triad that will make health care costs unbearable in the future. The belief persists despite a growing body of evidence in support of a more complicated picture. The belief is apparently supported by cross sectional data showing a relation between age and (rising) costs.Fuchs was the first to point to the fact that the relation between age and health care utilisation or costs is biased by the fact that the percentage of people in their last year of life (which costs well above average) is increasing rapidly with age.1 He hypothesised that if mortality in all age groups above 65 would be assumed to be constant, health care costs with age would also be constant.US Medicare data support this assumption. In addition, however, two further things complicate the picture: (1) health care costs for persons in their last year of life reach a maximum at about the age of 70 years and fall with higher age, and (2) health care costs for the group of survivors rise until the age of about 85, reach a maximum and fall with higher age.2 The marginal increase in lifetime costs associated with an addi...

Methods of quality management and quality assurance aim at improving medical facilities, procedures and services to benefit patients and avoid potential harm. It is prudent to call these measures "secondary technologies" because they are used to optimize the so-called "primary technologies" used in medicine such as diagnosis, therapy, rehabilitation and counseling. However, in light of the considerable efforts and high costs associated with quality assurance measures, it is important that these measures be subject to critical review. Like all other procedures or technologies used in health care, quality assurance measures must be reviewed with respect to their effects and costs prior to and during implementation. The primary issue of such pre-evaluation and re-evaluation is to analyze whether the benefits justify the costs and then to define how quality assurance measures can be used to help improve the outcomes of health care services. Quality assurance measures must focus on health care priorities. They should be limited to common and serious health problems, the core services of the different health care providers and to high-risk interventions. Quality assurance must contribute primarily to the health of patients and protect them from avoidable harm. Quality management must be patient and outcome oriented and should uphold the ideal of the responsible and informed patient, whose dignity and autonomy must be respected. Above all, strengthening the position of health care users requires comprehensive, comprehensible and easily accessible information on the targets and outcomes of quality management. This is a basic requirement for setting up a quality-oriented information culture in the health care system and should be given high priority.

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