Health Care Utilisation and Transitions between Health Care Settings in the Last 6 Months of Life in Switzerland

Abstract

BackgroundMany efforts are undertaken in Switzerland to enable older and/or chronically ill patients to stay home longer at the end-of-life. One of the consequences might be an increased need for hospitalisations at the end-of-life, which goes along with burdensome transitions for patients and higher health care costs for the society.AimWe aimed to examine the health care utilisation in the last six months of life, including transitions between health care settings, in a Swiss adult population.MethodsThe study population consisted of 11'310 decedents of 2014 who were insured at the Helsana Group, the leading health insurance in Switzerland. Descriptive statistics were used to analyse the health care utilisation by age group, taking into account individual and regional factors. Zero-inflated Poisson regression model was used to predict the number of transitions.ResultsMean age was 78.1 in men and 83.8 in women. In the last six months of life, 94.7% of the decedents had at least one consultation; 61.6% were hospitalised at least once, with a mean length of stay of 28.3 days; and nursing home stays were seen in 47.4% of the decedents. Over the same time period, 64.5% were transferred at least once, and 12.9% experienced at least one burdensome transition. Main predictors for transitions were age, sex and chronic conditions. A high density of home care nurses was associated with a decrease, whereas a high density of ambulatory care physicians was associated with an increase in the number of transitions.ConclusionsHealth care utilisation was high in the last six months of life and a considerable number of decedents were being transferred. Advance care planning might prevent patients from numerous and particularly from burdensome transitions.

Transitions Between Care Settings at the End of Life Among Older Homecare Recipients

“…Both personal characteristics and system factors were associated with transitions between care settings and hospitalizations toward the end of life, consistent with the Medical Outcome Study framework ( Tarlov et al, 1989 ) and previous research in the end-of-life domain (e.g., Aaltonen et al, 2014 ; Abarshi et al, 2010 ; Bähler et al, 2016 ; Gozalo et al, 2011 ). The findings were quite similar for transitions and hospitalizations, which is not surprising given that many of the transitions involved hospitalizations; in other words, there is overlap between the variables.…”

“…Research further indicates that transitions between care settings are influenced by a variety of personal factors, such as age, sex (e.g., Aaltonen et al, 2014 ; Abarshi et al, 2010 ; Bähler, Signorell, & Reich, 2016 ; Gozalo et al, 2011 ; Lawson et al, 2006 ; Wang et al, 2016 ) and medical conditions, such as dementia ( Aaltonen et al, 2012 ). Regional variation in care transitions has also been shown ( Aaltonen, Forma, Rissanen, Raitenen, & Jylhä, 2013 ; Gozalo et al, 2011 ; Wang et al, 2016 ), suggesting that transitions are influenced by regionally determined health care practices or health care supply.…”

Intensity of treatment in Swiss cancer patients at the end-of-life

“…Albeit, it needs to be considered that the CI in the latter association between the density of nursing home beds and intensive treatments is relatively wide and must therefore be interpreted with caution. Similar associations between treatment intensity and density of health care providers and infrastructure at the end-of-life were found in an earlier study conducted in Switzerland, 12 as well as in international studies. 4 , 5 In a recently published study, the use of home-visit nursing was associated with a significantly lower risk of hospitalizations related to pressure ulcers.…”

“… 3 , 11 The number of transitions between care settings also differed considerably between regions in Switzerland in the last 6 months before death. 12 While some differences in the intensity of treatment at the end-of-life certainly are justified, others might indicate overuse or underuse of treatment options in particular regions or subgroups. 13 , 14 The availability of health care services may play an important role: decedents who resided in regions with a higher availability of hospice services were shown to receive less intensive care at the end-of-life.…”

Preferences in end of life care substantially differ between the Netherlands and Japan

“…For example, the “percentage of deaths occurring in hospitals”, which is often used as an indicator, was 46.9% in England in 2016; with a 35.2% to 63.1% range between Care Commissioning Groups (CCGs). [ 1 ] Studies in 2013 and 2016 reported an average of 38% in Switzerland, with a considerable variation between cantons [ 2 , 3 ] . Also the complementary indicator: “the percentage of people who die at home” considerably varies between cantons: from 22.1% in Ticino (TI) to 33.3% in Aargau (AG).…”