The Importance of Proximity to Death in Modelling Community Medication Expenditures for Older People: Evidence From New Zealand

Abstract

BackgroundConcerns about the long term sustainability of health care expenditures and in particular prescribing expenditures has become an important policy issue in most developed countries. Previous studies suggest that proximity to death (PTD) has a significant effect on total health care expenditures, with its exclusion leading to an overestimation of likely growth. There are limited studies of pharmaceutical expenditures taking PTD into account. ObjectiveThis paper presents an empirical analysis of public medication expenditure on older individuals in New Zealand (NZ). The aim of the study is to examine the individual effects of age and proximity to death (PTD) using individual level data. MethodsThis study uses individual level dispensing data from 2008/2009 covering the whole population of medication users age 70 years or more and resident in New Zealand. A case control methodology is used to examine individual cost and medication use for a 12 month period for decedents (cases) and survivors (controls). A random effects two part model, with a Probit and Generalized Linear Model (GLM) is used to explore the effect of age and proximity to death on expenditures. ResultsThe impact of proximity to death on prescription expenditure is not as dramatic as studies reporting on Acute and/or long term care. The 12 month decedent to survivor mean expenditure ratio was 1.95, 2 2.09 for males and 1.82 for females. The additional cost of dying in terms of prescription drugs decreases with age, with those who die at 90 years of age or older consuming fewer drugs on average and having a lower mean expenditure than those who died in their 70s and 80s. The following variables were found to have a decreasing effect on the mean monthly prescription expenditures, a reduction of 2.2% for each additional year of age, 4.2% being in the Mãori ethnic group and 7.8% for Pacific Islanders. Increases in monthly expenditure were associated with being a decedent 32.1%-62.6% (depending on month), being of Asian origin 16.2% or a male 12.6%. ConclusionsGiven the variance reported between survivors and decedents, to improve accuracy future projections should include PTD in their models. Policies targeted at reducing expenditures should not focus on age but on ensuring appropriate and cost effective prescribing especially towards the end of life. Key points for decision makers: Despite prescription medications being the most common medical intervention there is limited evidence on how proximity to death and ageing affect prescribing expenditures for older people. In terms of expenditure on prescription medications, proximity to death would appear to be a more important driver than ageing and should therefore be considered in any future expenditure projections.

Health care and long-term care costs by age and proximity to death in a publicly funded universal system: A descriptive study of population data

“…In general, the cost ratio was smallest for services comprising the smallest proportions of TC, that is, GPs, medicine and mental health, but was still substantial in younger age groups for medicine and mental health. Relatively low ratios for GPs and medicine are also reported in other studies (Atella and Conti 2014, Moore et al 2014, Hoover et al 2002. The decedent/survivor ratio of per capita costs was lower for LTC than somatic care for all ages except for the age groups 70-84 years.…”

“…While some studies conclude that age is not important once PTD is taken into account (Felder et al 2010, Hyun et al 2015, Yu et al 2015 and others claim the marginal importance of PTD compared with population ageing for future health care costs (Colombier andWeber 2011, van Baal andWong 2012), both PTD and age are typically found to be relevant (Raitano 2006). However, this may vary depending on, for instance, the disease (Wong et al 2011) or the type of health care service under study (Atella and Conti 2014, Moore et al 2014, Werblow et al 2007, Häkkinen et al 2008, Larsson et al 2008. A particularly important distinction is between acute health care and long-term care.…”

Trends in and drivers of healthcare expenditure in the English NHS: a retrospective analysis

“…Changes in the distribution of determinants, such as population ageing and a rise in the number of outpatient visits, played a lesser role but were also important explanatory factors. For community prescribing, proximity to death might be a more important driver than age as there is evidence that the effects of age on prescribing expenditure are smaller when models control for TTD [13,43,44]. Gender also seems to be a driver of pharmaceutical expenditure: there is evidence that females in all age groups incur higher expenditure [29] and receive more prescriptions [13].…”

Evolution of health care utilization and expenditure during the year before death in 2015 among people with cancer: French snds-based cohort study

“…In their seminal study based on Swiss data, Zweifel et al (1999) concluded that HCE can be more explained by proximity to death (PTD) (1-2 years before death) than person's age [5]. An equivalent effect were reported in other countries for a panel of health care [2,[6][7][8][9][10][11][12][13]. Even in including 260 morbidities in their estimates, Howdon and Rice (2018) demonstrated an effect of PTD on HCE, although this effect was attenuated when comorbidities were considered [2].…”