Background
One of the major concerns relating to demographic aging is the increasing use of health care resources by the growing number of elderly (≥65 years) and oldest-old (≥80 years) patients. Survival and longevity have increased in several chronic conditions due to modern medical care [
1]. However, there is evidence that chronic medical conditions and their multiples (multimorbidity) increase with age and before death [
2]. Nowadays, the majority of people in industrialised countries die in health care institutions such as hospitals and nursing homes. However, there is a large variation in the proportion of deaths occurring in hospitals [
3]. In Europe, these differences are often explained by the differing availability of alternative health care services for elderly and oldest-old patients (i.e., nursing homes) [
4].
Previous research related to health care resource use has shown that the average cost of hospital care significantly increased with age. However, it is argued that not age per se is the main driver of health care costs, but ultimate closeness to death [
5,
6]. Nevertheless, the place of death has a considerable impact on health care resource use, since end-of-life care is generally more expensive in hospitals than in nursing homes, and even much more expensive than outpatient care at home [
7,
8]. Studies from the US and the Netherlands have shown that the last-year-of-life health expenditures constituted between 10 and 25 % of all medical expenses during life [
6,
8,
9]. There is evidence that these costs may even increase in the future.[
10]. In Switzerland, health insurance has been compulsory since 1996 and covers, in principle, all medical treatments and diagnostics prescribed by doctors. It also covers the costs of medical care provided in long-term care institutions [
11]. Patients contribute to the costs of care through co-insurance rates up to an annual ceiling and a modest flat daily co-payment for hospital stays. Three out of ten people have a private supplementary health insurance typically covering private rooms in hospitals. Switzerland-specific information concerning the costs of hospital stays in the last year of life is lacking. There is, however, no doubt that hospital inpatient stays are more expensive than any other kind of health care and therefore offer a large potential for cost saving.
A difficult clinical challenge is the admission of oldest-old patients to an intensive care unit (ICU). ICU care is expensive, highly rationed, morally charged, and therefore, decisions regarding admissions to ICUs remain crucial questions in oldest-old patients [
12]. There is evidence that admission rates to acute care hospitals as place of death decreased, while ICU admissions in the last month of life increased [
13]. In addition, huge differences regarding ICU admission rates and regarding physicians’ opinions of appropriateness of ICU care were observed between hospitals [
13,
14]. Furthermore, adequate support for shared decision-making and patient-care specific measures can increase the family satisfaction with ICU care and therefore better meet the patient’s and his/her family’s preferences of end-of-life care [
15].
It is well known that health care use depends not only on age and proximity to death, but also on other socio-demographic factors like gender, educational level, and marital status [
16]. Educational differences regarding morbidity and mortality are an uncontested finding in social epidemiology [
17‐
19]. There is also evidence that socio-demographic determinants have a significant influence on the place of death [
20,
21]. Furthermore, there is solid evidence of regional differences in health care use and place of death [
7,
22,
23]. However, to our knowledge, evidence on determinants of frequency and length of hospital stay in the time period preceding death is sparse.
We therefore explored, based on linked census and hospital discharge statistics, the potential impact of medical (e.g. multimorbidity) and social determinants (e.g., education, home ownership, marital status) on the aggregate length of hospital stay in the last year of life among those deceased in hospitals.
Results
We identified
N = 35,598 patients (18,993 men and 16,605 women) ≥65 years who died in 2007 and 2008 in hospital settings. Table
1 presents the characteristics of our study population.
Table 1
Baseline characteristics of patients deceased in hospitals in 2007 and 2008 (N = 35,598)
Length of hospital stays last 365 days, mean | 32.1 |
Length of hospital stays last 365 days, median | 20 |
Length of hospital stays last 365 days, 25th percentile | 7 |
Length of hospital stays last 365 days, 75th percentile | 44 |
Length of hospital stays last 365 days, SD | 38 |
Mean age at time of death (years) | 80.8 |
Sex
|
men | 53.4 % |
women | 46.6 % |
Cause of death
|
cancer | 35.5 % |
coronary heart disease | 12.5 % |
stroke | 8.0 % |
chronic obstructive pulmonary disease | 3.3 % |
dementia | 1.3 % |
other | 39.4 % |
Multimorbidity (assessed in time window 2–6 years before death)
|
no | 23.2 % |
yes | 34.2 % |
unknown (no hospital admission) | 42.7 % |
Intensive care during last hospital stay (ICU)
|
none | 83.2 % |
1–48 h | 8.2 % |
more than 48 h | 8.6 % |
Educational level
|
low | 38.3 % |
medium | 34.9 % |
high | 11.3 % |
unknown | 15.6 % |
House ownership
|
owner-occupier | 43.2 % |
tenant | 56.8 % |
Room category
|
regular | 77.9 % |
semi private/private | 22.1 % |
Marital status
|
never married | 8.0 % |
married | 50.4 % |
widowed | 34.5 % |
divorced | 7.1 % |
Nationality
|
Swiss | 92.2 % |
foreign | 7.8 % |
Language region
|
German | 67.5 % |
French | 27.4 % |
Italian | 5.1 % |
Nursing home bed density* | 6.7 |
We observed a strong right-skewed deviation of the distribution of aggregate number of days spent in a hospital during the last year of life. Less than one out of five patients received ICU care during the terminal hospital stay.
Aggregate length of hospital stay during the last year of life (mean, SD) and estimated incidence rate ratios (IRR) for baseline characteristics are presented in Table
2. A stratified analysis for the German and French speaking part of the country is given in Appendix
1 and
2.
Table 2
Mean aggregate length and results of the negative binomial regression analysis (N = 35,598)
Age (at time of death) (p < 0.001) | | | 0.98 |
0.98–0.99
|
Sex (p < 0.05) |
men | 32.3 | 38.7 |
1.00
| |
women | 31.9 | 38.2 | 1.03 |
1.00–1.06
|
Cause of death (p < 0.001) |
cancer (ref.)
| 39.1 | 36.4 |
1.00
| |
coronary heart disease | 23.6 | 34.8 | 0.68 |
0.65–0.70
|
stroke | 23.2 | 35.6 | 0.65 |
0.62–0.68
|
COPD | 35.6 | 44.3 | 0.89 |
0.83–0.95
|
dementia | 61.2 | 72.6 | 1.74 |
1.57–1.92
|
other | 29.0 | 38.3 | 0.81 |
0.78–0.83
|
Multimorbidity (p < 0.001) |
no (ref.)
| 33.9 | 39.7 |
1.00
| |
yes | 36.6 | 41.3 | 1.07 |
1.04–1.10
|
unknown (no hospital stay) | 27.5 | 34.8 | 0.79 |
0.77–0.82
|
ICU during last stay (p < 0.001) |
no (ref.)
| 33.3 |
39.5
|
1.00
| |
1–48 h | 20.3 | 29.9 | 0.65 |
0.62–0.67
|
more than 48 h | 31.3 | 33.2 | 0.97 |
0.93–1.01
|
Educational level (p < 0.001) |
medium (ref.)
| 31.3 | 36.1 |
1.00
| |
low | 31.3 | 37.6 | 0.98 |
0.95–1.01
|
high | 34.4 | 41.5 | 1.05 |
1.01–1.09
|
unknown | 34.0 | 43.2 | 1.06 |
1.02–1.10
|
House or flat owner (p < 0.001) |
tenant (ref.)
| 33.1 | 40.0 |
1.00
| |
owner-occupier | 30.7 | 36.4 | 0.93 |
0.91–0.95
|
Room category (p < 0.01) |
regular (ref.)
| 32.4 |
40.1
|
1.00
| |
semi-private/private | 31.1 | 32.2 | 1.04 |
1.01–1.07
|
Marital status (p < 0.001) |
married (ref.)
| 32.4 | 37.1 |
1.00
| |
never married | 33.1 | 42.9 | 1.04 |
0.99–1.08
|
widowed | 30.0 | 37.9 | 1.03 |
1.00–1.06
|
divorced | 38.4 | 44.9 | 1.12 |
1.07–1.17
|
Nationality (p < 0.001) |
Swiss (ref.)
| 31.4 | 37.8 |
1.00
| |
foreign | 39.8 | 45.1 | 1.09 |
1.04–1.14
|
Language region (p < 0.001) |
German (ref.)
| 27.6 | 34.1 |
1.00
| |
French | 42.1 | 46.5 | 1.36 |
1.32–1.40
|
Italian | 37.3 | 34.8 | 1.22 |
1.16–1.29
|
Nursing home bed densitya (p > 0.001) | | | 0.96 |
0.95–0.97
|
Increasing age was a significant predictor for shorter aggregate length of hospital stay in the last year of life. There were also significant differences in aggregate length of stay with respect to specific causes of death: compared to patients dying of cancer, those dying of coronary heart disease, stroke, and chronic obstructive pulmonary disease had a significantly shorter, while those dying of dementia significantly longer length of hospital stay. Multimorbidity significantly increased the aggregate duration of hospital stay. For those without any hospital admission within 2–6 years before death (and consequently no information about multimorbidity), the aggregate time spent in hospitals during the last year of life was significantly shorter than for those previously hospitalized but without a diagnosis of multimorbidity. For those who received ICU care for ≤48 h during the last hospitalisation, aggregate length of stay during the last year of life was significantly shorter than for those who received no ICU care or ICU care for >48 h. There was a remarkable difference between the French and the German speaking part regarding those who received ICU for >48 h (Appendix Tables
1 and
2): While this group had a significantly longer mean aggregate length of stay in the German speaking part, we found the opposite effect in the French speaking part. Patients with a high or unknown educational level had significantly longer aggregate stays than those with a medium or low educational level. Home ownership was a significant predictor of shorter aggregate length of stay. Those hospitalized in a semi-private/private room category (proxy for a private health insurance plan) had a significant longer aggregate stay than those hospitalized in a regular room category (proxy for a compulsory health insurance plan). Divorced patients had significantly longer aggregate stays compared to those married, widowed, and never married. Swiss citizens had significantly shorter aggregate stays than foreigners. Compared to the German speaking region, the aggregate length of hospital stay in the last year of life was longer in the Italian and even more so in the French speaking part of Switzerland. We also found a significant effect of nursing bed density on the aggregate length of stay: high regional nursing bed density was associated with a shorter aggregate length of hospital stays during the last year of life.
Discussion
As expected, health-related characteristics such as specific cause of death, multimorbidity, and admission to intensive care during the last hospitalization had a significant impact on the aggregate length of hospital stays during the last year of life. However, the duration was not dependent on health-related characteristics alone, but also on a variety of social determinants such as educational level, home ownership, hospital room category (proxy of the health insurance plan), language region, and nursing bed density.
A noteworthy observation was the substantial variation between aggregate length of hospital stays during the last year of life in the different language regions of Switzerland. Patients living in the Italian, and particularly those living in the French part spent more days in hospitals during the last year of life than those living in the German part. Prior studies gave already evidence for regional variation in health care use in Switzerland and in the US [
7,
22]. Consistently, a recent study from Switzerland found that people living in the French or Italian part were more likely to die in an institution than those living in the German part [
20]. One could argue that this might point to a higher propensity for more aggressive (and possibly futile) care at the end-of-life due to cultural differences between the language regions [
29].
The well-known divergence between the preferred and actual place of death might be due to unmet wishes of patients and their families regarding hospital and long-term care admissions before death and might represent an indicator of a low quality of dying [
30‐
32]. Therefore, home-based palliative care models, which decrease the time spent in hospitals during the last months of life, may increase the quality of dying and end-of-life care [
33,
34]. Different palliative care models have been developed in some European countries to implement alternative ways and increase the quality of end-of-life care, however, their effectiveness and impact on care before death varies substantially [
35]. A successful integration of palliative care services in the ICU can increase the quality, save costs and improve patient and family satisfaction [
36]. Unfortunately, due to regional variation and lack of reliable data, an evaluation of palliative care in Switzerland is difficult [
37].
Another remarkable observation is the variation of ICU care during the terminal hospitalization before death. In the US, around 20 % of deaths occur in ICU settings [
9] despite questionable benefits regarding survival and quality of life [
14]. Therefore, ICU care offers an important potential for health costs saving [
9]. In our study population, 16.8 % of all patients received ICU care during the terminal hospitalization. Many of those with an ICU stay ≤48 h died shortly after admission. Such a “sudden death” was associated with a significant shorter length of aggregate hospital stay in the last year of life. However, regarding aggregate length of hospital stay in the last year of life, those with an ICU stay >48 h did not significantly differ from those receiving no ICU care at all.
Multimorbidity was another informative determinant of aggregate length of hospital stay during the last year of life: Multimorbidity diagnosed during hospitalizations within 2–6 years before death was associated with a longer aggregate length of hospital stay in the last year of life, probably due to worse health status and therefore more medical needs of these often very sick patients. Conversely, patients without hospitalization within 2–6 years before death (and therefore no information on multimorbidity) had substantially shorter aggregate hospital stays and received less medical care.
We also found evidence for effects of socio-economic differences on the aggregate length of hospital stays. However, compared to other studies on morbidity and mortality differences in the old age [
17‐
19], our results were less consistent. Higher educational level was associated with increased aggregate length of stay. Conversely, home ownership, another proxy for higher socio-economic position, was associated with a significantly shorter aggregate length of stays. Patients with presumably better health insurance plans (semi-private/private room category) had longer stays compared to those with regular coverage plans. A similar study from Finland showed that educational level had little effect on hospital care in the last 7 years preceding death [
16]. Conversely, socio-economic characteristics were important determinants of admission to and death in a nursing home but not of acute care hospital length of stay [
16,
20]. Finally, regional attributes like language region and nursing home bed density were more consistent predictors of aggregate length of hospital stays in the last year of life compared to socio-economic determinants. As research on differences in health care between the two major language regions in Switzerland is scarce, it is difficult to elucidate our results. We found evidence for cultural differences in hospital treatments before death, because longer hospital stays, which imply more aggressive treatments before death, were more common in the French and Italian speaking part of Switzerland compared to the German speaking part. This result is in line with higher odds of hospitals as place of death in those regions [
26]. On the other side, nursing home bed density – known to be lower in the French speaking part [
38] – had a higher negative impact on length of hospital stays in this region, suggesting an important role of supply-sensitive care.
Strengths and limitations
One major strength of our study is the national coverage and the size of the study population. Another strength is the uniqueness of the data base generated by linking census with mortality and other administrative data. Furthermore, our study gives empirical evidence for several health indicators considering an extended time period before, and therefore little related to death.
Besides such strengths, the study has some limitations: As usual for secondary data and particularly administrative data analyses, by far not all desirable information is available (e.g., information about palliative care) and the use of proxy variables with limited validity is inevitable. However, the use of such weak measures does not necessarily lead to a systematic information bias but rather results in a non-differential misclassification and therefore underestimation of the true association. In Switzerland, there is no statistical information on the outpatient health care. Therefore it was not possible to assess diagnostic information of people that have not been hospitalized during the study period. As we restricted the study population to people having died in hospitals, our study population is not representative for the general population above 65 years. This is the reason why some causes of death (e.g. dementia) have only small percentages. Another limitation of the study is the incomplete linkage of all deaths to a census record as well as to a respective hospital record.
The percentage of hospital deaths is in line with another study from Switzerland [
39]. Our study is based on a virtually complete nationwide assessment of hospitalizations in 2002–2008 and thus mirrors the situation in Switzerland at that time. But due to differences in methodology, study populations and health care systems, we cannot validly compare our results with those of other countries.
Conclusions
The aggregate time spent in hospitals in the last year of life is mainly determined by differential health conditions and therefore, differential needs of medical care. However, remarkable unexplained disparities between the German and the Latin (French and Italian) speaking region of Switzerland remain: frequent and/or longer hospital stays in the last year of life are more common in the French and Italian speaking part of the country, probably due to cultural differences. Therefore, more detailed studies need to evaluate, whether these differences are based on patients’ health care needs and preferences, or whether they are supply-driven. As hospital care in general and ICU care in particular is expensive and often unwanted by those deceasing, more efforts to minimize aggressive care at the end-of-life – especially in the Latin regions of Switzerland – may be a promising target of health policy.
Acknowledgements
We thank the Swiss Federal Statistical Office for providing mortality and census data, and for the support, which made the construction of the Swiss National Cohort and this study possible. The members of the Swiss National Cohort Study Group are Matthias Egger (Chairman of the Executive Board), Adrian Spoerri and Marcel Zwahlen (all Bern), Milo Puhan (Chairman of the Scientific Board), Matthias Bopp (both Zurich), Nino Künzli (Basel), Fred Paccaud (Lausanne), and Michel Oris (Geneva).