presents demographics and dual-use patterns of our sample, both overall and grouped by dementia status. More than half of our sample were between the ages of 75 and 84, along with 33 percent between 67 and 74, and 11 percent age 85 or older. Eighty-five percent were white, and as is typical for an elderly VA cohort, over 98 percent were male. Eighty-seven percent received at least some care through the Medicare system during the final 2 years of life. Our estimated dementia prevalence by age, race, and sex is presented in . We identified 31.5 percent of decedents as having dementia at the end of life, with a higher prevalence of dementia among older decedents (p<.001), among women (p<.001), and among blacks (p<.001).
Patient Demographics and Veterans Affairs (VA)-Medicare Dual-Use Patterns*
Estimated End-of-Life Dementia Prevalence by Age, Race, and Sex
presents descriptive statistics on days of acute inpatient care and ICU care during the final 30 days of life. Compared with decedents without dementia, decedents with dementia on average received more days of acute inpatient care (6.7 versus 6.0, p<.001), but spent fewer days in the ICU (1.4 versus 1.8, p<.001). We also found that older decedents received less acute care near the end of life, compared with younger decedents. These patterns of utilization were also evident during the final 90 days of life and the final year of life (not shown).
Acute Inpatient Days and Intensive Care Unit (ICU) Days during the Last 30 Days of Life, by Dementia Status and Age
Comparisons between VA and Medicare utilization at the patient level likely reveal more about patient dual-use patterns than about differences in practice patterns between the two systems. However, it is notable that the vast majority of these elderly VA users obtained at least some care through Medicare, and on average they received more acute care through the Medicare system at the end of life than through the VA system. Compared with patients who only used VA, dual-users were more likely to have dementia (p<.001), were older (p<.001), were more likely to be white (p<.001), and were slightly more likely to be male (p<.01) (not shown).
and present the use of aggressive treatments per acute stay during the final 30 days of life, by dementia status and age. There were 122,740 acute stay discharges during the final 30 days of life, representing 94,100 unique patients (31,654 with dementia). Forty-five thousand three hundred and sixteen of these stays occurred in VA, and 77,424 were provided through Medicare. Overall, 55.7 percent of patients had at least one acute stay in the final 30 days of life, including 59.4 percent of patients with dementia, and 53.9 percent of patients without dementia (not shown). We found that across age groups and in both health care systems, patients with dementia were less likely to receive aggressive treatments during a given acute hospital stay, with a few exceptions in dialysis treatment. This general pattern was also evident during the final 90 days of life and the final year of life, again with dialysis providing the only exceptions (not shown).
VA and Medicare Aggressive Treatment Use per Acute Stay in the Last 30 Days of Life, by Dementia Status and Age
Overall Aggressive Treatment Use per Acute Stay in the Last 30 Days of Life, by Dementia Status and Age.
For all ages combined, the overall differences in aggressive treatment use between VA and Medicare were significant at the .001 level for each aggressive treatment except ICU admission, with a p-value of .067. All of these differences, including ICU admission, were significant at the .01 level after controlling for demographic and clinical factors in a probit regression.
presents results from stay-level probit regressions of each aggressive treatment on dementia status, controlling for age group, sex, race, Charlson comorbidity score (excluding dementia diagnoses), and principal diagnosis for the stay. VA analyses also control for the number of ICU beds per 100,000 unique patients in the station where the stay occurred. Results are presented for VA, Medicare, and both systems combined; because the models control for age group, we do not break out results by age groups as in previous tables. The coefficients (dF/dx) represent the difference in likelihood of receiving the given aggressive treatment for a patient with dementia, compared with a patient without dementia, at the means of the control variables. Note that results are reported in percentage points and not as percent differences. For example, the difference in overall ICU admission rates from would be reported as 8.7 percentage points, but this indicates that patients with dementia were 22 percent less likely than patients without dementia to be admitted into the ICU. Likewise, the difference in cardiac catheter use would be reported as a 2.2 percentage point difference and indicates that patients with dementia were 67 percent less likely to receive cardiac catheterization than patients without dementia.
Probit Results: Regressing Each Aggressive Treatment on Dementia Status and Covariates, for Veterans Affairs (VA) and Medicare Acute Stays in the Last 30 Days of Life*
In both systems, we found that after controlling for other factors, patients with dementia were substantially less likely to receive each of the aggressive treatments. At the means of the other independent variables, patients with dementia were 7.5 percentage points less likely to be admitted to the ICU (95 percent confidence interval [CI], 6.9–8.1; percent of stays with ICU admission =36.8 percent), 5.4 percentage points less likely to be placed on a ventilator (95 percent CI, 5.0–5.9; percent of stays with ventilator use =17.1 percent), 0.7 percentage points less likely to receive cardiac catheterization (95 percent CI, 0.6–0.8; percent of stays with cardiac catheterization =2.7 percent), 1.4 percentage points less likely to receive pulmonary artery monitoring (95 percent CI, 1.2–1.5; percent of stays with pulmonary artery monitoring =2.6 percent), and 0.6 percentage points less likely to receive dialysis (95 percent CI, 0.4–0.8; percent of stays with dialysis =4.6 percent). We found similarly low levels of aggressive treatment for patients with dementia when including the final 90 days of life and the final year of life (not shown).