The influence of multimorbidity on hospital, intensive care, and emergency department use at the end of life for patients with chronic conditions

Thesis (Master's)--University of Washington, 2016-03

Abstract Background: Multimorbidity, defined as 3 or more co-existing conditions, poses unique challenges for patients, providers, and the health care system overall. These challenges include accurate prediction of prognosis, delivery of appropriate care and provision of coordinated care. An understanding of the impact of multimorbidity on health care utilization at the end of life may provide insights into interventions that improve the quality of health care provided to patients with multimorbidity. Objective: To determine differences in hospital utilization at the end of life for patients with multimorbidity compared with patients with one or two chronic diseases. Research Design: Mortality follow-back analysis using Washington State death records and electronic health records of patients at UW Medicine. Population: Patients in the UW Medicine system who had at least one chronic condition and died between 2011 and 2015. Measures: Healthcare use in the last 30 days of life including hospitalization, emergency department use, intensive care unit admission, as well as 30-day hospital readmission in the last 90 days of life and death in hospital. Results: Patients with multimorbidity had significantly higher utilization in the last 30 days of life for each category than those with a single diagnosis (inpatient admission 0.33 vs 0.22, p<0.001; ED admission 0.04 vs 0.03, p<0.001; and ICU admission 0.26 vs 0.15, p<0.001.) In addition, patients with multimorbidity were more likely to have a 30-day readmission in the last 90 days of life (0.12 vs 0.08) and death in hospital (0.45 vs 0.36, p<0.01.) Specific combinations of diseases were associated with utilization that was not simply additive. Cancer and COPD particularly had significant and contrasting impacts on hospital utilization, with cancer generally lessening and COPD increasing the effects. Conclusion: Multimorbidity is associated with increased healthcare utilization at the end of life. However, individual combinations of chronic conditions result in unpredictable interactions. Providers must consider the multimorbidity and specific combinations of disease when determining a patient’s treatment plan. Further research will add understanding to these complex relationships.