Comparing End-of-Life Care for Older Adults Across High-Income Countries: Implications for the U.S.
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Project Summary The US has shorter life expectancy but spends 50%-70% more on healthcare than other peer countries. In 2011, the National Academy of Medicine (NAM) convened an expert panel to explore this paradox and recommend solutions. It concluded that “Data are simply lacking to fully understand the causal factors responsible for each of the diseases and injuries that disproportionately affect the US population and recommended that the NIH develop a portfolio of research focusing on international comparisons. In 2018, Drs. Cram and Landon founded the International Health Systems Research Collaborative (IHSRC) to systematically compare healthcare utilization, treatment patterns, and outcomes across five high-income countries (US, Canada, England, the Netherlands, and Israel) for cohorts of patients presenting with common diagnoses at a similar point in their care trajectory. Our IHSRC team has published more than 28 peer-reviewed manuscripts including papers in highly impactful journals such as JAMA and BMJ. We have presented our research at outside universities, at the Centers for Medicare and Medicaid Services (CMS), on podcasts, and at national meetings including Academy Health and the International Health Economics Association (IHEA). The overarching objective of this competitive renewal is to leverage our IHSRC infrastructure to explore differences in end-of-life (EOL) care and treatment intensity for older adults with poor-prognosis conditions across countries. Our application is highly responsive to NIA Notice of Special Interest 24-004 (released March 6, 2024). There is a strong rationale for focusing on EOL care because little prior research has compared care across countries and many of the results from our prior international comparisons utilizing data from 2-3 countries found significant differences in treatment patterns across countries. Our research will include all 11 current IHSRC members, but this application will focus on our original 5 countries plus Australia and Taiwan for which we are requesting funding under this proposal. Our proposal has three Aims that assess: 1) treatment intensity using retrospective decedent cohorts of older adults during their 12-months of life; 2) patterns of hospitalization, procedures, and EOL care in prospectively defined cohorts with an incident poor prognosis diagnosis (e.g., cancer, Alzheimer’s disease and related dementias); 3) a structured review of each country’s public insurance program practices and funding for EOL care (stage 1) and key informant interviews with practicing clinicians (primary care, geriatrics, palliative care) and other stakeholders (stage 2) to provide richer contextual information about EOL care in each country. In aggregate, these Aims will allow us to comprehensively explore the interplay between institutional and system factors and funding of EOL care and the treatment intensity and outcomes of older adults across countries.
