NIHR DC Discover

NIHR Signal Multiple illnesses and end-of-life care drive high healthcare costs in old age

Published on 24 October 2017

doi: 10.3310/signal-000496

Ageing on its own does not drive healthcare costs. Instead, this research found that the increasing number of health conditions and age-related impairments along with the proximity to death are more strongly linked to healthcare costs than age alone.

This UK study investigated healthcare costs in people over 80 years old. Costs increased to the mid-90s before declining again. Proximity to death was the strongest predictor of cost, which was higher for people aged 80-84: £10,027 per year versus £7,021 per year for those over 100. Multiple illnesses also had a strong influence, with each additional health complaint progressively increasing costs.

This suggests that to provide person-centred and efficient healthcare services for all, planning should take account of the number and types of conditions rather than age alone.

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Why was this study needed?

Getting older is associated with increased healthcare costs. The number of individuals aged over 80 years in the UK has increased by 65% in the last decade. This raises concerns about the pressures this will place on healthcare resources.

Getting older is also associated with having more than one health condition at the same time, often referred to as multi-morbidity. Although a large proportion of lifetime healthcare costs incur as people reach the end of life, ageing is also associated with multi-morbidity and consequently complex healthcare needs.

This study aimed to untangle the extent to which increasing healthcare costs in the very old are attributable to multi-morbidities and proximity to death, rather than increasing age alone. This is essential to understand how to design healthcare services appropriately for the ageing population.

What did this study do?

This cohort study used routine general practice data from the Clinical Practice Research Datalink (CPRD) on consultations, number of health conditions, drugs prescribed and referrals to healthcare specialists. Information was available for 98,220 adults aged 80 years or older, collected from 372 GP practices over a five year period (2010-2014). Hospital episodes were identified for the same people.

The researchers modelled how annual healthcare costs were associated with age, gender, number of health conditions, the severity of the condition, age-related impairments and how close the person was to death. The age-related impairments they considered included problems with memory, walking, hearing and eyesight.

The authors did not have information on where people lived. Living in residential care incurs high health and social care costs which may not be recorded in CPRD, and this would lead to an underestimate of costs.

What did it find?

  • Total per person annual healthcare costs increased from age 80-84 years (£3,588) to 85-95 years (£4,018) before reaching a maximum in the 90-94 age group (£4,115) and then declining after that (£3,931 for 95-99 years, £2,867 for 100 years +). Secondary care costs were highest in the 90-94 age group (£2,737), and primary care in 95-99 year-olds (£676).
  • Although women were more likely than men to use healthcare services, there were no differences between healthcare costs overall between men and women.
  • The likelihood of using healthcare services did not change with age, except for people aged over 100 who were less likely to incur healthcare costs than 80-84 year-olds.
  • As the number of multi-morbidities in each individual increased so did the likelihood of increased healthcare costs.
  • Proximity to death was the strongest predictor of incurring high healthcare costs. However, the cost of end-of-life care decreased with increasing age. Healthcare costs in the last 12 months of life were £10,027 for people aged 80-84 years compared with £7,021 for people aged over 100 years.

What does current guidance say on this issue?

The Kings Fund (2016) investigated pressures in general practice by analysing another database collecting GP contact data called ResearchOne. The Kings Fund report revealed that although people are living longer, this has led to a rise in the number of those living with chronic and often multiple conditions. Furthermore, the largest growth in the average number of chronic conditions was seen in people aged 85 and over.

The Department of Health (2012) reports that although the likelihood of having a long-term condition increases with age, by 2034 the number of people 85 and over is projected to be 2.5 times that in 2009, reaching 3.5 million people (5% of the population).

What are the implications?

Multi-morbidity and nearing the end of life appear to be the main drivers of costs in the very old population (80+), rather than age.

For healthcare delivery, this suggests a shift away from predicting healthcare costs based on age alone.

The likelihood that people will need medical care – and its cost - might be measured by the number of different conditions at one time, frequency of contact with the health service, proximity to death, and socioeconomic status.

This study also adds to the growing body of research supporting the use of GP data to plan commissioning decisions and make healthcare services responsive to specific populations.

Citation and Funding

Hazra N C, Rudisill C, Gulliford M C. Determinants of health care costs in the senior elderly: age, comorbidity, impairment, or proximity to death? Eur J Health Econ. 2017. [Epub ahead of print].

This project was funded by the National Institute for Health Research Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and Kings College London, and in part by the Dunhill Medical Trust (grant number: R392/1114).

Bibliography

Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43.

DH. Long term conditions compendium of information: third edition. London: Department of Health; 2012.

Gijsen R, Hoeymans N, Schellevis F, et al. Causes and consequences of comorbidity: a review. J Clin Epidemiol. 2001;54(7):661-74.

MHRA. Clinical Practice Research Datalink. London: Medicines & Healthcare Products Regulatory Agency; 2017.

NHS Digital. General Practice Extraction Service. Leeds; 2017.

NICE. Multi-morbidity: clinical assessment and management. NG56. London: National Institute for Health and Care Excellence; 2016.

Salisbury C, Johnson C, Purdy S, et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011;61(582):e12-21.

The King’s Fund. Understanding pressures in general practice. London: The King’s Fund; 2016.

van den Akker M, Buntinx F, Metsemakers JFM, et al. Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol. 1998;51(5):367-75.

Walker A. Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Chronic Illn. 2007;3(3):202-18.

Why was this study needed?

Getting older is associated with increased healthcare costs. The number of individuals aged over 80 years in the UK has increased by 65% in the last decade. This raises concerns about the pressures this will place on healthcare resources.

Getting older is also associated with having more than one health condition at the same time, often referred to as multi-morbidity. Although a large proportion of lifetime healthcare costs incur as people reach the end of life, ageing is also associated with multi-morbidity and consequently complex healthcare needs.

This study aimed to untangle the extent to which increasing healthcare costs in the very old are attributable to multi-morbidities and proximity to death, rather than increasing age alone. This is essential to understand how to design healthcare services appropriately for the ageing population.

What did this study do?

This cohort study used routine general practice data from the Clinical Practice Research Datalink (CPRD) on consultations, number of health conditions, drugs prescribed and referrals to healthcare specialists. Information was available for 98,220 adults aged 80 years or older, collected from 372 GP practices over a five year period (2010-2014). Hospital episodes were identified for the same people.

The researchers modelled how annual healthcare costs were associated with age, gender, number of health conditions, the severity of the condition, age-related impairments and how close the person was to death. The age-related impairments they considered included problems with memory, walking, hearing and eyesight.

The authors did not have information on where people lived. Living in residential care incurs high health and social care costs which may not be recorded in CPRD, and this would lead to an underestimate of costs.

What did it find?

  • Total per person annual healthcare costs increased from age 80-84 years (£3,588) to 85-95 years (£4,018) before reaching a maximum in the 90-94 age group (£4,115) and then declining after that (£3,931 for 95-99 years, £2,867 for 100 years +). Secondary care costs were highest in the 90-94 age group (£2,737), and primary care in 95-99 year-olds (£676).
  • Although women were more likely than men to use healthcare services, there were no differences between healthcare costs overall between men and women.
  • The likelihood of using healthcare services did not change with age, except for people aged over 100 who were less likely to incur healthcare costs than 80-84 year-olds.
  • As the number of multi-morbidities in each individual increased so did the likelihood of increased healthcare costs.
  • Proximity to death was the strongest predictor of incurring high healthcare costs. However, the cost of end-of-life care decreased with increasing age. Healthcare costs in the last 12 months of life were £10,027 for people aged 80-84 years compared with £7,021 for people aged over 100 years.

What does current guidance say on this issue?

The Kings Fund (2016) investigated pressures in general practice by analysing another database collecting GP contact data called ResearchOne. The Kings Fund report revealed that although people are living longer, this has led to a rise in the number of those living with chronic and often multiple conditions. Furthermore, the largest growth in the average number of chronic conditions was seen in people aged 85 and over.

The Department of Health (2012) reports that although the likelihood of having a long-term condition increases with age, by 2034 the number of people 85 and over is projected to be 2.5 times that in 2009, reaching 3.5 million people (5% of the population).

What are the implications?

Multi-morbidity and nearing the end of life appear to be the main drivers of costs in the very old population (80+), rather than age.

For healthcare delivery, this suggests a shift away from predicting healthcare costs based on age alone.

The likelihood that people will need medical care – and its cost - might be measured by the number of different conditions at one time, frequency of contact with the health service, proximity to death, and socioeconomic status.

This study also adds to the growing body of research supporting the use of GP data to plan commissioning decisions and make healthcare services responsive to specific populations.

Citation and Funding

Hazra N C, Rudisill C, Gulliford M C. Determinants of health care costs in the senior elderly: age, comorbidity, impairment, or proximity to death? Eur J Health Econ. 2017. [Epub ahead of print].

This project was funded by the National Institute for Health Research Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and Kings College London, and in part by the Dunhill Medical Trust (grant number: R392/1114).

Bibliography

Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37-43.

DH. Long term conditions compendium of information: third edition. London: Department of Health; 2012.

Gijsen R, Hoeymans N, Schellevis F, et al. Causes and consequences of comorbidity: a review. J Clin Epidemiol. 2001;54(7):661-74.

MHRA. Clinical Practice Research Datalink. London: Medicines & Healthcare Products Regulatory Agency; 2017.

NHS Digital. General Practice Extraction Service. Leeds; 2017.

NICE. Multi-morbidity: clinical assessment and management. NG56. London: National Institute for Health and Care Excellence; 2016.

Salisbury C, Johnson C, Purdy S, et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011;61(582):e12-21.

The King’s Fund. Understanding pressures in general practice. London: The King’s Fund; 2016.

van den Akker M, Buntinx F, Metsemakers JFM, et al. Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol. 1998;51(5):367-75.

Walker A. Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Chronic Illn. 2007;3(3):202-18.

Determinants of health care costs in the senior elderly: age, comorbidity, impairment, or proximity to death?

Published on 1 September 2017

Hazra, N. C.,Rudisill, C.,Gulliford, M. C.

Eur J Health Econ , 2017

Ageing is assumed to be accompanied by greater health care expenditures but the association is also viewed as a 'red herring'. This study aimed to evaluate whether age is associated with health care costs in the senior elderly, using electronic health records for 98,220 participants aged 80 years and over registered with the UK Clinical Practice Research Datalink and linked Hospital Episode Statistics (2010-2014). Annual costs of health care utilization were estimated from a two-part model; multiple fractional polynomial models were employed to evaluate the non-linear association of age with predicted health care costs while also controlling for comorbidities, impairments, and death proximity. Annual health care costs increased from 80 years ( pound2972 in men, pound2603 in women) to 97 (men; pound4721) or 98 years (women; pound3963), before declining. Costs were significantly elevated in the last year of life but this effect declined with age, from pound10,027 in younger octogenarians to pound7021 in centenarians. This decline was steeper in participants with comorbidities or impairments; pound14,500 for 80-84-year-olds and pound6752 for centenarians with 7+ impairments. At other times, comorbidity and impairments, not age, were main drivers of costs. We conclude that comorbidities, impairments, and proximity to death are key mediators of age-related increases in health care costs. While the costs of comorbidity among survivors are not generally associated with age, additional costs in the last year of life decline with age.

The NICE guidelines for multi-morbidity, clinical assessment and management (2016), define multi-morbidity as presence of two or more long-term health conditions, which can include physical and mental health conditions, on-going conditions, complex symptoms such as frailty or pain, sensory impairment and alcohol and substance misuse.

The Clinical Practice Research Data link (CPRD; 2017) is a governmental, not-for-profit research service, jointly funded by the NIHR and the Medicines and Healthcare product Regulatory Agency. CPRD data is available for public-benefiting research only, and covers around 7% of the UK population, mainly GP surgeries in the south of England.

Expert commentary

This was a large study and makes use of a well-validated clinical database representing 7% of the UK population. One obvious weakness is that the study only considers cost in those aged over 80, not the whole population.

The study makes an important contribution to disproving the hypothesis that “the ageing population” is driving the current problems in the NHS. 

There are two obvious implications. Firstly, the study underscores the idea that we should collectively move towards a preventive, generalist-led, person-centred model of care.

Secondly, the study provides important evidence towards downgrading the importance of age per se in calculating resource allocation formulae and upgrading morbidity.

Greg Fell, Director of Public Health, Sheffield