DÄ internationalArchive39/2019Hospitalization and Intensive Therapy at the End of Life

Original article

Hospitalization and Intensive Therapy at the End of Life

A national analysis of DRG statistics from 2007–2015

Dtsch Arztebl Int 2019; 116: 653-60. DOI: 10.3238/arztebl.2019.0653

Fleischmann-Struzek, C; Mikolajetz, A; Reinhart, K; Curtis, J R; Haase, U; Thomas-Rüddel, D; Dennler, U; Hartog, C S

Background: Germany has more intensive care unit (ICU) beds per capita than the USA, but the utilization of these resources at the end of life is unknown.

Methods: Retrospective observational study using nationwide German hospital discharge data (DRG statistics; DRG, diagnosis-related groups) from 2007 to 2015. We investigated hospital deaths and use of intensive care services during terminal hospitalizations. Population-based incidences were standardized to the age and sex distribution of the German population.

Results: Standardized hospital admission rates increased by 0.8% annually (from 201.9 to 214.6 per 1000 population), while hospital admissions involving ICU care increased by 3.0% annually (from 6.5 to 8.2 per 1000 population). Among all deaths in the German population, the proportion of hospital deaths with ICU care increased by 2.3% annually (from 9.8% to 11.8%). Among all hospital deaths, the proportion involving ICU care increased by 2.8% annually from 20.6% (2007) to 25.6% (2015). In patients aged 65 and older, the use of intensive care services during terminal hospitalizations increased 3 times faster than hospital deaths.

Conclusion: Use of intensive care services during terminal hospitalizations increased across all age groups, particularly the elderly. The increased need for end-of-life care in the ICU calls for improvements in educational, policy, and reimbursement strategies. It is unclear whether ICU care was appropriate and compliant with patient preferences.

LNSLNS

Healthcare systems in high-income countries are challenged by a growing population of elderly patients with increasing comorbidities and rising demand for technologically advanced care. These trends raise questions about the appropriate use of intensive care services at the end of life.

When faced with a serious illness, most people prefer to die at home (1). In contrast, intensive therapy signifies some of the most aggressive aspects of care, which can potentially worsen the experience of death for patients and their families and may increase burnout and distress among ICU personnel (2, 3). On the other hand, intensive care can stabilize an acute life-threatening condition and some intensive palliative treatments may be better performed in an ICU when patients are in crisis. Importantly, providing high-quality end-of-life care requires skills in decision-making and communication and the collaboration of a well-functioning interdisciplinary team (2).

In Germany, models predict that the total number of deaths will rise by 26.0% from 2009 to 2050 (4). Approximately 50% of Germans die in hospital (5). In 2004–2005, Germany had a higher rate of ICU admissions/100 000 population than the USA and 6–10 times more ICU admissions than Canada, the Netherlands, or the UK (6). USA data suggest increasing ICU care at the end of life: between 2000 and 2009, the proportion of deaths among patients ≥ 66 years with ICU treatment in the last month of life grew from 24.3% to 29.2% (7). There are also indications that the use of intensive care at the end of life in this age group is directly linked to ICU capacity (8).

Little is known about the use of intensive care at the end of life in Germany. The goal of this study is to examine trends in hospital deaths and use of intensive care services during terminal hospitalizations. The results provide information on the scope and trends of intensive care use at the end of life for policy makers, clinicians, patients, and relatives.

Methods

Details of study methodology can be found in the eMethods. In short, we used the German diagnosis-related groups (DRG) statistics for the analysis of hospitalizations with and without intensive care. We used the population and deaths statistics of the German Federal Statistical Office and data on hospital/ICU beds from the Federal Health Monitoring Service. We identified patients of all ages between 2007 and 2015 and excluded cases with unknown age and sex (Figure 1). We opted for a conservative approach to identify ICU treatment by codes for operations and procedures (OPS codes 8–980, 8–98c, 8–98d, 8–98f, = intensive care complex treatment). Use of intensive care services during terminal hospitalizations was determined by the number of patients who died in hospital and received ICU care at any time during their hospital stay. We calculated annual population-based incidences and standardized these to the German population structure according to the age and sex distribution as of 31 December 2007 based on nationwide population data of the Federal Statistical Office for 2007–2015.

Flow chart showing case identification and absolute numbers of cases in 2015
Flow chart showing case identification and absolute numbers of cases in 2015
Figure 1
Flow chart showing case identification and absolute numbers of cases in 2015

Results

Development of ICU bed numbers

Between 2007 and 2015, the number of ICU beds increased by a mean of 2.06% per annum (p.a.), from 23 357 to 27 489. In contrast, the number of hospitals and hospital beds declined by a mean of 0.81% and 1.1% p.a., respectively (eTable 1).

Development of ICU beds
Development of ICU beds
eTable 1
Development of ICU beds

Trends in hospitalization and intensive care use from 2007–2015

We analyzed a total of 16.6 million hospitalizations in 2007 and 18.7 million in 2015 (Figure 1). Standardized rates of hospital admissions increased only slightly by a mean of 0.8% p.a. between 2007 and 2015. In contrast, the mean increase of hospital admissions involving intensive care p.a. was 3.0% and thus 3 times higher (Table 1).

Hospitalizations and intensive care use from 2007 to 2015
Hospitalizations and intensive care use from 2007 to 2015
Table 1
Hospitalizations and intensive care use from 2007 to 2015

Among hospital patients receiving intensive care, median age increased from 69 [interquartile range, IQR 57–77] to 71 [58–79] years (eTable 2). Hospital length of stay declined from median 14 [8–24] to 13 [7–22] days. The proportion of patients receiving mechanical ventilation increased from 25.0% to 30.5%, and for mechanical ventilation > 4 days from 15.6% to 16.2%. The proportion of patients with multimorbidity (≥ 2 comorbidities) increased from 55.2% to 57.5%. There were increases in congestive heart failure, renal disease, chronic pulmonary disease, and peripheral vascular disease, while myocardial infarction and malignancy decreased (eFigures 1 and 2). The use of palliative care services was very low but increased from 0.1% to 0.7% (eTable 2). Documentation of intensive care cases with increased complexity rose rapidly after the more rigorous OPS code 8–93f was introduced in 2013 to describe cases with increased complexity and higher costs (eFigure 3a).

Development of hospital deaths involving ICU care in Germany from 2007 to 2015. The numbers of deaths are expressed in thousands (k)
Development of hospital deaths involving ICU care in Germany from 2007 to 2015. The numbers of deaths are expressed in thousands (k)
Figure 3
Development of hospital deaths involving ICU care in Germany from 2007 to 2015. The numbers of deaths are expressed in thousands (k)
Changes in comorbidities for all hospital discharges involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
Changes in comorbidities for all hospital discharges involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
eFigure 1
Changes in comorbidities for all hospital discharges involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
Changes in comorbidities for all hospital deaths involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
Changes in comorbidities for all hospital deaths involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
eFigure 2
Changes in comorbidities for all hospital deaths involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
Number of intensive care hospitalizations from 2007 to 2015 according to different codes for the classification of operations and procedures (OPS codes)
Number of intensive care hospitalizations from 2007 to 2015 according to different codes for the classification of operations and procedures (OPS codes)
eFigure 3
Number of intensive care hospitalizations from 2007 to 2015 according to different codes for the classification of operations and procedures (OPS codes)
Demographics, comorbidities, and resource use for hospital patients with intensive care treatment
Demographics, comorbidities, and resource use for hospital patients with intensive care treatment
eTable 2
Demographics, comorbidities, and resource use for hospital patients with intensive care treatment

Trends in discharge dispositions of survivors

Table 2 shows the discharge dispositions of survivors of hospitalization who had received intensive care. The majority of patients were discharged home or to other hospitals. Discharges to nursing homes increased by a mean 8.0% p.a., while discharges to rehabilitation facilities decreased by a mean of 3.5% p.a. Only few patients were discharged to a hospice. eTable 3 explains the discharge categories.

Discharge dispositions of survivors of hospitalization involving intensive care
Discharge dispositions of survivors of hospitalization involving intensive care
Table 2
Discharge dispositions of survivors of hospitalization involving intensive care
Discharge disposition according to the DRG statistics
Discharge disposition according to the DRG statistics
eTable 3
Discharge disposition according to the DRG statistics

Trends in overall hospital deaths and deaths involving ICU care from 2007 to 2015

Standardized rates of hospital deaths declined from 4.8/1000 to 4.4/1000 population (mean −1.1% p.a.) and the proportion of all Germans who died in hospital decreased from 47.6% to 45.9% (mean −0.4% p.a). In contrast, hospital deaths involving ICU care increased from 1.0/1000 to 1.2/1000 population (mean +2.3% p.a.) (Table 1, Figure 2). In 2007, every fifth patient who died in hospital had received intensive care; in 2015, it was every fourth (mean +2.8% p.a.). Hospital and ICU mortality rates were essentially stable (from 2.4% to 2.3% and from 15.0% to 14.8%, respectively). Over time, more of the patients who died in hospital and received intensive care had congestive heart failure, renal disease, chronic pulmonary disease, or cerebrovascular disease than did patients with ICU care overall (eFigures 1 and 2).

Crude and standardized rates of death
Crude and standardized rates of death
Figure 2
Crude and standardized rates of death

Trends in overall hospital deaths and deaths involving ICU care stratified by age from 2007 to 2015

Figure 3, eTable 4, and eFigure 4 depict hospital deaths and deaths involving ICU care for different age groups. The increasing trend of deaths involving ICU care was most marked in the age group 65 years and older. In this age group, the number of hospital deaths involving ICU care increased approximately 3 times faster than the number of overall hospital deaths. In patients ≥ 85 years, hospital deaths involving ICU care increased by a mean of 7.0% p.a. and thus 2 times faster than hospital deaths (eTable 4). The introduction in 2010 of new OPS codes for intensive care use in children and adolescents resulted in a temporary reduction of ICU use codes for this age group (Figure 3, eFigure 3b).

Hospital deaths per year stratified by age group. The bars represent the years from 2007 to 2015. The numbers of deaths are presented in thousands (k)
Hospital deaths per year stratified by age group. The bars represent the years from 2007 to 2015. The numbers of deaths are presented in thousands (k)
eFigure 4
Hospital deaths per year stratified by age group. The bars represent the years from 2007 to 2015. The numbers of deaths are presented in thousands (k)
Overall hospital deaths and hospital deaths involving ICU care in different age groups during the period 2007 to 2015
Overall hospital deaths and hospital deaths involving ICU care in different age groups during the period 2007 to 2015
eTable 4
Overall hospital deaths and hospital deaths involving ICU care in different age groups during the period 2007 to 2015

Discussion

Our study investigated trends in hospital deaths and intensive care treatment during terminal hospitalizations between 2007 and 2015. In 2015, approximately 50% of Germans died in hospital and 25% of hospital deaths occurred during or after intensive care treatment. Compared with 2007, hospital deaths decreased, but terminal hospitalizations involving ICU care increased. In 2007, one in five hospital deaths occurred after ICU care; by 2015, this proportion had increased to one in four. In patients ≥ 65 years, deaths involving ICU care increased 3 times faster than hospital deaths. Hospital deaths involving intensive care in patients ≥ 85 years increased 2 times faster than hospital deaths.

These findings raise questions about the potential reasons for the growth in use of intensive care treatment. Population demographics is unlikely to be the major contributor, because age- and sex-standardized incidence rates also increased. Another possible explanation is increasing morbidity and disease severity: ICU patients are getting sicker and older (9), which may account for an increasing demand for intensive care in hospitals (10). Moreover, economic incentives may play a role. In the DRG system, hospitals’ profits increase exponentially with the numbers of days when mechanical ventilation is used and staffing ratios are low (11). This economic incentive may explain why ICU capacity and occupancy rates are increasing steadily in hospitals of all sizes (12), although the total number of hospital beds is going down (13), and may have accelerated the increase in “complex” intensive care cases we observed after introduction of the more rigorous yet better financed OPS codes 8–98f.

In 2012, the number of ICU beds in Germany was 31.8/100 000 (14), more than in the USA and double the European average (15). Importantly, this development goes along with one of the lowest nurse-to-patient ratios in Europe (16). In England, where financial incentives and societal perspectives are different, analysis of hospital discharge data showed that only 5.1% of deaths involved intensive care and there was almost no use of intensive care services in patients aged ≥ 85 years (17).

Although the absolute number of palliative care treatments increased tenfold from 541 to 5084, overall the utilization of palliative care services was low compared with other countries. The lack of palliative care may also play a role in rising ICU utilization at the end of life. Less aggressive and expensive alternatives such as hospices or home-based palliative care have helped to reverse the trend of terminal hospitalizations in the UK (18). In-hospital palliative care services can potentially reduce the need for terminal ICU care (19). Our study showed that only 0.1% of hospitalized patients with ICU care were discharged to a hospice versus 5.9% of patients with sepsis in the USA (20). In Canada, nearly half of the patients who died in hospital received inpatient palliative care (21). The Netherlands have double the rate of inpatient palliative care services (1.27/100,000 population) compared with Germany (0.73) (22).

The question to what extent intensive therapy would be desired by informed patients or contributes to overtreatment—which in turn worsens the burden on the treatment team and increases healthcare costs—cannot be answered based on the administrative data we analyzed. However, our data describe important trends with implications for patients, relatives, health care professionals, and policy makers. Further prospective studies are needed to evaluate the benefits and harm of ICU utilization at the end of life.

Broadening the view to other countries, one sees that in the USA, for example, the use of mechanical ventilation among hospitalized nursing home residents with advanced dementia doubled from 2000 to 2013 without improving survival (8). At the hospital level, an increase in the number of ICU beds over time was associated with increasing use of mechanical ventilation for these patients (8).

In a German single-center survey among relatives of patients with sepsis, 23% stated that the intensity of treatment had not been consistent with the patients’ wishes (23). However, the prevalence of advance directives is only 9–13% in patients who die in the ICU in Germany (24, 25). Although advance directives are rarely specific enough to enable definitive decisions regarding treatment intensity at the end of life (26) and may have little or no impact on the intensity of the therapy provided (25, 27), the low prevalence of advance directives indicates that awareness of the importance of such directives is low in the general population. This may contribute to increasing use of intensive care services during terminal hospitalizations. In the USA, it is assumed that the increasing demand for ICU treatment with stable staffing levels and resources will have negative implications for all ICU patients and will increase demands on ICU treatment providers still further (28).

Taken together, our data show the growing demand for end-of-life care in the ICU and suggest an opportunity to implement and strengthen palliative care in the hospital and particularly in the ICU (2). Given that most critically ill patients have lost decision-making capacity, decisions to change the goal of treatment or not to admit patients with a poor prognosis lie in the hands of physicians and family members. For some patients, palliative treatments may be better performed in an ICU and by trained and experienced ICU clinicians. However, end-of-life care demands interdisciplinary collaboration, decision making, and communication with the family. Acquisition and implementation of the corresponding skills will require additional educational programs, better reimbursement, and increased staffing levels (11).

Strengths and limitations

The strength of this study is its representativeness, based as it is on nationwide administrative data. In addition, we selected a conservative approach to identify use of ICU care. The coding is strictly supervised by government agencies and routinely cross-checked by trained physicians of the medical service of the health insurance companies in Germany (MDK).

This study also has important limitations:

We cannot provide information on severity of critical illness, clinical decision making, or patients’ presumed or actual preferences. Therefore, we cannot assess whether use of intensive care at the end of life was appropriate and compliant with patient preferences. Nevertheless, the fact that end-of-life care in the ICU increases in older patients is important.

We cannot differentiate whether a hospitalized patient died during or after the ICU treatment. Although our approach allows understanding of ICU utilization during terminal hospitalizations, it does not permit identification of the proportion of patients who die in the ICU. We can neither retrace transfers between ICU and ward nor know the underlying medical and ethical decisions.

We cannot identify patients who were discharged from the ICU for palliative care elsewhere. However, low coding for palliative care services or hospice transfer make it unlikely that this applied to many patients.

There may be selection bias in that patients who died within 24 h of admission to the ICU were not included as per OPS coding prerequisites. This may lead to underestimation of hospital deaths after use of intensive care.

Since the patients are anonymized, multiple hospital admissions for individual patients and transfers between hospitals cannot be identified. This is not a limitation for exploring terminal hospitalizations but restricts our ability to examine repeat admissions and transfers.

Finally, coding of healthcare services and comorbidities may contain inaccuracies, be influenced by coding incentives, and change over time. These incentives may have led to increased coding of intensive care services in general with high relevance for monetary reimbursement. Therefore, the interpretation of trends based on the DRG statistics data remains tentative. Further prospective data are needed to better understand the underlying mechanisms of the observed increase in use of ICU services during terminal hospitalizations.

Conclusion

In the context of growing availability of ICU beds in Germany, we found an increase in hospital deaths among patients who received intensive care across all adult age groups, particularly the elderly, from 2007 to 2015. This increase in end-of-life care in the ICU calls for increased efforts to identify and implement patient preferences and develop policy and reimbursement strategies to improve the quality of care for these patients as their life draws to an end.

Acknowledgment
The authors acknowledge Dr. Hannah Wunsch, who provided helpful comments during the writing of the draft.

Data source
The research data center of the Federal Statistical Office and the statistical offices of the German federal states (DRG statistics 2007–2015)

Funding
This study was supported by the Federal Ministry of Education and Research (BMBF) through the Center for Sepsis Control and Care (CSCC; FKZ: 01EO1002 and 01EO1502) via InfectControl2020 (FKZ: 03ZZ0819B).

Conflict of interest statement
Prof.Reinhart is a partner in InflaRx Jena and a consultant for Adrenomed Henningsdorf Berlin.

Dr. Dennler has received reimbursement of congress attendance fees and travel costs from Aesculap Akademie.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 29 January 2019, revised version accepted on 8 July 2019

Corresponding author
PD Dr. med. Christiane S. Hartog
Klinik für Anästhesiologie und Intensivmedizin
Charité Universitätsmedizin Berlin
Charitéplatz 1, 10117 Berlin, Germany
Christiane.hartog@mailbox.org

Cite this as:
Fleischmann-Struzek C, Mikolajetz A, Reinhart K, Curtis JR, Haase U, Thomas-Rüddel D, Dennler U, Hartog CS: Hospitalization and intensive therapy at the end of life—a national analysis of DRG statistics from 2007–2015. Dtsch Arztebl Int 2019; 116: 653–60. DOI: 10.3238/arztebl.2019.0653

Supplementary material

For eReferences please refer to:
www.aerzteblatt-internatioanl.de/ref3919

eMethods, eTables, eFigures:
www.aerzteblatt-international.de/19m0653

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*Joint first authors
Center for Sepsis Control and Care, University Hospital Jena:
Dr .med. Carolin Fleischmann-Struzek, Prof. Dr. med. Konrad Reinhart, Dr. med. Daniel Thomas-Rüddel
Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena: Dr. phil. Anna Mikolajetz, Prof. Dr. med. Konrad Reinhart, Dr. med. Daniel Thomas-Rüddel
BIH Guest Professorship/Charité Foundation, Department of Anesthesiology and Intensive Care Medicine, Charité University Medical Center, Berlin: Prof. Dr. med. Konrad Reinhart
Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA: Prof. J. Randall Curtis MD
Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA: Prof. J. Randall Curtis MD
Department of Anesthesiology and Intensive Care Medicine, Charité University Medical Center, Berlin: Dr. med. Ulrike Haase, PD Dr. med. Christiane S. Hartog
Medical Controlling Division, Munich Hospital: Dr. med. Ulf Dennler
Bavaria Hospital,Kreischa: PD Dr. med. Christiane S. Hartog
Flow chart showing case identification and absolute numbers of cases in 2015
Flow chart showing case identification and absolute numbers of cases in 2015
Figure 1
Flow chart showing case identification and absolute numbers of cases in 2015
Crude and standardized rates of death
Crude and standardized rates of death
Figure 2
Crude and standardized rates of death
Development of hospital deaths involving ICU care in Germany from 2007 to 2015. The numbers of deaths are expressed in thousands (k)
Development of hospital deaths involving ICU care in Germany from 2007 to 2015. The numbers of deaths are expressed in thousands (k)
Figure 3
Development of hospital deaths involving ICU care in Germany from 2007 to 2015. The numbers of deaths are expressed in thousands (k)
Key messages
Hospitalizations and intensive care use from 2007 to 2015
Hospitalizations and intensive care use from 2007 to 2015
Table 1
Hospitalizations and intensive care use from 2007 to 2015
Discharge dispositions of survivors of hospitalization involving intensive care
Discharge dispositions of survivors of hospitalization involving intensive care
Table 2
Discharge dispositions of survivors of hospitalization involving intensive care
Changes in comorbidities for all hospital discharges involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
Changes in comorbidities for all hospital discharges involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
eFigure 1
Changes in comorbidities for all hospital discharges involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
Changes in comorbidities for all hospital deaths involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
Changes in comorbidities for all hospital deaths involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
eFigure 2
Changes in comorbidities for all hospital deaths involving intensive care from 2010 (gray bullets) to 2015 (black bullets)
Number of intensive care hospitalizations from 2007 to 2015 according to different codes for the classification of operations and procedures (OPS codes)
Number of intensive care hospitalizations from 2007 to 2015 according to different codes for the classification of operations and procedures (OPS codes)
eFigure 3
Number of intensive care hospitalizations from 2007 to 2015 according to different codes for the classification of operations and procedures (OPS codes)
Hospital deaths per year stratified by age group. The bars represent the years from 2007 to 2015. The numbers of deaths are presented in thousands (k)
Hospital deaths per year stratified by age group. The bars represent the years from 2007 to 2015. The numbers of deaths are presented in thousands (k)
eFigure 4
Hospital deaths per year stratified by age group. The bars represent the years from 2007 to 2015. The numbers of deaths are presented in thousands (k)
Development of ICU beds
Development of ICU beds
eTable 1
Development of ICU beds
Demographics, comorbidities, and resource use for hospital patients with intensive care treatment
Demographics, comorbidities, and resource use for hospital patients with intensive care treatment
eTable 2
Demographics, comorbidities, and resource use for hospital patients with intensive care treatment
Discharge disposition according to the DRG statistics
Discharge disposition according to the DRG statistics
eTable 3
Discharge disposition according to the DRG statistics
Overall hospital deaths and hospital deaths involving ICU care in different age groups during the period 2007 to 2015
Overall hospital deaths and hospital deaths involving ICU care in different age groups during the period 2007 to 2015
eTable 4
Overall hospital deaths and hospital deaths involving ICU care in different age groups during the period 2007 to 2015
1. Gomes B, Calanzani N, Gysels M, Hall S, Higginson IJ: Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care 2013; 12: 7 CrossRef MEDLINE PubMed Central
2.Curtis JR, Vincent JL: Ethics and end-of-life care for adults in the intensive care unit. Lancet 2010; 376: 1347–53 CrossRef MEDLINE
3.Hartog CS, Hoffmann F, Mikolajetz A, et al.: Nicht-nutzbringende Therapie und emotionale Erschöpfung in der Lebenszeitpflege : Ergebnisse einer Umfrage unter Intensivstation Personal. Anästhesist 2018; 67: 850–8 CrossRef MEDLINE CrossRef MEDLINE
4.Simon ST, Gomes B, Koeskeroglu P, et al.: Bevölkerung, Sterblichkeit und Sterbeort in Deutschland (1950–2050) – Auswirkungen auf die Pflege am Lebensende in der Zukunft. Öffentliche Gesundheit 2012; 126: 937–46.
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