Use of Advance Care Planning Billing Codes for Hospitalized Older Adults at High Risk of Dying: A National Observational Study
We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated “surprise question” (SQ; “Would you be surprised if the patient died in the next year?”) for inpatient admissions served to prime hospitalists and triggered an icon next to the patient’s name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered “no” and 4.1% SQ-prompted who answered “yes” (for non-SQ prompted cases, the fraction was 3.5%; P < .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.
© 2019 Society of Hospital Medicine
DISCUSSION
In this large national hospital-based physician practice group, the rates of ACP among acute care patients 65 years of age and older were very low despite the use of education and IT- and incentive-based strategies to encourage ACP conversations among seriously ill older adults. Priming physicians to reflect on the patient’s risk of dying at the time of admission was associated with the doubling of ACP rates.
Despite some lawmakers’ concerns that the ACP billing code may be overused and therefore become a financial burden to the Medicare program6, we find the very low use of ACP billing in a population for whom having goals of care conversations is critical—seriously ill older adults who the physician would not be surprised if they died in the next year. This gap is significant because these ACP conversations, when they did occur, were associated with a comfort-focused trajectory, including a more than four-fold increase in hospice referral at discharge.
Causal inference is limited because of the observational nature of the study. While we hypothesize that priming the physicians to reflect on prognosis activated them to prioritize ACP, based on a prior scenario-based randomized trial,7 illness severity likely drives ACP conversations. Specifically, patients on observation status (who had missing SQ data) and those for whom the physician answered “yes” to the SQ are less sick than other patients. Additional decision-making heuristics in addition to mortality risk may influence ACP conversations, as suggested by the independent influence of diagnoses, such as dementia or cancer, on ACP. Notably, however, the large amounts of unexplained variation at the physician and the hospital levels exceed the amounts explained by any individual observed patient factor.
Other key limitations of this study include the use of ACP billing as a primary outcome rather than observed and documented ACP conversations and the lack of information on the quality of ACP conversations. These findings reflect the uptake of ACP billing rates soon after the code was introduced. ACP billing rates have likely increased since the first quarter of 2017. Future work should explore diffusion and variation in physician-specific use over time. Finally, despite the nationwide sample, findings may not be generalizable to hospitalists who have not received training and financial incentives for ACP billing.
This study reinforces the possibility that variation in ACP conversations may contribute to variation in end-of-life treatment intensity between providers.8-10 Low ACP rates among even those with high hospitalist-predicted mortality risk and considerable between-provider variation underscore the need for quality improvement interventions to increase hospital-based ACP.
Acknowledgments
The authors thank Jared Wasserman, Maxwell Bessler, Devon Zoller MD, Mark Rudolph MD, Kristi Franz, and Weiping Zhou for their research assistance.
Disclosures
The authors have nothing to disclose.
Funding
National Institute on Aging award P01 AG019783
