Demographics and Demographics and Associated Costs of Dying for Associated Costs of Dying for

Enrolled VeteransEnrolled VeteransPreliminary FindingsPreliminary Findings

James Breckenridge, PhDJames Breckenridge, PhD

James Hallenbeck, MDJames Hallenbeck, MD

Co-Principal InvestigatorsCo-Principal Investigators

VA Palo Alto HCS VA Palo Alto HCS

Questions Driving StudyQuestions Driving Study

Why do people die where they do?Why do people die where they do? What explains patterns of variance in What explains patterns of variance in

venue of death?venue of death? What patient-specific and what What patient-specific and what

system variables affect these system variables affect these patterns?patterns?

How do costs vary by venue of How do costs vary by venue of deathdeath What accounts for cost differencesWhat accounts for cost differences

Co-InvestigatorsCo-Investigators

Susan Ettner, PhD, UCLASusan Ettner, PhD, UCLA

Karl Lorenz, MD, West LA VAMCKarl Lorenz, MD, West LA VAMC

This project is funded This project is funded by a grant from the by a grant from the

Robert Wood Johnson Robert Wood Johnson FoundationFoundation

Questions for the VAQuestions for the VA

Should the VA invest in palliative care?Should the VA invest in palliative care? Is such care “cost-effective”?Is such care “cost-effective”? Could adequate dollars be cost-shifted or Could adequate dollars be cost-shifted or

avoided to justify such an investment? avoided to justify such an investment? Why is there such variance across VA Why is there such variance across VA

regions and facilities? regions and facilities?

Is palliative care is luxury the VA cannot afford, or can

the VA not afford not to have palliative care?

Questions beyond VAQuestions beyond VA To what extent do any cost savings made To what extent do any cost savings made

possible through the provision of palliative possible through the provision of palliative care result from referral biases and to care result from referral biases and to what extent do they result from systems of what extent do they result from systems of care provided?care provided?

To what extent are known geographic To what extent are known geographic variations in end-of-life care in the variations in end-of-life care in the Medicare world similar or different in the Medicare world similar or different in the VA?VA? Corollary: Are geographic variations Corollary: Are geographic variations

immutable or can a different system of care immutable or can a different system of care influence these patterns? influence these patterns?

Veteran Deaths – Basic Veteran Deaths – Basic FactsFacts

29% of Americans dying each year are 29% of Americans dying each year are veteransveterans

The majority of veterans are not The majority of veterans are not enrolled for by care by the VAenrolled for by care by the VA

A majority of enrolled veterans do not A majority of enrolled veterans do not die in VA facilitiesdie in VA facilities

For veterans who do die in a VA facility, For veterans who do die in a VA facility, remarkable heterogeneity exists as to remarkable heterogeneity exists as to where they die and how much it costswhere they die and how much it costs

Annual Veteran Annual Veteran DeathsDeaths

A small percentage of veterans die as inpatients in VA facilities

National VA Mortality by VISN FY2000

0

500

1000

1500

2000

2500

3000

VISN

# Dea

ths b

y Loc

ation VAMC Total Deaths

Hospital Deaths

Nursing Home Deaths

Patient Demographics Patient Demographics VA Inpatient Deaths VA Inpatient Deaths

47% over age 7547% over age 75

45% married45% married

Median annual income < $10,000Median annual income < $10,000 25% no reported income25% no reported income

35% Service Connected 35% Service Connected

Many veterans dying as inpatients have poor social support structures

MethodologyMethodology Identify relevant population for analysis: Identify relevant population for analysis:

All veterans during FY 00-02 with at least All veterans during FY 00-02 with at least one institutional stay: one institutional stay: 805,311805,311 individuals individuals

From this population identify those From this population identify those veterans who died during this time period: veterans who died during this time period: 148,122148,122 (18%)(18%)

Identify last institutional venue:Identify last institutional venue: ICU, Acute Care (non-ICU), Nursing Home, ICU, Acute Care (non-ICU), Nursing Home,

Other, Dedicated Palliative Care Bed Other, Dedicated Palliative Care Bed Analyze associated demographics and Analyze associated demographics and

costscosts

Please note: these Please note: these results reflect results reflect

preliminary data – preliminary data – results subject to results subject to

ongoing data validation ongoing data validation

DO NOT CITEDO NOT CITE

Patients dying during Patients dying during last institutional staylast institutional stay

79, 216 (53% )79, 216 (53% ) died in an died in an institutional setting at some time institutional setting at some time over three year periodover three year period

27%

38%

17%

8%

10% ICU Deaths

Acute Care Deaths

NHC Deaths

Ded. Palliative Care BedDeaths (est)

Deaths in Other Setting

Costs of Terminal StaysCosts of Terminal Stays

Percentage of Patients by Terminal Venue

27%

38%

25%

10% ICU Death

Acute Care Death

NHC Death

Other Setting

Annual direct cost of terminal admits:Annual direct cost of terminal admits: $387,367,000$387,367,000

Percentage total cost by venue

38%

29%

18%

4%

11%ICU Deaths

Acute Care Deaths

NHC Deaths

Ded. Palliative CareDeaths

Other Setting

Cost per Day and Cost per Day and Average LOSAverage LOS

AveragAveragee

MedianMedian AveragAverage LOSe LOS

AdditioAdditional nal DaysDays

ICUICU $1624$1624 $1406$1406 10.710.7 3.4 3.4 acuteacute

AcuteAcute $641$641 $536$536 10.310.3 2.1 ICU2.1 ICU

NHCNHC $253$253 $230$230 44.544.5

PalliativPalliative e

CareCare

$278$278 $262$262 2424

What if…What if…

Dying patients were redistributed among Dying patients were redistributed among ICU, Acute and Nursing Home venues ICU, Acute and Nursing Home venues such that:such that: Percentage dying in ICU = % dying in ICUs Percentage dying in ICU = % dying in ICUs

under Medicare: 16.9% of acute care deathsunder Medicare: 16.9% of acute care deaths The ratio of nursing home to acute care The ratio of nursing home to acute care

deaths became 2:1. (Predicated within 30 deaths became 2:1. (Predicated within 30 years nationally by experts such as Joan Teno)years nationally by experts such as Joan Teno)

No change in cost per day per venue or LOS No change in cost per day per venue or LOS for dying patientsfor dying patients

Theoretical Cost Savings Theoretical Cost Savings with Better Patient with Better Patient

DistributionDistribution8%

42%

50%

ICU

Acute Care

NHC

5382 5382 patients per year patients per year currently dying in acute currently dying in acute care would need to be care would need to be transferred to nursing transferred to nursing

homeshomes

Annual Cost Savings to Annual Cost Savings to VA with RedistributionVA with Redistribution

$40,494,886 –$40,494,886 –assuming assuming

redistribution redistribution into into new new nursing nursing

home beds at home beds at $253 per day$253 per day

What if these patients went What if these patients went into into dedicated palliative care dedicated palliative care

bedsbeds and this utilization and this utilization replaced existing NH replaced existing NH

workload?workload? Only incremental cost would be the difference Only incremental cost would be the difference

in cost between a non-hospice NH bed per day in cost between a non-hospice NH bed per day (approximately $220/day and a dedicated (approximately $220/day and a dedicated palliative care bed $278/day (3.2 million/year) *palliative care bed $278/day (3.2 million/year) * Using these values annual VA savings: ~ Using these values annual VA savings: ~

$48,000,000/year$48,000,000/year The estimated 54,435 BDOC annually these veterans The estimated 54,435 BDOC annually these veterans

would use would be approximately 1.3% of 4.3 would use would be approximately 1.3% of 4.3 million annual BDOC in VA nursing homesmillion annual BDOC in VA nursing homes

*Not counting any possible CNH or Fee Basis resulting *Not counting any possible CNH or Fee Basis resulting from possible shift in workloadfrom possible shift in workload

ICU Terminal Stay ICD9 ICU Terminal Stay ICD9 CodesCodes

Diagnosis Diagnosis Freq %Freq %

Diagnosis Diagnosis Freq %Freq %SUBENDO INFARCT, INITIAL 467 2.19

AMI NOS, INITIAL 459 2.15FOOD/VOMIT PNEUMONITIS 424 1.98CRNRY ATHRSCL NATVE VSSL 407 1.9CARDIAC ARREST 368 1.72ACUTE RENAL FAILURE NOS 339 1.59ALCOHOL CIRRHOSIS LIVER 331 1.55GASTROINTEST HEMORR NOS 246 1.15MAL NEO UPPER LOBE LUNG 229 1.07MAL NEO BRONCH/LUNG NOS 206 0.96INTRACEREBRAL HEMORRHAGE 184 0.86URIN TRACT INFECTION NOS 181 0.85ATRIAL FIBRILLATION 174 0.81HYPOVOLEMIA 171 0.8OTHER PULMONARY INSUFF 170 0.8STAPH AUREUS PNEUMONIA 168 0.79SHOCK W/O TRAUMA NEC 164 0.77CRBL ART OCL NOS W INFRC 162 0.76ACUTE PANCREATITIS 158 0.74STAPH AUREUS SEPTICEMIA 155 0.73AMI ANTERIOR WALL, INIT 146 0.68AC VASC INSUFF INTESTINE 141 0.66ABDOM AORTIC ANEURYSM 138 0.65AMI INFERIOR WALL, INIT 137 0.64HUMAN IMMUNO VIRUS DIS 135 0.63HEPATIC COMA 123 0.58

AMI ANTERIOR WALL, INIT 146 0.68AC VASC INSUFF INTESTINE 141 0.66ABDOM AORTIC ANEURYSM 138 0.65AMI INFERIOR WALL, INIT 137 0.64HUMAN IMMUNO VIRUS DIS 135 0.63HEPATIC COMA 123 0.58CVA 121 0.57PNEUMOCOCCAL PNEUMONIA 117 0.55CHR AIRWAY OBSTRUCT NEC 115 0.54PULM EMBOL/INFARCT NEC 103 0.48CIRRHOSIS OF LIVER NOS 102 0.48AORTIC VALVE DISORDER 98 0.46MAL NEO LOWER LOBE LUNG 97 0.45PLEURAL EFFUSION NOS 94 0.44PSEUDOMONAL PNEUMONIA 93 0.44INTESTINAL OBSTRUCT NOS 92 0.43ACT MYL LEUK W/O RMSION 91 0.43RUPT ABD AORTIC ANEURYSM 91 0.43HEMATEMESIS 87 0.41POSTINFLAM PULM FIBROSIS 78 0.36HYPOTENSION NOS 77 0.36ANOXIC BRAIN DAMAGE 76 0.36ATH EXT NTV ART GNGRENE 76 0.36CHRONIC RENAL FAILURE 76 0.36SEPTICEMIA NEC 73 0.34AMI ANTEROLATERAL, INIT 72 0.34

Acute Care Terminal IC9 Acute Care Terminal IC9 CodesCodes

PNEUMONIA, ORGANISM NOS 2108 6.97CHF NOS 1398 4.62FOOD/VOMIT PNEUMONITIS 1184 3.92MAL NEO BRONCH/LUNG NOS 894 2.96OBS CHR BRNC W ACT EXA 796 2.63ACUTE RESPIRATRY FAILURE 744 2.46HYPOVOLEMIA 613 2.03URIN TRACT INFECTION NOS 585 1.93ACUTE RENAL FAILURE NOS 577 1.91MAL NEO UPPER LOBE LUNG 576 1.9SEPTICEMIA NOS 512 1.69ALCOHOL CIRRHOSIS LIVER 433 1.43CRBL ART OCL NOS W INFRC 388 1.28SUBENDO INFARCT, INITIAL 330 1.09SECOND MALIG NEO LIVER 297 0.98CVA 279 0.92MALIGN NEOPL PROSTATE 274 0.91GASTROINTEST HEMORR NOS 261 0.86AMI NOS, INITIAL 240 0.79MAL NEO LOWER LOBE LUNG 240 0.79HUMAN IMMUNO VIRUS DIS 232 0.77CHR AIRWAY OBSTRUCT NEC 219 0.72CRNRY ATHRSCL NATVE VSSL 219 0.72INTRACEREBRAL HEMORRHAGE 216 0.71MAL NEO BRONCH/LUNG NEC 214 0.71CARDIAC ARREST 200 0.66

STAPH AUREUS PNEUMONIA 199 0.66SECONDARY MALIG NEO BONE 197 0.65MAL NEO LIVER, PRIMARY 189 0.62HEPATIC COMA 187 0.62ATRIAL FIBRILLATION 185 0.61MALIG NEO MAIN BRONCHUS 166 0.55HYP RENAL NOS W REN FAIL 163 0.54CHRONIC RENAL FAILURE 158 0.52SECONDARY MALIG NEO LUNG 152 0.5STAPH AUREUS SEPTICEMIA 152 0.5ACT MYL LEUK W/O RMSION 149 0.49SEC MAL NEO BRAIN/SPINE 140 0.46ACUTE PANCREATITIS 139 0.46PLEURAL EFFUSION NOS 136 0.45INTERTROCHANTERIC FX-CL 132 0.44MALIG NEO PANCREAS NOS 128 0.42SECOND MALIG NEO PLEURA 126 0.42OTHER PULMONARY INSUFF 124 0.41CIRRHOSIS OF LIVER NOS 121 0.4BRONCHOPNEUMONIA ORG NOS 119 0.39PNEUMOCOCCAL PNEUMONIA 119 0.39PSEUDOMONAL PNEUMONIA 119 0.39MALIGNANT NEO COLON NOS 116 0.38INTESTINAL OBSTRUCT NOS 114 0.38PULM EMBOL/INFARCT NEC 110 0.36

Diagnosis Freq %Diagnosis Freq %Diagnosis Freq %Diagnosis Freq %

Nursing Home Terminal Nursing Home Terminal ICD9 CodesICD9 Codes

MAL NEO BRONCH/LUNG NOS 1645 7.99ALZHEIMERS DISEASE 3311 =PICKS DISEASE 1120 5.44REHABILITATION PROC NEC 859 4.17MALIGN NEOPL PROSTATE 783 3.8ORGANIC BRAIN SYND NEC 670 3.25CHF NOS 616 2.99MAL NEO UPPER LOBE LUNG 551 2.68CHR AIRWAY OBSTRUCT NEC 534 2.59RADIOTHERAPY ENCOUNTER 413 2.01ARTERIOSCLER DEMENT NOS 374 1.82SECONDARY MALIG NEO BONE 324 1.57ENCOUNTR PALLIATIVE CARE 316 1.54PARALYSIS AGITANS 290 1.41PNEUMONIA, ORGANISM NOS 282 1.37SEC MAL NEO BRAIN/SPINE 277 1.35LATE EF-HEMPLGA SIDE NOS 271 1.32MALIGNANT NEO COLON NOS 247 1.2SECOND MALIG NEO LIVER 247 1.2MAL NEO LOWER LOBE LUNG 201 0.98MALIG NEO PANCREAS NOS 195 0.95SECONDARY MALIG NEO LUNG 187 0.91ALCOHOL CIRRHOSIS LIVER 185 0.9PHYSICAL THERAPY NEC 185 0.9FOOD/VOMIT PNEUMONITIS 180 0.87CHRONIC RENAL FAILURE 166 0.81MAL NEO ESOPHAGUS NOS 166 0.81

MAL NEO LIVER, PRIMARY 164 0.8MALIG NEO BLADDER NOS 162 0.79MALIG NEOPL KIDNEY 153 0.74OBS CHR BRNC W ACT EXA 149 0.72MAL NEO BRONCH/LUNG NEC 145 0.7HUMAN IMMUNO VIRUS DIS 140 0.68CVA 136 0.66MALIGNANT NEOPLASM NOS 136 0.66MALIG NEO BRAIN NOS 128 0.62MALIG NEO MAIN BRONCHUS 126 0.61SENILE DEMENTIA UNCOMP 124 0.6MAL NEO RECTOSIGMOID JCT 123 0.6DECUBITUS ULCER 115 0.56MULT MYELM W/O REMISSION 108 0.52MALIGNANT NEOPL RECTUM 107 0.52HYP RENAL NOS W REN FAIL 105 0.51COR ATH UNSP VSL NTV/GFT 97 0.47MULTIPLE SCLEROSIS 97 0.47CRNRY ATHRSCL NATVE VSSL 93 0.45MALIG NEOPL STOMACH NOS 85 0.41MAL NEO PANCREAS HEAD 76 0.37ACUTE RESPIRATRY FAILURE 75 0.36MAL NEO HEAD/FACE/NECK 73 0.35PRIM CARDIOMYOPATHY NEC 72 0.35CRBL ART OCL NOS W INFRC 71 0.34

Diagnosis Freq %Diagnosis Freq %Diagnosis Freq %Diagnosis Freq %

Patients in Dedicated Patients in Dedicated Palliative Care BedsPalliative Care Beds

TAPC Survey identified 37 facilities TAPC Survey identified 37 facilities with dedicated beds or unitswith dedicated beds or units To date have full SSNs from 22/37 (59% To date have full SSNs from 22/37 (59%

of TAPC respondents)of TAPC respondents) These units in combination reported 233 These units in combination reported 233

beds/384 total beds reported in this beds/384 total beds reported in this category (61% of such beds)category (61% of such beds)

3896 patients identified to date3896 patients identified to date

Dedicated Palliative Care Dedicated Palliative Care BedsBeds

Average Cost per day: Average Cost per day: $278$278 Average Length of Stay: Average Length of Stay: 24 days24 days

Total direct cost for three years: Total direct cost for three years: $25,386,135$25,386,135

Of 3724 matched in our Of 3724 matched in our database:database:

Projected Number in Projected Number in Dedicated Beds and Dedicated Beds and

Associated CostsAssociated Costs Assuming surveyed programs were Assuming surveyed programs were

representative of programs not representative of programs not surveyed:surveyed: Estimated number of veterans dying in Estimated number of veterans dying in

dedicated beds: 6,330 over three yearsdedicated beds: 6,330 over three years Estimated direct cost of such care over Estimated direct cost of such care over

three year period: $41,000,000three year period: $41,000,000

Dedicated Palliative Care Dedicated Palliative Care Bed ICD9 CodesBed ICD9 Codes

MAL NEO BRONCH/LUNG NOS 396 10.63MALIGN NEOPL PROSTATE 206 5.53MAL NEO UPPER LOBE LUNG 128 3.44CHF NOS 112 3.01SECONDARY MALIG NEO BONE 107 2.87SECOND MALIG NEO LIVER 82 2.2CHR AIRWAY OBSTRUCT NEC 73 1.96SEC MAL NEO BRAIN/SPINE 71 1.91MAL NEO LIVER, PRIMARY 70 1.88RADIOTHERAPY ENCOUNTER 68 1.83MAL NEO LOWER LOBE LUNG 54 1.45MALIGNANT NEO COLON NOS 54 1.45PNEUMONIA, ORGANISM NOS 50 1.34SECONDARY MALIG NEO LUNG 50 1.34MAL NEO ESOPHAGUS NOS 49 1.32ALCOHOL CIRRHOSIS LIVER 48 1.29ALZHEIMERS DISEASE 3311 =PICKS DISEASE 42 1.13ENCOUNTR PALLIATIVE CARE 42 1.13REHABILITATION PROC NEC 42 1.13FOOD/VOMIT PNEUMONITIS 41 1.1MALIG NEOPL KIDNEY 41 1.1PARALYSIS AGITANS 40 1.07MALIG NEO MAIN BRONCHUS 39 1.05MALIG NEO BLADDER NOS 38 1.02MAL NEO BRONCH/LUNG NEC 35 0.94MALIG NEO PANCREAS NOS 33 0.89

MALIGNANT NEOPLASM NOS 31 0.83OBS CHR BRNC W ACT EXA 29 0.78MALIGNANT NEOPL RECTUM 28 0.75MAL NEO RECTOSIGMOID JCT 26 0.7MALIGNANT NEO LIVER NOS 25 0.67MULT MYELM W/O REMISSION 25 0.67ORGANIC BRAIN SYND NEC 24 0.64CHRONIC RENAL FAILURE 23 0.62HUMAN IMMUNO VIRUS DIS 22 0.59MALIG NEO BRAIN NOS 22 0.59OTH LYMP UNSP XTRNDL ORG 21 0.56PRIM CARDIOMYOPATHY NEC 21 0.56ACUTE RENAL FAILURE NOS 20 0.54MAL NEO HEAD/FACE/NECK 20 0.54SECONDARY MALIG NEO NEC 20 0.54CIRRHOSIS OF LIVER NOS 19 0.51MALIG NEOPL STOMACH NOS 19 0.51ARTERIOSCLER DEMENT NOS 18 0.48MAL NEO PANCREAS HEAD 18 0.48OBS CHR BRNC W/O ACT EXA 18 0.48HEPATIC COMA 17 0.46URIN TRACT INFECTION NOS 17 0.46ACT MYL LEUK W/O RMSION 16 0.43HYP RENAL NOS W REN FAIL 16 0.43LATE EF-HEMPLGA SIDE NOS 16 0.43

Diagnosis Diagnosis Freq %Freq %

Diagnosis Freq %Diagnosis Freq %

Of top 50 Palliative Care Of top 50 Palliative Care ICD 9 CodesICD 9 Codes

73% cancer Diagnoses73% cancer Diagnoses

8% unclear as to actual diagnosis8% unclear as to actual diagnosis

19% Non-cancer diagnoses19% Non-cancer diagnoses

Non-cancer Diagnoses:Non-cancer Diagnoses:

CHF 112COPD 102Cirrhosis 84Organic Brain 98Renal Failure 59AIDS 22

Of 2513 codes (67% of sample) Of 2513 codes (67% of sample) total # with the following total # with the following

diagnoses over 3 yearsdiagnoses over 3 years

Are non-cancer diagnoses under-represented in Are non-cancer diagnoses under-represented in VA dedicated PC programs?VA dedicated PC programs?

Direct Costs of Care for Direct Costs of Care for Last Six Months and Last Last Six Months and Last

Year of LifeYear of LifeInstitutional Institutional

CostsCostsOutpatient Outpatient

& Fee & Fee CostsCosts

TotalTotal

Direct Direct CostsCosts

Six Six MonthsMonths

$743,162,000$743,162,000 $159,604,$159,604,000000

$902,766,$902,766,000000

One One

YearYear$966,439,000$966,439,000 $204,832,$204,832,

000000$1,172,23$1,172,23

7,0007,000

VA Cost per Veteran for VA Cost per Veteran for Last Year of LifeLast Year of Life

Direct Cost: $27,798 per Direct Cost: $27,798 per veteranveteran

With est. 37% indirect cost:With est. 37% indirect cost: $44,124 $44,124 per veteranper veteran

Comparison: Medicare Comparison: Medicare Claims Data age 65-74: Claims Data age 65-74: $31,800 /year $31,800 /year Hogan et al. Hogan et al. Health AffairsHealth Affairs 2001, 2001,

based on 1997 claims databased on 1997 claims data

ESTIMATED DIRECT AND ESTIMATED DIRECT AND INDIRECT COST: INDIRECT COST: $1,749,608,000$1,749,608,000

What percent of the VHA What percent of the VHA Budget is Spent on the Budget is Spent on the

Last Year of Life?Last Year of Life?

Of approximately Of approximately $17,000,000,000 $17,000,000,000 allocated per year allocated per year by VHA for clinical by VHA for clinical care over, 10% is care over, 10% is

for care in the last for care in the last year of lifeyear of life

Patients not Dying in VA Patients not Dying in VA FacilitiesFacilities

Less known about where these Less known about where these veterans dieveterans die

What are “risk factors” for dying in a What are “risk factors” for dying in a VA facility vs. outside?VA facility vs. outside? DiagnosisDiagnosis Socioeconomic variablesSocioeconomic variables Distance from VA facilityDistance from VA facility Facility characteristicsFacility characteristics

Deaths with 30 days and Deaths with 30 days and > 30 days post discharge> 30 days post discharge

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

ICU Death Acute CareDeath

NHC Death OtherSetting

Died in Venue

Within 30 Days

>30 Days

Cumulative deaths by Cumulative deaths by last venuelast venue

ICD9 Codes for patients dying ICD9 Codes for patients dying within 30 days of an acute care within 30 days of an acute care

admit N=16,560admit N=16,560CHF NOS 1017 6.13PNEUMONIA, ORGANISM NOS 842 5.08OBS CHR BRNC W ACT EXA 590 3.56FOOD/VOMIT PNEUMONITIS 492 2.97URIN TRACT INFECTION NOS 489 2.95HYPOVOLEMIA 452 2.73MAL NEO BRONCH/LUNG NOS 406 2.45MAL NEO UPPER LOBE LUNG 330 1.99ACUTE RENAL FAILURE NOS 228 1.37SUBENDO INFARCT, INITIAL 191 1.15ATRIAL FIBRILLATION 189 1.14SECOND MALIG NEO LIVER 186 1.12CRNRY ATHRSCL NATVE VSSL 181 1.09ALCOHOL CIRRHOSIS LIVER 180 1.09SECONDARY MALIG NEO BONE 158 0.95SEC MAL NEO BRAIN/SPINE 157 0.95MAL NEO LOWER LOBE LUNG 143 0.86MALIGN NEOPL PROSTATE 139 0.84CHR AIRWAY OBSTRUCT NEC 137 0.83GASTROINTEST HEMORR NOS 124 0.75MAL NEO LIVER, PRIMARY 124 0.75CHEMOTHERAPY ENCOUNTER 115 0.69PLEURAL EFFUSION NOS 107 0.65ANEMIA NOS 106 0.64CRBL ART OCL NOS W INFRC 106 0.64HUMAN IMMUNO VIRUS DIS 99 0.6

MAL NEO BRONCH/LUNG NEC 94 0.57MALIG NEO MAIN BRONCHUS 94 0.57SECOND MALIG NEO PLEURA 94 0.57ACUTE RESPIRATRY FAILURE 84 0.51HEPATIC COMA 83 0.5CVA 82 0.49SECONDARY MALIG NEO LUNG 81 0.49FX NECK OF FEMUR NOS-CL 78 0.47HYP RENAL NOS W REN FAIL 78 0.47HYPERCALCEMIA 76 0.46VENOUS THROMBOSIS NEC 76 0.46AMI NOS, INITIAL 72 0.43CELLULITIS OF LEG 72 0.43DMII OTH NT ST UNCNTRLD 72 0.43STAPH AUREUS PNEUMONIA 71 0.43SYNCOPE AND COLLAPSE 71 0.43BLOOD IN STOOL 66 0.4CONVULSIONS NEC 65 0.39CIRRHOSIS OF LIVER NOS 64 0.39SEPTICEMIA NOS 64 0.39INTESTINAL OBSTRUCT NOS 63 0.38MALIG NEO PANCREAS NOS 63 0.38MAL NEO PANCREAS HEAD 62 0.37CHEST PAIN NEC 61 0.37MALIGNANT NEO COLON NOS 61 0.37

Diagnosis Diagnosis Freq %Freq %

Diagnosis Freq %Diagnosis Freq %

Future WorkFuture Work Cost comparison analysis, using Cost comparison analysis, using

techniques such as instrumental techniques such as instrumental variables and propensity scoresvariables and propensity scores

Break down of data by VISN and Break down of data by VISN and individual facilities, creating “score individual facilities, creating “score cards” on key indicatorscards” on key indicators

More detailed analysis of “risk factors” More detailed analysis of “risk factors” for dying in certain venues and for dying in certain venues and categoriescategories

More detailed examination of transitions More detailed examination of transitions among venuesamong venues