The last century saw remarkable gains in life expectancy—an extraordinary 30 years in the United States and in other developed countries. Whereas improvements in the earlier portion of the century were largely nonmedical (nutrition, sanitation, housing, etc.), those of the second half were clearly due to medical innovation—drugs, devices and procedures. It is therefore not surprising that health care expenditures have grown 2.8% per year more rapidly than the rest of the economy for the past 30 years. At the beginning of the 20th century, only 41% of live births could expect to reach age 65; by the end of the century the percentage doubled. However, these advances are not without their costs. At age 65, 4 out of 5 men and 9 out of 10 women are not in the labor force, and 4 out of ten have a physical or mental disability. Almost half of all hospital beds are filled with patients 65 years of age and older. Therefore, any gains in longevity are likely to be associated with increasing rather than decreasing societal financial burdens.
Since the vast majority of eldercare is financed through federal entitlement programs, the federal government, concerned with the very real potential of a crippling acceleration of national debt, is increasingly faced with the ironic conundrum of greeting each new medical advance/success with suspicion if not outright fear. If internal cardioverter defibrillators are shown (as they have been in large prospective randomized trials) to increase the life expectancy of patients with congestive heart failure who have reduced ventricular systolic function, the potential costs are enormous. Approximately five million Americans suffer from heart failure; approximately half of these have reduced ventricular systolic function. These devices cost upwards of $50,000 each, not counting hospitalization and implantation and care and monitoring expenses. This would amount to a total cost in the billions of dollars. If cardiac resynchronization therapy (placement of sophisticated biventricular pacemakers) is demonstrated to benefit a large portion of this population (as it has), the incremental expense is substantial. If cardiac surgery, once inconceivable in those over 75, is increasingly demonstrated (as recently shown by our studies at the Florida Heart Research Institute) to provide comparable long-term improvements in patient perception of quality of life with operative survival that rivals that of younger patients, how do we weigh the costs with the benefits? Clearly care of these elderly patients is more costly—they are more prone to complications, they tend to have longer hospital stays and a greater need for postoperative support care. What then becomes the metric by which we determine that the benefits warrant the expense??
There is a methodology for comparing the expenses of various medical interventions—the Quality-Adjusted Life Years. This methodology applies a cost-utility approach to creating a simple arithmetic model to compare various health-care interventions. It is assumed that one year of life in perfect health has a value of 1.0, death has a value of 0.0, and one year in less than perfect health has a value somewhere in-between. Therefore, one can compare the years of life predicted to result from a treatment, multiplied by the relative quality of life of those years, to arrive at the QALY’s. Unfortunately, there is tremendous subjectivity in the evaluation of life quality, with different values of the same status when assessed by different populations. Moreover, health status is personal—the manner in which one individual views his health status may differ radically from that of the population mean, even if perfect objective testing where available. Even more perplexing, health status is not static, but rather dynamic with time. Let us examine the 80 year old with congestive heart failure from aortic valve stenosis. The progressive shortness of breath and disability will increase with time. On the other hand, the postoperative disability after successful valve replacement surgery, although it may be profound, will dissipate with time. Assessment is likely to be based on perception at the time it is being asked, not over the course of years being evaluated.
In short, care of the elderly stands at the forefront of our values as a society—faced with increasing financial pressures, how do we choose to provide care for that sector of society which requires the greatest expense yet is least able to return productivity to the system? The answers are far from clear, but the questions need to be framed in a manner which will enable us to begin to make the decisions. Although we can certainly not be the arbiter of these decisions, we at FHRI are committed to supplying the information necessary to make informed decisions.
The last century saw remarkable gains in life expectancy—an extraordinary 30 years in the United States and in other developed countries. Whereas improvements in the earlier portion of the century were largely nonmedical (nutrition, sanitation, housing, etc.), those of the second half were clearly due to medical innovation—drugs, devices and procedures. It is therefore not surprising that health care expenditures have grown 2.8% per year more rapidly than the rest of the economy for the past 30 years. At the beginning of the 20th century, only 41% of live births could expect to reach age 65; by the end of the century the percentage doubled. However, these advances are not without their costs. At age 65, 4 out of 5 men and 9 out of 10 women are not in the labor force, and 4 out of ten have a physical or mental disability. Almost half of all hospital beds are filled with patients 65 years of age and older. Therefore, any gains in longevity are likely to be associated with increasing rather than decreasing societal financial burdens.
