How have casemix, cost and hospital stay of inpatients in the last year of life changed over the past decade? Evidence from Italy.

Healthcare utilisation and expenditure are highly concentrated in hospital inpatient services, in particular in end-of-life care with the peak occurring in the very last year of life, regardless of patient age. Few scientific studies have investigated hospital costs and stays of patients at the end of life, and even fewer studies have analysed their evolution over time. In this paper, we exploit hospitalisation data for the Lombardy region of Italy with the aim of studying the evolution of hospital casemix, costs and stays of chronic patients, and compare the last year of life of two cohorts of patients who died in 2005 and 2014. Despite an overall three-year increase in the age at death, the results showed a significant decrease in hospital costs and use due to reduced interventions and length of hospital stays. However, this was not associated with an increase in quality of life/conditions (as indicated by clinical casemix as a proxy) for end-of-life patients; patients' casemix characteristics and clinical condition, as measured by the number of comorbidities, disease severity, prevalence of pulmonary disease and heart failure diagnosis, significantly worsened over the decade. This gives rise to important health policy concerns on how to identify effective policies and possible changes in healthcare system organisation to move from hospital-centred care to a community-centred approach whose value has been demonstrated during the COVID-19 pandemic.