Association of advance care planning with hospital use and costs at the end of life: a population-based retrospective cohort study.

Objective: To investigate associations between the availability and timing of digitally available advance care planning (ACP) documents and hospital use and costs during the last 6 months of life.

Design: Retrospective population-based cohort study using data linkage.

Setting: 11 public hospitals in Queensland, Australia.

Participants: 5586 decedents with ACP documents were directly matched 1:2 to 11 172 control decedents based on age category, sex, location, year of death and principal diagnosis code for the last-known hospital admission.

Exposure: ACP discussions with documents uploaded to a widely accessible statewide digital platform. Directly matched subgroup analyses investigated differences between decedents with ACP documents available at three different times prior to death: ≥6 months, between 1 and 6 months, and <1 month.

Main Outcomes And Measures: Emergency department (ED) presentations, hospital and intensive care unit (ICU) admissions, and in-hospital deaths, expressed as adjusted OR (aOR). Secondary outcomes were hospital bed-days and costs.

Results: ACP decedents with documents uploaded ≥6 months prior to death, compared with controls, had fewer ED presentations (aOR 0.90, 95% CI 0.81 to 1.00), hospitalisations (aOR 0.83, 95% CI 0.74 to 0.92), ICU admissions (aOR 0.23, 95% CI 0.10 to 0.48), and in-hospital deaths (aOR 0.56, 95% CI 0.51 to 0.63), and lower adjusted mean hospital costs per person over the last 6 months of life ($A2290 less (95% CI -$4116 to -$463)). Conversely, decedents with ACP documents uploaded less than 6 months prior to death showed higher rates of ED presentations and hospital admissions and greater hospital costs relative to controls.

Conclusion: The association between digitally available ACP documents and health service use and cost differed based on the timing of ACP upload, with documents available ≥6 months prior to death being associated with less hospital use and costs.