Escalating Health Care Expenditures in Cancer Decedents’ Last Year of Life: A Decade of Evidence from a Retrospective Population-Based Cohort Study in Taiwan

Hung, Yen Ni; Liu, Tsang Wu; Wen, Fur‐Hsing; Chou, Wen Chi; Tang, Siew Tzuh

doi:10.1634/theoncologist.2016-0283

Cited by 23 publications

(13 citation statements)

References 44 publications

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“…1,2 One strategy to achieve this aim is advance care planning (ACP) 3 to explore patient preferences for life-sustaining treatments (LSTs) 4,5 and clarify misunderstandings 6 about their efficacy at EoL, actively involve patients in EoL care decision-making, and align EoL care with patients' goals and preferences. 1,2,4,5 Providing such value-based EoL care to terminally ill patients with cancer may not only "individualize" EoL cancer care 2 and counteract the international trend toward increasingly aggressive and costly EoL care, [7][8][9] but also may facilitate adjustment to the uncertainty inherent in EoL care decision-making, thus alleviating anxiety and depressive symptoms and improving quality of life (QoL). 10,11 The few randomized controlled trials (RCTs) of ACP studies targeting terminally/seriously ill patients [12][13][14][15][16][17][18][19] have shown that ACP not only increases physicianpatient EoL care discussions, [12][13][14][15][16][17][18][19] (earlier) completion of advance directives, 13,[16][17][18] and concordance between preferred and received EoL care, 13,16 but also does not detrimentally affect patients' anxiety, depression, and QoL.…”

Section: Introductionmentioning

confidence: 99%

Advance Care Planning Improves Psychological Symptoms But Not Quality of Life and Preferred End-of-Life Care of Patients With Cancer

Tang

Chen

Wen

et al. 2019

Journal of the National Comprehensive Cancer Network

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Background: This study was conducted to examine whether a longitudinal advance care planning (ACP) intervention facilitates concordance between the preferred and received life-sustaining treatments (LSTs) of terminally ill patients with cancer and improves quality of life (QoL), anxiety symptoms, and depressive symptoms during the dying process. Patients and Methods: Of 795 terminally ill patients with cancer from a medical center in Taiwan, 460 were recruited and randomly assigned 1:1 to the experimental and control arms. The experimental arm received an interactive ACP intervention tailored to participants’ readiness to engage in this process. The control arm received symptom management education. Group allocation was concealed, data collectors were blinded, and treatment fidelity was monitored. Outcome measures included 6 preferred and received LSTs, QoL, anxiety symptoms, and depressive symptoms. Intervention effectiveness was evaluated by intention-to-treat analysis. Results: Participants providing data had died through December 2017. The 2 study arms did not differ significantly in concordance between the 6 preferred and received LSTs examined (odds ratios, 0.966 [95% CI, 0.653–1.428] and 1.107 [95% CI, 0.690–1.775]). Participants who received the ACP intervention had significantly fewer anxiety symptoms (β, −0.583; 95% CI, −0.977 to −0.189; P= .004) and depressive symptoms (β, −0.533; 95% CI, −1.036 to −0.030; P= .038) compared with those in the control arm, but QoL did not differ. Conclusions: Our ACP intervention facilitated participants’ psychological adjustment to the end-of-life (EoL) care decision-making process, but neither improved QoL nor facilitated EoL care honoring their wishes. The inability of our intervention to improve concordance may have been due to the family power to override patients’ wishes in deeply Confucian doctrine–influenced societies such as Taiwan. Nevertheless, our findings reassure healthcare professionals that such an ACP intervention does not harm but improves the psychological well-being of terminally ill patients with cancer, thereby encouraging physicians to discuss EoL care preferences with patients and involve family caregivers in EoL care decision-making to eventually lead to patient value–concordant EoL cancer care.

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Section: Introductionmentioning

confidence: 99%

Advance Care Planning Improves Psychological Symptoms But Not Quality of Life and Preferred End-of-Life Care of Patients With Cancer

Tang

Chen

Wen

et al. 2019

Journal of the National Comprehensive Cancer Network

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“…A comparative study in seven developed countries showed that 40.3% of patients were admitted to the ICU in the USA and approximately 18% of patients were admitted to the ICU in the six other countries 42. The mean cost is US$18 234 per capita, which is lower than those of developed countries, such as Canada (US$21 840), Norway (US$19 783), the USA (US$18 500),42 South Korea, Japan and Taiwan (annual cost of US$68 773 in 2010) 43. The cost increased dramatically as death approached, similar to the results that SEER-Medicare costs revealed 44.…”

Section: Discussionmentioning

confidence: 99%

“…This phenomenon may be related to the traditional Chinese concept of death and suggests ineffective and irrational utilisation and low-value service provision 50. However, this finding is inconsistent with the conclusion that patients prefer to receive relatively passive care in Taiwan 43. Third, cost also depends on the place of death, and cost increased rapidly as death approached.…”

Section: Discussionmentioning

confidence: 99%

End-of-life cost and its determinants for cancer patients in urban China: a population-based retrospective study

Pan

Zhang

et al. 2019

BMJ Open

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ObjectiveThis study aimed to define the end-of-life (EOL) healthcare utilisation and its cost and determinants for cancer patients and to proactively inform related strategies in mainland China.DesignA population-based retrospective study.Setting and participantsData from 894 cancer patients were collected in urban Yichang, China from 01 July 2015 to 30 June 2017.Outcome measuresEmergency department (ED) visits, outpatient and inpatient hospitalisation services, intensive care unit (ICU) admission and total costs were used as the main outcomes.ResultsIn this study, 66.8% of the 894 patients were male, and the average age was 60.4 years. Among these patients, 37.6% died at home, and patients had an average of 4.86 outpatient services, 2.23 inpatient hospitalisation services and 1.44 ED visits. Additionally, 5.9% of these patients visited the ICU at least once. During the EOL periods, the costs in the last 6 months, 3 months, 1 month and 1 week were US$18 234, US$13 043, US$6349 and US$2085, respectively. The cost increased dramatically as death approached. The estimation results of generalised linear regression models showed that aggressive care substantially affected expenditure. Patients with Urban Employee Basic Medical Insurance spent more than those with Urban Resident-based Basic Medical Insurance or the New Rural Cooperative Medical Scheme. The place of death and the survival time are also risk factors for increased EOL cost.ConclusionThe findings suggested that the EOL cost for cancer patients is associated with aggressive care, insurance type and survival time. Timing palliative care is urgently needed to address ineffective and irrational healthcare utilisation and to reduce costs.Ethics and disseminationThis study was approved by the Ethics Committee of the Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571). All the data used in this study were de-identified.

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“…14 Therefore, hospice care should be offered not only shortly before death (i.e., within the last month of life) but also throughout the dying trajectory (i.e., in the last six months of life) to improve quality of life at EOL. In this way, hospice care may more effectively mitigate the trend of increasingly aggressive cancer care and escalating cancer care expenditures, 8,9,11 thereby ensuring the sustainability of health care systems for cancer patients and facilitating a better dying experience for terminally ill cancer patients.…”

Section: Discussionmentioning

confidence: 99%

Hospice Exposure Is Associated With Lower Health Care Expenditures in Taiwanese Cancer Decedents' Last Year of Life: A Population-Based Retrospective Cohort Study

Hung

Wen

Liu

et al. 2018

Journal of Pain and Symptom Management

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Context. Evidence for the association of hospice exposure with lower health care expenditures at end of life (EOL) remains inconclusive and neglects EOL care being concentrated in patients' last few months. Objective. The association between hospice exposure and health care expenditures in cancer patients' last one, three, six, and 12 months was evaluated. Methods. In this population-based, retrospective cohort study, Taiwanese cancer decedents in 2001e2010 (N ¼ 195,228) were matched 1:1, with proportions of matched hospice users reaching 87.8%, by a hospice-utilization propensity score. For each matched pair, exposure to hospice (time from hospice enrollment to death) was matched to equivalent periods for hospice nonusers before death. Hospice-care associations with health care expenditures were evaluated by hospice use/exposure interactions with multilevel linear regression modeling using generalized estimating equations. Results. The unadjusted main effect showed lower total mean health care expenditures for hospice users than for hospice nonusers only in the last one and three months (rate ratio [95% CI]: 0.86 [0.81, 0.90] and 0.93 [0.89, 0.96], respectively). However, after accounting for exposure time, hospice care was significantly associated with lower health care expenditures at exposures of #30, #60, and #180 days for health care expenditures measured in the last one and three months, six months, and 12 months, respectively. Savings for patients with lengthy hospice stays were neutralized or even disappeared. Conclusion. Hospice care was associated with lower health care expenditures when it could actively intervene in EOL care. Hospice philosophy should be applied not only shortly before death but also throughout the dying trajectory to achieve maximum cost savings.

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Escalating Health Care Expenditures in Cancer Decedents’ Last Year of Life: A Decade of Evidence from a Retrospective Population-Based Cohort Study in Taiwan

Cited by 23 publications

References 44 publications

Advance Care Planning Improves Psychological Symptoms But Not Quality of Life and Preferred End-of-Life Care of Patients With Cancer

Advance Care Planning Improves Psychological Symptoms But Not Quality of Life and Preferred End-of-Life Care of Patients With Cancer

End-of-life cost and its determinants for cancer patients in urban China: a population-based retrospective study

Hospice Exposure Is Associated With Lower Health Care Expenditures in Taiwanese Cancer Decedents' Last Year of Life: A Population-Based Retrospective Cohort Study

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