Health Care Costs in the Last Week of Life

Abstract

Background Life-sustaining medical care of cancer patients at the end-of-life (EOL) is costly. Patient-physician discussions about EOL wishes were found to be associated with lower rates of intensive interventions. Methods Coping with Cancer (CwC) is an NCI/NIMH-funded, longitudinal, multi-institutional study of 627 advanced cancer patients. Patients were interviewed at baseline and followed through death. Costs for ICU/hospital stays, hospice care and life-sustaining procedures (e.g., ventilation, resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases. Results 188 patients (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 145 patients did not differ in socio-demographic characteristics, recruitment sites, illness acknowledgement or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the aggregate costs of care were $1876 (SE=177) for patients who reported EOL discussions compared with $2917 (SE=285) for patients who did not (in 2008 US dollars), a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) [p=0.002]. Patients with higher costs had worse quality of death (Pearson partial r=-0.17, p=0.006) in their final week. Conclusions Advanced cancer patients who reported EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life

“…4,137 Some studies have reported benefits. 128,[130][131][132]138,139 These tend to be based on surveys, and to focus on a comparative reduction in days and deaths in hospital and costs associated with care in the last year of life. Detering et al 128 report the results of a randomised controlled trial in Australia in which patients receiving a structured ACP intervention were more likely to die in their preferred place.…”

“…ACP is reported to increase the chances of patients dying in their preferred place, assumed usually to be home, and experiencing less invasive (and less costly) treatment. 128,[130][131][132]138,139 Nevertheless, evidence regarding the effectiveness of ACP is limited and conflicting. 4 The policy is not based on evidence about patients' and the public's understanding and experience of ACP, their preferences for how and when this should be discussed, or their attitudes to death and dying.…”

Ten clinician-driven strategies for maximising value of Australian health care

“…In one study, 25% of beds in 69 intensive care units (ICUs) were occupied by patients whom attending intensivists perceived as receiving inappropriate care. 62 A more conservative or palliative approach to end-of-life care has been shown, in the case of patients with advanced cancer, to prolong survival, improve symptoms, avoid invasive care, reduce hospital stays and lower costs (by up to one-third 63 ) compared with more aggressive care. 64 Similar outcomes are possible if advance care planning was systematically applied to patients with end-stage chronic diseases.…”

Using tethered-personal health records for pre-liminary end-of-life discussions with medical providers: Preferences of African American vs. Caucasian primary care patients

“…ACP helps patients to: (a) reflect on their goals, beliefs, and values; (b) consider future medical treatment preferences; (c) appoint and prepare a surrogate decision-maker; and (d) document their wishes regarding future medical treatment [3] . There are a number of favorable outcomes associated with ACP, including: increased satisfaction with care; improved patient quality of life in terminal illness; and better psychological outcomes for family members after patient death [3][4][5] .…”

“…PHRs also aid individuals in taking a more active role in health management and decision-making [5] . PHRs make up-to-date, personal health information accessible to patients.…”