National In-Hospital Outcomes of Pregnancy in Women With Single Ventricle Congenital Heart Disease

Most patients with single ventricle (SV) congenital heart disease are expected to survive to adulthood. Women with SV are often counseled against pregnancy; however, data on pregnancies in these women are lacking. We sought to evaluate in-hospital outcomes of pregnancy in women with SV. We used nationally representative data from the 1998 to 2012 National Inpatient Sample to identify women ≥18 years of age admitted to the hospital with International Classification of Diseases-9th Revision codes for an intrauterine pregnancy and a diagnosis of hypoplastic left heart syndrome, tricuspid atresia, or common ventricle. A matched comparison group without a diagnosis of congenital heart disease or pulmonary hypertension was identified from the database. National estimates of hospitalizations were calculated. Length of stay, hospital charges, and complications were analyzed and compared between groups. Charge data were adjusted to 2012 dollars. There were 282 admissions of pregnant women with SV (69% with deliveries) and 1,405 admissions in the control group (88% with deliveries). Vaginal delivery was more common in SV (74% vs 71%, p <0.001). Length of stay (4.1 ± 0.91 vs 2.8 ± 0.18 days, p <0.001) and charges ($30,787 ± 8,109 vs $15,536 ± 1,006, p <0.0001) were higher in the SV group. Complications occurred in most SV admissions and were more common in the SV group than in the control group. No deaths occurred. Cardiovascular complications occurred in 25% of pregnancy-related hospitalizations, although in-hospital pregnancy-related death is rare. Vaginal delivery is common in these patients. These data suggest that pregnancy and vaginal delivery can be tolerated in women with SV, although the risk for a cardiovascular event is significantly higher than in the general population.

[Gastos hospitalarios por neumonía neumocóccica invasora en adultos en un hospital general en Chile]

Pneumococcal infections are important for their morbidity and economic burden, but there is no economical data from adults patients in Chile.

AIMS

Estimate direct medical costs of bacteremic pneumococcal pneumonia among adult patients hospitalized in a general hospital and to evaluate the sensitivity of ICD 10 discharge codes to capture infections from this pathogen.

METHODS

Analysis of hospital charges by components in a group of patients admitted for bacteremic pneumococcal pneumonia, correction of values by inflation and conversion from CLP to US$.

RESULTS

Data were collected from 59 patients admitted during 2005-2010, mean age 71.9 years. Average hospital charges for those managed in general wards reached 2,756 US$, 8,978 US$ for those managed in critical care units (CCU) and 6,025 for the whole group. Charges were higher in CCU (p < 0.001), and patients managed in these units generated 78.3% of the whole cost (n = 31; 52.5% from total). The median cost in general wards was 1,558 US$, and 3,993 in CCU. Main components were bed occupancy (37.8% of charges), and medications (27.4%). There were no differences associated to age, comorbidities, severity scores or mortality. No single ICD discharge code involved a S. pneumoniae bacteremic case (0% sensitivity) and only 2 cases were coded as pneumococcal pneumonia (3.4%).

CONCLUSIONS

Mean hospital charges (~6,000 US dollars) or median values (~2,400 US dollars) were high, underlying the economic impact of this condition. Costs were higher among patients managed in CCU. Recognition of bacteremic pneumococcal infections by ICD 10 discharge codes has a very low sensitivity.

Hospital Charge and Health-Care Quality in Bariatric Surgery

To determine if hospital charges correlate with patient outcomes after bariatric surgery. A retrospective review of 46,180 patients who underwent bariatric surgery from 2004-2010 was performed. Patients were identified using the New York Statewide Planning and Research Cooperative System database. Hospitals were categorized on estimates from a multiple linear regression model for charge: low (<$25,027.00), medium ($25,027.00-$35,449.00), and high (≥$35,449.01). Patient outcomes were compared among the charge classification. Of the 46,180 patients, 24 per cent underwent operations in low-, 26 per cent in medium-, and 23,082 (50%) in high-charge hospitals. Controlling for patient demographics, comorbidity, insurance, and operative procedure, multivariable logistic regression demonstrated no significant difference in major complication or mortality among charges. Hospital charge does not correlate with improved outcomes. This is significant given the adverse association between price inflation and rising insurance premiums. Inflated hospital charges may also discriminate against certain patient populations including the uninsured and those with high-deductible insurance plans.

Treatment of Type 2 diabetes mellitus in Chongqing of China: unaffordable care for the poor

AIM

This study aims to investigate the medical expenditure of people with Type 2 diabetes mellitus in Chongqing, China; to explore factors that contribute to the expenditure; and to examine the financial burden placed on households, particularly poor households.

METHODS

A cross sectional survey was conducted with a sample of people diagnosed with Type 2 diabetes mellitus in 2014. Of the 664 people eligible, 76% were interviewed. Descriptive statistics and log-linear regression were used to examine respondents' age, sex and level education, location of residence, income and type of health insurance associated with out-of-pocket expenditure on accessing diabetes mellitus care.

RESULTS

In a year, average out-of-pocket expenditure on the purchase of drugs from pharmacies and having outpatient care were US $333 and US $310, respectively. The average out-of-pocket expenditure on accessing inpatient care was 3.7 times (US $1159) that of accessing outpatient care. After adjusting for age and sex, out-of-pocket expenditure on diabetes care was significantly higher for people covered by the Urban Employee Basic Medical Insurance programme and those enrolled in the identified priority diseases reimbursement programme, which provided higher reimbursement rates for outpatient and (or) inpatient care. Out-of-pocket expenditures on the purchase of drugs from pharmacies, having outpatient and inpatient care, respectively, were 9.8%, 16.2% and 62.6% of annual household income in low-income group.

CONCLUSION

Even with health insurance coverage, poor people with Type 2 diabetes mellitus suffered from significant financial hardship. This has significant implications for models of care and healthcare financing in China with the growing burden of diabetes.

Implementation of a Clinical Documentation Improvement Curriculum Improves Quality Metrics and Hospital Charges in an Academic Surgery Department

BACKGROUND

Accurate clinical documentation (CD) is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. New requirements have mandated adoption of ICD-10-CM coding systems, adding another layer of complexity to CD. A clinical documentation improvement (CDI) and ICD-10 training program was created for health care providers in our academic surgery department. We aimed to assess the impact of our CDI curriculum by comparing quality metrics, coding, and reimbursement before and after implementation of our CDI program.

STUDY DESIGN

A CDI/ICD-10 training curriculum was instituted in September 2014 for all members of our university surgery department. The curriculum consisted of didactic lectures, 1-on-1 provider training, case reviews, e-learning modules, and CD queries from nurse CDI staff and hospital coders. Outcomes parameters included monthly documentation completion rates, severity of illness (SOI), risk of mortality (ROM), case-mix index (CMI), all-payer refined diagnosis-related groups (APR-DRG), and Surgical Care Improvement Program (SCIP) metrics. Financial gain from responses to CDI queries was determined retrospectively.

RESULTS

Surgery department delinquent documentation decreased by 85% after CDI implementation. Compliance with SCIP measures improved from 85% to 97%. Significant increases in surgical SOI, ROM, CMI, and APR-DRG (all p < 0.01) were found after CDI/ICD-10 training implementation. Provider responses to CDI queries resulted in an estimated $4,672,786 increase in charges.

CONCLUSIONS

Clinical documentation improvement/ICD-10 training in an academic surgery department is an effective method to improve documentation rates, increase the hospital estimated reimbursement based on more accurate CD, and provide better compliance with surgical quality measures.

Burden of USA hospital charges for traumatic brain injury

OBJECTIVES

This study sought to estimate charges associated with USA hospital visits for traumatic brain injury (TBI), compare charges from 2006-2010 and evaluate factors associated with higher charges.

METHODS

The Nationwide Emergency Department Sample database, 2006-2010, was used to estimate charges for emergency department visits and inpatient hospital stays associated with TBI and trends in charges over time were compared. Multivariable linear regression was used to evaluate factors associated with visit charges.

RESULTS

In 2010, there were $21.4 billion (95% confidence interval (CI) = $17.7-$25.2 billion) in charges for TBI-related admissions, an increase of 22% from 2006. Charges for ED visits resulting in discharge or transfer were $8.2 billion (95% CI = $7.4-$8.9 billion), an increase of 94% from 2006. The proportion of charges for TBI-related visits was disproportionately higher than the proportion of visits for TBI across all years of the study (p < 0.001). Patient age and gender, West region, trauma centre status, non-paediatric hospital designation, metropolitan location and hospital ownership were independently associated with higher charges.

CONCLUSIONS

There was a substantial charge burden from TBI-related hospital visits and charges increased disproportionately to visit volume. There are patient and hospital factors independently associated with higher charges. These findings, as well as methods to reduce the charge burden and charge disparities, deserve further study.

Has Price Competition Changed Hospital Revenues and Expenses in New York?

This study analyzes the factors that influenced hospital expenses and revenues prior to and following the enactment of the New York State Health Care Reform Act of 1996 (HCRA)—the period from 1994–1999. HCRA was expected to encourage price competition which in turn was anticipated to lower hospital revenues and expenses. We measured the differential effects on hospital revenues and expenses in markets with varying degrees of competition. We also measured the relationship between hospital revenues and expenses and the increased concentration resulting from the formation of local hospital systems. We found that revenues and expenses both grew more slowly for hospitals located in more competitive markets; hospital systems that increased concentration tended to have higher revenues. In the short run at least, price competition induced by HCRA did constrain both hospital expense and revenue growth, although the increase in hospital mergers countered this trend.

Financial Considerations Insurance and Coverage Issues in Intestinal Transplantation

Objective

To increase healthcare workers' knowledge of reimbursement concerns.

Methods

Chronological survey of transplants reimbursed at the University of Nebraska Medical Center from December 1997 to October 2003, which include accounts of 30 patients who received intestine transplants.

Conclusions

Gross billed hospital charges for the past 30 transplantations ranged from $112094 to $667597. Length of stay ranged from 18 to 119 days. Charges include organ procurement fees. All 30 intestine transplants were reimbursed by third-party healthcare coverage; combination of coverage; and/or patient and family payments, which resulted in adherence to financial guidelines prearranged by the hospital. Financial guidelines are usually cost plus a percentage. Thirteen transplantations occurred after April 2001, when Medicare made a national coverage decision to reimburse this form of transplantation. Since then, obtaining surgical authorization and reimbursement is easier. Most insurance companies and state public health agencies accept intestinal transplantations as a form of treatment. Researching transplant coverage before evaluation is essential to be compensated adequately. Financial guidelines will secure the fiscal success of the program. Educating patients to insurance and entitlements may reduce the out-of-pocket cost to patients. Transplant financial coordinators coordinate these efforts for the facility. The best coverage option for the patient and transplant programs is a combination of commercial healthcare coverage, secondary entitlement program, and fund-raising. With length of stay ranging up to 119 days and a lifetime of posttransplant outpatient follow-up care, it is beneficial for the facility to also have a fundraising program to assist patients.

Robotic versus laparoscopic radical nephrectomy: comparative analysis and cost considerations

INTRODUCTION

Robotic-assisted laparoscopic radical nephrectomy (RRN) is an increasing utilized alternative to laparoscopic radical nephrectomy (LRN); however, there is a little data on comparative effectiveness and cost of these procedures. We analyzed perioperative outcomes and hospital charge difference among patients undergoing laparoscopic radical nephrectomy (LRN) and robotic radical nephrectomy (RRN).

MATERIALS AND METHODS

Our institutional renal mass registry was queried for patients who underwent either LRN or RRN from 2010 to 2014. Demographic, perioperative outcomes and hospital charge data were compared between surgical approaches.

RESULTS

Overall, 319 minimally invasive radical nephrectomies were performed during the study period. Of these, 243 were LRN and 76 were RRN. Patient demographic and tumor characteristics were similar between groups. Among operative characteristics, operative time (136 min versus 139 min, p = 0.531), intraoperative complications (2.8% versus 2.0%, p = 0.650), and length of stay (2 days versus 2 days, p = 0.745) were similar for LRN and RRN, respectively. Estimated blood loss (50 mL versus 100 mL, p = 0.041) and rate of conversion to an alternative surgical approach (1.0% versus 11.1%, p < 0.001) were higher in RRN. RRN cases were also more likely to include lymph node dissection (12.6% versus 24.2%, p = 0.031). Total charges trended higher for RRN but did not meet traditional levels of significance ($14,913 versus $16,265, p = 0.171).

CONCLUSIONS

RRN appears to be a clinically equivalent alternative to LRN with similar perioperative outcomes, albeit at greater hospital charges.

Quality Competition Among Hospitals: The Effects of Perceived Quality and Perceived Expensiveness on Health Care Consumers

Quality of care rather than price is the main concern in health care. However, does price not matter at all? To investigate what quality and cost factors influence whether patients perceive health care services as expensive and will recommend a hospital to other patients, the authors analyzed data from a national survey of patients in Taiwan in 2002. A total of 6725 subjects returned questionnaires. Results from logistic regression models showed that (1) a patient's perception of expense was determined simultaneously with the perceived quality and the out-of-pocket price of care, (2) a patient's perception of hospital quality appeared to be the most important determinant for recommending a hospital, and(3) while the out-of-pocket price did not affect a patient's recommendation, the perceived expense of the services did. The perceived value rather than the price itself-is the essence of quality competition in Taiwan's health care market.

Shock, but no shift: Hospitals' responses to changes in patient insurance mix

Medicaid reimburses healthcare providers for services at a lower rate than any other type of insurance coverage. To account for the burden of treating Medicaid patients, providers claim that they must cost-shift by raising the rates of individuals covered by private insurance. Previous investigations of cost-shifting has produced mixed results. In this paper, I exploit a disabled Medicaid expansion where crowd-out was complete to investigate cost-shifting. I find that hospitals reduce the charge rates of the privately insured. Given that Medicaid is expanding in several states under the Affordable Care Act, these results may alleviate cost-shifting concerns of the reform.

Study of Treatment Expense of Patients with Congenital Malformations of Craniofacial in Srinagarind Hospital between 2010 and 2014

OBJECTIVES

To report the treatment expenses of the congenital malformations of craniofacial of in-patients of Srinagarind Hospital between 2010 and 2014

MATERIAL AND METHOD

The expenses of congenital malformations of craniofacial in-patients of Srinagarind Hospital were studied by analyzing the actual amount charged and the reimbursement of treatment expenses.

RESULTS

One thousand eight hundred forty five in-patients were treated 2,144 times. The average treatment was about once or twice per person. Male patients were 54.1% and female were 45.9%. About 84% of the patients were under the universal coverage, with an average Relative Weight (RW) between 2010 and 2014 of 1.6988, 1.7059, 1.4847, 1.4165, and 1.5096, respectively. The average of the RW and the treatment expenses differentiated by the patients’ eligible medical expenses for self-paid, Government or State Enterprise Officer (OFC), Social Security Scheme (SSS), and universal coverage (UC) were 1.0398, 1.1596, 1.2759, 1.3477, respectively. The average RW calculated under diagnosis-related group (DRG) for each patient was 1.3148. The estimated RW of OFC at 13,378 and UC at 9,600 baht per RW were 18,081, 14,535, 14,259, and 17,118 baht, for an average of 16,842 baht. The average of the treatment expenses charged by the hospital to the OFC was 14,535 baht and to the UC was 17,118 baht for each treatment. The treatment expense under DRG was lower than the cost under the hospital charge by 2,051,072 baht.

CONCLUSION

The present study analyzed the treatment expense by patients’ eligible medical expenses between 2010 and 2014. The universal coverage and government or state enterprise officer’s charges were reimbursed to the hospital under DRG system for 32,257,000 baht while the hospitals actual charges were 34,308,072 baht. This indicated that Srinagarind Hospital must set up the fund to support congenital malformations of craniofacial patients for a minimum sum of 410,214 baht per year. This is likely to increase in the future.

Melanoma Extirpation with Immediate Reconstruction: The Oncologic Safety and Cost Savings of Single-Stage Treatment

BACKGROUND

The timing of reconstruction following melanoma extirpation remains controversial, with some advocating definitive reconstruction only when the results of permanent pathologic evaluation are available. The authors evaluated oncologic safety and cost benefit of single-stage neoplasm extirpation with immediate reconstruction.

METHODS

The authors reviewed all patients treated with biopsy-proven melanoma followed by immediate reconstruction during a 3-year period (January of 2011 to December of 2013). Patient demographic data, preoperative biopsies, operative details, and postoperative pathology reports were evaluated. Cost analysis was performed using hospital charges for single-stage surgery versus theoretical two-stage surgery.

RESULTS

During the study period, 534 consecutive patients were treated with wide excision and immediate reconstruction, including primary closure in 285 patients (55 percent), local tissue rearrangement in 155 patients (30 percent), and skin grafting in 78 patients (15 percent). The mean patient age was 67 years (range, 19 to 98 years), and the median follow-up time was 1.2 years. Shave biopsy was the most common diagnostic modality, resulting in tumor depth underestimation in 30 patients (6.0 percent). Nine patients (2.7 percent) had positive margins on permanent pathologic evaluation. The only variables associated with positive margins were desmoplastic melanoma (p = 0.004) and tumor location on the cheek (p = 0.0001). The mean hospital charge for immediate reconstruction was $22,528 compared with the theoretical mean charge of $35,641 for delayed reconstruction, leading to mean savings of 38.5 percent (SD, 7.9 percent).

CONCLUSION

This large series demonstrates that immediate reconstruction can be safely performed in melanoma patients with an acceptable rate of residual tumor requiring reoperation and significant health care cost savings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Coronary Bypass Surgery in Patients Aged 70 Years and Over: Mortality, Morbidity, Length of Stay and Hospital Cost

The objective of this investigation was to compare the outcome of isolated coronary artery bypass grafting surgery in patients ≥ 70 years with those < 70. The cardiac surgery database of the Institute was used to obtain the characteristics of patients undergoing coronary artery bypass grafting between January 2000 and September 2001. The patients were divided into those ≥ 70 years of age and those < 70 years old. A Parsonnet risk score was determined for each patient for the analysis of mortality, length of stay and hospital charges. During the study period, 1594 cases of isolated coronary artery bypass grafting were carried out. 184 (11.5%) cases were performed in the older group. The 30-day mortality for patients aged 70 and over was 7 (3.3%) out of 184 while that of patients < 70 years of age was 47 (3.8%) out of 1410 ( p < 0.740). The overall hospital mortality was 10 (5.4%) of 184 and 53 (3.8%) of 1410 ( p < 0.272) respectively. Apart from a higher incidence of wound infection in elderly patients, the frequency of other major complications was comparable in both groups. The average length of postoperative stay for the elderly patients was 10.4 ± 0.9 days compared to 8.7 ± 0.2 days for the younger group ( p < 0.049). The mean hospital charge in patients ≥ 70 was RM 25,160.38 ± 1656.75 whereas for patients < 70, it was RM 21,801.47 ± 308.91 ( p < 0.048). This study supports the continued performance of coronary artery bypass grafting in patients ≥ 70 years. Advanced age alone should not deter a cardiac surgeon from offering such a potentially beneficial intervention.

Does Acupuncture Treatment Affect Utilization of Other Hospital Services at an Urban Safety-Net Hospital?

BACKGROUND

Little is known regarding the interaction between acupuncture and biomedical healthcare among vulnerable patient populations. In particular, the association between acupuncture and total cost of healthcare has not been characterized.

METHODS

Total hospital system visits and associated charges were retrospectively reviewed among patients who received acupuncture at a large safety-net hospital system from 2007 to 2014. Inclusion criteria were Medicare or Medicaid insurance coverage, older than age 18 years, and one or more on-site acupuncture appointments. Patients were stratified into five groups based on the number of acupuncture visits: 1-3, 4-6, 7-9, 10-12, or 13-15 treatments. The total number of biomedical hospital visits and total associated charges were compared 6 months before and 6 months after initiation of acupuncture.

RESULTS

A total of 329 patients met our inclusion criteria. Although not statistically significant, there appeared to be an association between acupuncture treatment and a decrease in total hospital charges. The group receiving 1-3 acupuncture treatments showed a per-patient average increase in total charges in the 6-month period after acupuncture ($1771.34; p = 0.38). The patients who received 7-9 treatments showed the largest average decrease in total charges ($8967.24; p = 0.17).

CONCLUSION

This study shows a previously unreported aggregate relationship between number of treatments and total healthcare charges in a single urban safety-net hospital. Given the sample size available and the heterogeneity of the patient population, no statistically significant associations could be established between initiation of acupuncture treatment and charges. However, some suggestive patterns were observed. Further prospective studies with a matched-group control are warranted to further explore this relationship. Additional study across wider locations is warranted to best guide practitioners and hospitals in designing efficacious, high-value integrative medicine programs.

A Quasi-Experimental Study Analyzing the Effectiveness of Portable High-Efficiency Particulate Absorption Filters in Preventing Infections in Hematology Patients during Construction

OBJECTIVE

The increased risk of infection for patients caused by construction and renovation near hematology inpatient clinics is a major concern. The use of high-efficiency particulate absorption (HEPA) filters can reduce the risk of infection. However, there is no standard protocol indicating the use of HEPA filters for patients with hematological malignancies, except for those who have undergone allogeneic hematopoietic stem cell transplantation. This quasi-experimental study was designed to measure the efficacy of HEPA filters in preventing infections during construction.

MATERIALS AND METHODS

Portable HEPA filters were placed in the rooms of patients undergoing treatment for hematological malignancies because of large-scale construction taking place near the hematology clinic. The rates of infection during the 6 months before and after the installation of the portable HEPA filters were compared. A total of 413 patients were treated during this 1-year period.

RESULTS

There were no significant differences in the antifungal prophylaxis and treatment regimens between the groups. The rates of infections, clinically documented infections, and invasive fungal infections decreased in all of the patients following the installation of the HEPA filters. When analyzed separately, the rates of invasive fungal infections were similar before and after the installation of HEPA filters in patients who had no neutropenia or long neutropenia duration. HEPA filters were significantly protective against infection when installed in the rooms of patients with acute lymphocytic leukemia, patients who were undergoing consolidation treatment, and patients who were neutropenic for 1-14 days.

CONCLUSION

Despite the advent of construction and the summer season, during which environmental Aspergillus contamination is more prevalent, no patient or patient subgroup experienced an increase in fungal infections following the installation of HEPA filters. The protective effect of HEPA filters against infection was more pronounced in patients with acute lymphocytic leukemia, patients undergoing consolidation therapy, and patients with moderate neutropenia.

Estimates of Parainfluenza Virus-Associated Hospitalizations and Cost Among Children Aged Less Than 5 Years in the United States, 1998-2010

BACKGROUND

Parainfluenza virus (PIV) is the second leading cause of hospitalization for respiratory illness in young children in the United States. Infection can result in a full range of respiratory illness, including bronchiolitis, croup, and pneumonia. The recognized human subtypes of PIV are numbered 1-4. This study calculates estimates of PIV-associated hospitalizations among U.S. children younger than 5 years using the latest available data.

METHODS

Data from the National Respiratory and Enteric Virus Surveillance System were used to characterize seasonal PIV trends from July 2004 through June 2010. To estimate the number of PIV-associated hospitalizations that occurred annually among U.S. children aged <5 years from 1998 through 2010, respiratory hospitalizations from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample were multiplied by the proportion of acute respiratory infection hospitalizations positive for PIV among young children enrolled in the New Vaccine Surveillance Network. Estimates of hospitalization charges attributable to PIV infection were also calculated.

RESULTS

Parainfluenza virus seasonality follows type-specific seasonal patterns, with PIV-1 circulating in odd-numbered years and PIV-2 and -3 circulating annually. The average annual estimates of PIV-associated bronchiolitis, croup, and pneumonia hospitalizations among children aged <5 years in the United States were 3888 (0.2 hospitalizations per 1000), 8481 per year (0.4 per 1000 children), and 10,186 (0.5 per 1000 children), respectively. Annual charges for PIV-associated bronchiolitis, croup, and pneumonia hospitalizations were approximately $43 million, $58 million, and $158 million, respectively.

CONCLUSIONS

The majority of PIV-associated hospitalizations in young children occur among those aged 0 to 2 years. When vaccines for PIV become available, immunization would be most effective if realized within the first year of life.

Comparison of Site of Death, Health Care Utilization, and Hospital Expenditures for Patients Dying With Cancer in 7 Developed Countries

IMPORTANCE

Differences in utilization and costs of end-of-life care among developed countries are of considerable policy interest.

OBJECTIVE

To compare site of death, health care utilization, and hospital expenditures in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using administrative and registry data from 2010. Participants were decedents older than 65 years who died with cancer. Secondary analyses included decedents of any age, decedents older than 65 years with lung cancer, and decedents older than 65 years in the United States and Germany from 2012.

MAIN OUTCOMES AND MEASURES

Deaths in acute care hospitals, 3 inpatient measures (hospitalizations in acute care hospitals, admissions to intensive care units, and emergency department visits), 1 outpatient measure (chemotherapy episodes), and hospital expenditures paid by insurers (commercial or governmental) during the 180-day and 30-day periods before death. Expenditures were derived from country-specific methods for costing inpatient services.

RESULTS

The United States (cohort of decedents aged >65 years, N = 211,816) and the Netherlands (N = 7216) had the lowest proportion of decedents die in acute care hospitals (22.2.% and 29.4%, respectively). A higher proportion of decedents died in acute care hospitals in Belgium (N = 21,054; 51.2%), Canada (N = 20,818; 52.1%), England (N = 97,099; 41.7%), Germany (N = 24,434; 38.3%), and Norway (N = 6636; 44.7%). In the last 180 days of life, 40.3% of US decedents had an intensive care unit admission compared with less than 18% in other reporting nations. In the last 180 days of life, mean per capita hospital expenditures were higher in Canada (US $21,840), Norway (US $19,783), and the United States (US $18,500), intermediate in Germany (US $16,221) and Belgium (US $15,699), and lower in the Netherlands (US $10,936) and England (US $9342). Secondary analyses showed similar results.

CONCLUSIONS AND RELEVANCE

Among patients older than 65 years who died with cancer in 7 developed countries in 2010, end-of-life care was more hospital-centric in Belgium, Canada, England, Germany, and Norway than in the Netherlands or the United States. Hospital expenditures near the end of life were higher in the United States, Norway, and Canada, intermediate in Germany and Belgium, and lower in the Netherlands and England. However, intensive care unit admissions were more than twice as common in the United States as in other countries.