Medical care utilization and costs on end-of-life cancer patients: The role of hospice care

Journey to inpatient hospice care: A qualitative study on the decision-making process of Chinese family caregivers of persons with terminal cancer

OBJECTIVE

To understand family caregivers' decision-making process to place their family members with terminal cancer in inpatient hospice care, especially in the social-cultural contexts whereby the caregivers have a dominant say about the care of their seriously ill family members.

METHODS

A qualitative study with a phenomenological approach was undertaken to understand the lived experience of caregivers of persons with terminal cancer in the decision-making process. Semi-structured qualitative interviews were conducted with a purposive sample of 17 caregivers in Shanghai, China. Thematic analysis was used to analyze the data.

RESULTS

The caregivers underwent a winding and socioculturally mediated four-stage process. The stages are (i) trigger for alternatives: lost hope for a cure, (ii) meandering the see-saw process, (iii) the last straws: physical limitations and witnessing unbearable suffering, and (iv) the aftermath: acceptance versus lingering hope. Caregivers' attitudes towards death and their family members with advanced cancer expressed care wishes influence the state of the aftermath.

CONCLUSIONS

Chinese sociocultural values and beliefs about caregiving and death provide insightful explanations for the observed process.

PRACTICAL IMPLICATIONS

Training healthcare professionals in cultural competence, developing an effective hospice referral system, and delivering socioculturally acceptable death education are critical interventions to facilitate better decision-making experiences.

Exploring the effects of acceptable palliative care models on survival time and healthcare expenditure among patients with cancer: a national longitudinal population-based study

OBJECTIVE

Hospice care ensures better end-of-life quality by relieving terminal symptoms. Prior research has indicated that hospice care could prolong survival and reduce end-of-life medical expenditures among patients with cancer. However, the dearth of studies on the effects of hospice care type and use sequence on survival time and end-of-life medical expenditures substantiates the need for investigation.

DATA SOURCES AND STUDY SETTING

Two million random records were obtained from the National Health Insurance Research Database.

STUDY DESIGN

We estimated the effects of the type and sequence of hospice care use on survival time and medical expenditures among advanced cancer patients. This was a cross-sectional study.

DATA COLLECTION/EXTRACTION METHODS

Patient data were collected from 2 million random records provided by the National Health Insurance Research Database of Taiwan. We included people with cancer and excluded patients under 20 years of age; 2860 patients remained after matching.

PRINCIPAL FINDINGS

The results indicated that the average survival time of patients who received inpatient palliative care (1022 days) was significantly shorter than that of patients who did not receive palliative care (P < 0.001), but the health care expenditure during the entire course of cancer therapy was not the lowest. Interestingly, patients who received inpatient palliative care had the lowest health care expenditure at 1 year or month before the end of life (P < 0.001).

CONCLUSION

The type and sequence of palliative care affected the survival time and health care expenditures of cancer patients. Receiving palliative care did not prolong survival but rather reduced health care expenditures. The sequence of receiving palliative care significantly affected health care expenditures.

Awareness and Utilization of Palliative Care Among Advanced Cancer Patients in Asia

CONTEXT

To date, little is known about palliative care (PC) awareness and utilization in low- and middle-income countries (LMICs) in Asia.

OBJECTIVES

This study aimed to investigate PC awareness and its predictors, utilization of PC services, and perceived utilization barriers among advanced cancer patients from select hospitals in Asian LMICs.

METHODS

This cross-sectional study analyzed data of 759 advanced cancer patients at major hospitals of four LMICs in Asia (i.e., Bangladesh, Philippines, Sri Lanka, and Vietnam). The predictors of PC awareness were investigated using multivariable logistic regression.

RESULTS

Overall PC awareness was 30.8% (n = 234). Patients with higher education (OR = 1.0; CI = 1.0,1.1), from upper-middle or high-income households (compared to low-income) (OR = 2.0; CI = 1.2,3.3), awareness of disease severity (OR = 1.5; CI = 1.0,2.2), and higher pain severity (OR = 1.1; CI = 1.0,1.2) had higher odds of PC awareness. Compared to patients who perceived themselves as being very informed about disease trajectory, those who were unsure (OR = 0.5; CI = 0.3,0.8) or uninformed (OR = 0.5; CI = 0.3,0.9) had lower odds of PC awareness. The PC utilization rate was 35.0% (n = 82) among those with PC awareness, and 47.8% (n = 66) among patients recommended PC by a healthcare professional (n = 138). The most cited PC utilization barriers were currently receiving anti-cancer treatment (n = 43; 33.9%), and having insufficient information about PC (n = 41; 32.3%).

CONCLUSION

The low awareness of PC services in these major hospitals in Asian LMICs highlights that more effort may be required to promote the awareness of PC in this region. The efforts should especially focus on those from disadvantaged groups to reduce the gap in PC awareness.

Medical cost of advanced illnesses in the last-year of life-retrospective database study

OBJECTIVE

This study aims to quantify medical care utilisation, and to describe the cost trajectories of individuals with advanced illnesses in the last-year of life, differentiated by advanced cancer, end-stage organ failure and progressive neurological disorders.

METHODS

This retrospective database study included decedents who had previous inpatient or outpatient encounters at a public hospital in Singapore. Patients with advanced diseases were identified based on diagnostic codes and clinical criteria. Using a look-back approach, the amount of healthcare services utilised and the corresponding mean monthly and annual costs to the healthcare system in the last 12-months of life were quantified.

RESULTS

The last 12-months of life among 6,598 decedents was associated with £20,524 (95% confidence interval: £20,013-£21,036) in medical costs, of which 80% was accounted for by inpatient admissions. Costs increased sharply in the last 2-months of life, with a large proportion of monthly costs accounted for by inpatient admissions which rose rapidly from 61% at 12-months prior to death to 94% in the last-month of life. Compared to patients with cancer, individuals diagnosed with non-cancer advanced illnesses accumulated 1.6 times more healthcare costs in the last-year of life with significant differences across patients with end-stage organ failure and progressive neurological disorders.

CONCLUSION

Healthcare costs varied across disease conditions at the end-of-life. With advance care planning and close collaboration between the inpatient clinical team and the community providers, it may be possible to re-direct some of the hospitalisation costs to community-based palliative care services.

Inpatient Hospice Palliative Care Unit and Palliative Consultation Service Enhance Comprehensive Quality of Life Outcomes in Terminally Ill Cancer Patients: A Prospective Longitudinal Study

This study aimed to explore the effectiveness of an inpatient hospice palliative care unit (PCU) and palliative consultation service (PCS) on comprehensive quality of life outcome (CoQoLo) among terminally ill cancer patients. This was a prospective longitudinal study. Terminally ill cancer patients who met the inclusion criteria and received PCU or PCS in a northern Taiwanese medical center were recruited. The CoQoLo Inventory was used to measure CoQoLo level pre- and seven days following hospice care between August 2018 and October 2019. A total of 90 patients completed the study. No significant differences were found in CoQoLo levels between the PCU and PCS groups pre- and seven days following care. However, the CoQoLo level of patients significantly improved seven days following care in both PCU and PCS groups, compared with pre-hospice care. Patients' age, religious belief, marital status, closeness with family, palliative prognostic index (PPI), and symptom severity were significant concerning CoQoLo levels after adjusting for patients' baseline characteristics. PCU and PCS showed no difference in CoQoLo levels, but both of them can improve CoQoLo among terminally ill cancer patients. These patients could receive PCU or PCS to achieve a good CoQoLo at the end-of-life stage.

A cost-utility analysis of avelumab for metastatic Merkel cell carcinoma in Taiwan

BACKGROUND

Metastatic Merkel cell carcinoma (mMCC) has traditionally been managed with palliative chemotherapy regimens or best supportive care (BSC). Avelumab, a novel anti-programmed death-ligand 1 (PD-L1) human monoclonal antibody for mMCC treatment, is being studied in the pivotal JAVELIN Merkel 200 trial.

AIM

Incorporating trial results, this analysis aimed to evaluate the cost-utility of avelumab in Taiwan.

METHODS AND RESULTS

A de novo partitioned-survival model with three key health states related to survival (progression-free disease, progressed disease, and death) was applied in this study. The data of clinical efficacy, safety, and patient utilities were obtained from the JAVELIN Merkel 200 trial, literature review, and Taiwanese clinical expert opinion. Cost-utility analysis was performed, and results were presented as cost per quality-adjusted life year (QALY) gained. For treatment-naïve patients, the incremental cost-effectiveness ratios (ICERs) for avelumab vs BSC and avelumab vs chemotherapy were US$44885.06 and US$42993.06 per QALY gained, respectively. As to treatment-experienced mMCC patients, avelumab was associated with ICERs of US$27243.06 (vs BSC)/US$26557.43 (vs chemotherapy) per QALY gained. All ICERs remained consistently within the willingness-to-pay (WTP) threshold of US$53,333.33 per QALY gained.

CONCLUSION

This study demonstrated avelumab to be a cost-effective treatment option for both treatment-experienced and treatment-naïve mMCC patients with very poor prognosis in Taiwan.

Clinical and Socio-demographic Profile of Hospice Admissions: Experience from New Delhi

Background:

Our hospice caters to referrals from the wide areas in the northern Indian territory. A descriptive analysis of hospice admissions can bring to light, the status of palliative care in the region overall.

Aim:

The aim was to assess the clinical and demographic profile of hospice admissions in New Delhi during the time period 2016–2017.

Methods:

Hospice admission records from the calendar year 2016 were digitized from paper charts, and statistical analysis was carried out using SPSS v21. Patient and caregiver demographic profile and dominant referral and utilization patterns were retrospectively assessed.

Results:

One hundred and fifty-four admissions (mean age 51.8 ± 15 years; 60% females) were recorded. Up to one-third of the patients (48, 31%) were single at the time of admission. Majority of the patients had below 10^th grade literacy level (116, 75.3%) and belonged to low socioeconomic status. Two large tertiary care centers were the most common referrers (54.6%). The top three diagnoses were head-and-neck cancers (56, 36.4%), gastrointestinal cancers (27, 17.5%), and metastatic breast cancer (23, 14.9%). Major patient-reported debilities were pain (73%), dysphagia (51%), and incontinence (45%). The mean duration from diagnosis to hospice referral was 2.7 ± 0.7 years. Majority of the patients (76%) reported to have undergone some form of oncologic treatment. Up to two-thirds of the patients received opioids with or without additional supportive care.

Conclusion:

Pain, dysphagia, and incontinence were the most common reasons for hospice referral, with incontinence being significantly correlated with the divorced status. There were no differences in the prevalence of other symptoms with relation to the marital status. Data on hospice utilization patterns in India are limited to pilot experiences. More data are needed to drive national-level policies.

Differences in medical costs for end-of-life patients receiving traditional care and those receiving hospice care: A retrospective study

Background

Hospice care has a positive effect on medical costs. The correlation between survival time after receiving hospice care and medical costs has not been previously investigated in the literature on Taiwan. This study aimed to compare the differences in medical costs between traditional care and hospice care among end-of-life patients with cancer.

Methods

Data from Taiwan’s National Health Insurance program on all patients who had passed away between 2010 and 2013 were used. Those whose year of death was between 2010 and 2013 were defined as end-of-life patients. The patients were divided into two groups: traditional care and hospice care. We then analyzed the differences in end-of-life medical cost between the two groups.

Results

From 2010 to 2013, the proportion of patients receiving hospice care significantly increased from 22.2% to 41.30%. In the hospice group, compared with the traditional group, the proportions of hospital stays over 14 days and deaths in a hospital were significantly higher, but the proportions of outpatient clinic visits; emergency room admissions; intensive care unit admissions; use of ventilator; use of cardiopulmonary resuscitation; and use of hemodialysis, surgery, and chemotherapy were significantly lower. Total medical costs were significantly lower. A greater number of days of survival for end-of-life patients when receiving hospice care results in higher saved medical costs.

Conclusion

Hospice care can effectively save a large amount of end-of-life medical costs, and more medical costs are saved when patients are referred to hospice care earlier.

Cancer and end of life: the management provided during the year and the month preceding death in 2015 and causes of death in France

PURPOSE

The management of cancer patients at the end of life in France and their causes of death are not well known.

METHODS

People managed for cancer in 2014-2015, who died in 2015 and who were covered by the national health insurance general scheme (77% of the French population) were selected from the national health data system in order to analyze the health care reimbursed during the year and the month before their death.

RESULTS

This study included 125,497 people (mean age 73 years, SD 12.5) managed for cancer: colorectal: 12%, lung: 18%, prostate: 9%, breast: 8% and other: 62%. Almost 67% of people died in short-stay hospitals (SSH), 8% died in rehabilitation units (Rehab), 4% died in hospital at home (HaH), 5% died in skilled nursing homes (SNH) and 15% died at home or another place. The mean annual duration of all types of hospitalization was 70 days (SD 66) and 59% of patients had received hospital palliative care (HPC). During the last month of life, 42% of people had attended an emergency department at least once and people who had received HPC were less often admitted to an intensive care unit (10% versus 23%, 15% overall). During the month before death, 17% of patients had received intravenous chemotherapy (lung 23%, breast 21%) and 9% had received a pharmacy reimbursement for another form of chemotherapy (prostate 24%, breast 19%). The main cause of death was a tumour for 81% of patients: after management of lung cancer in 91% of cases, breast cancer in 81% of cases, colorectal cancer in 76% of cases and prostate cancer in 63% of cases.

CONCLUSIONS

Cancer management and death mostly occurred in SSH in France. Cancer patients frequently attend the emergency department and frequently receive chemotherapy during the last month of life. These data continue to contrast with those observed in Scandinavian- and English-speaking countries, in which management of the end of life at home is preferred.

Caring for frail older patients in the last phase of life : Challenges for general practitioners in the integration of geriatric and palliative care

BACKGROUND

The best possible care for frail older patients at the end of life can require the integration of geriatric and palliative approaches, possibly with different accentuations at different times. General practitioners (GP) are particularly important in this context: they provide patients with low-threshold primary care close to their homes and provide both general palliative care and geriatric services.

OBJECTIVE

What are the challenges for GPs in caring for frail older patients at the end of their lives?

MATERIAL AND METHODS

A secondary data analysis of 52 qualitative interviews was carried out, which were serially obtained at 4 points in time over a period of 18 months with 14 family doctors. In addition, one focus group with five GPs took place. The analysis was carried out according to the principles of grounded theory.

RESULTS

The results show that GPs see the care of frail older patients at the end of their lives through a) the growing number of older people, b) multimorbidity and complexity of the problem areas, c) the integration of geriatric and palliative approaches, d) the high average age of general practitioners and the lack of junior staff and e) the problem of ensuring care in rural areas as a major challenge. The practical transition between geriatric and palliative care is considered by GPs to be fluid and there is a desire for more integration of both disciplines.

CONCLUSION

In this study GPs perceived a large overlap between geriatric and palliative care. Both approaches should be offered for a selection of patients as a combined service. In the future a systematic network between GPs and geriatricians in practices, clinics, and day clinics will be necessary.

Management and intensity of medical end-of-life care in people with colorectal cancer during the year before their death in 2015: A French national observational study

The care pathway of patients with colorectal cancer (CRC) 1 year prior to death, their causes of death and the healthcare use, and associated expenditure remain poorly described together. People managed for CRC (2014‐2015), covered by the national health insurance general scheme and who died in 2015 were selected from the national health data system. A total of 15 361 individuals (mean age: 75 years, SD: 12.5 years) were included, almost 66% of whom died in short‐stay hospital (SSH), 9% in hospital at home (HaH), 4% in rehabilitation units (Rehab), 6% in skilled nursing homes (SNH), and 15% at home. At least one other cancer was identified for one‐third of these people. Almost one‐half of people presented cardiovascular comorbidity, 21% had chronic respiratory disease, and 13% had a neurological or degenerative disease. During the last month of life, 83% were admitted at least once to SSH, 39% had at least one emergency department admission, 17% were admitted to an intensive care unit, 15% received at least one chemotherapy session (<60 years: 27%), and 5% received oral chemotherapy. Eighty‐eight percent of the 60% of individuals who received hospital palliative care (HPC) vs 75% of those without HPC were admitted to SSH at least once during the last month. Cancer was the main cause of death for 84% (SSH: 85%, home: 77%) and corresponded to CRC for 64% of them. The mean annual expenditure per person during the last year of life was €43 398 (SSH: €48 804). This study suggests a relatively high level of HPC use during the year before death for people with CRC in France. High rates of emergency department, intensive care, and chemotherapy use were observed during the last month of life. However, management is very largely SSH‐based with a small proportion of deaths at home.

The impact of health literacy on knowledge, Attitude and decision towards hospice care among community-dwelling seniors

The aim of this study was to investigate the relationships between health literacy and hospice knowledge, attitude and decision in community-dwelling elderly participants. This cross-sectional study enrolled 990 community-dwelling elderly participants in three residential areas, with a mean age of 71.53 ± 7.22 years. Health literacy was assessed using the Mandarin version of the European Health Literacy Survey Questionnaire. Knowledge, attitude and decision towards hospice care were assessed using an interviewer-administered questionnaire. Partial least squares were used for data analysis. More than half of the respondents had sufficient knowledge of hospice care (60.7%) and a positive attitude (77.3%) and positive decision (85%) towards hospice care. In the structural equation model, general health literacy positively predicted knowledge (β = 0.73, p <0.001), attitude (β = 0.06, p = 0.038) and decision (β = 0.14, p < 0.001) towards hospice care. General health literacy had a greater overall effect on hospice decision (β = 0.57) than hospice knowledge (β = 0.54). In addition, disease prevention health literacy also demonstrated a higher level of influence on hospice decision (β = 0.59) than hospice knowledge (β = 0.53). Health literacy was associated with hospice knowledge, attitude and decision. Incorporating health literacy interventions into hospice promotion strategies is recommended.

Geographical disparities in treatment and health care costs for end-of-life cancer patients in China: a retrospective study

Background

Cancer imposes substantial burdens on cancer suffers, their families and the health system, especially in the end of life (EOL) of care patients. There are few developing country studies of EOL health care costs and no specialist studies of the disparities in cancer treatment and care costs by geographical location in China. We sought to examine geographical disparities in the types of cancer treatments and care costs during the last 3 months of life for Chinese cancer patients.

Methods

Using snowball sampling and face-to-face interviews, field research was conducted with a specialist questionnaire. Data were collected on 792 cancer patients who died between July 2013 and June 2016 in China. Total EOL health care costs were modeled using generalized linear models (GLMs) with log link and gamma distribution.

Results

Total health care costs were highest for urban (US$12,501) and western region (US$9808) patients and lowest for rural (US$5996) and central region (US$5814) patients. Our study revealed about 40% of the health care expenses occur in the last three months of life, and was mainly driven by hospital costs that accounted for about 70% of EOL expenditures. Patients faced out-of-pocket expenses for health care, with the ability to borrow from family and friends also impacting the type of treatment and health facility. Life-extending treatments per cancer patient was about two times that of patients receiving conservative treatments.Urban patients were more likely to receive life-extending treatments, financed by higher incomes and a greater capacity to borrow from family and friends to bridge the gap between health insurance reimbursements and out-of-pocket expenditures. Cancer patients in western region and urban area were significantly more likely to access hospice care.

Conclusions

We found significant urban-rural and regional disparities in EOL types of cancer treatment, utilization of medical care and the health care expenditures. The EOL cancer care costs imposed heavy economic burdens in China.We recommend better clinical guidelines, improved EOL conversations and fuller information on treatment regimes among patients, family caregivers and doctors. Policies and information should pay more attention to palliative care options and the socio-cultural context of cancer care decision-making by family.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5237-1) contains supplementary material, which is available to authorized users.

Palliative care and end-of-life health care utilization in elderly patients with pancreatic cancer

Background

Palliative care has been associated with improved survival and quality of life, with lower rate of end-of-life health care utilization and cost. We examined trends in palliative care utilization in older pancreatic cancer patients.

Methods

Pancreatic cancer patients with and without palliative care consults were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database between 2000 and 2009. Trend of palliative care use was studied. Emergency room/intensive care unit (ICU) utilization and costs in the last 30 days of life were compared between both groups using propensity score-matched (PSM) analysis.

Results

Of the 54,130 patients, 3,166 (5.8%) received palliative care and 70% received it in the last 30 days of life. The proportion of patients receiving palliative care increased from 1.4% in 2000 to 7.4% in 2009 (P<0.001). Patients with palliative care were more likely to be older, Asian and women. In the unmatched and PSM population, the average visits to the ER in the last 30 days of life were significantly higher for patients who received palliative care, and had a significantly higher cost of care. Similarly, ICU length of stay in the last 30 days of life was higher in patients who did not receive palliative care in both PSM and unmatched patients. Cost of care and number of ICU admissions were not different between palliative and non-palliative care groups in PSM and unmatched patients.

Conclusions

In this study of Medicare patients with pancreatic cancer, palliative care use has increased between 2000 and 2009. Palliative care was largely offered close to the end of life and was not associated with reduced health care utilization or cost.