Medical Costs and Healthcare Utilization among Cancer Decedents in the Last Year of Life in 2009

Medical care costs at the end of life among older adults with cancer: a national health insurance data-based cohort study

OBJECTIVE

Along with aging, the elderly population with cancers is increasing. The costs of end-of-life (EOL) care are particularly high among cancer patients. The purpose of this study was to investigate the trends in medical costs in the last year of life among older adults with cancer.

DESIGN, SETTING, AND PARTICIPANTS

Using the Health Insurance Review and Assessment Services (HIRA) database for the period 2016-2019, we identified older adults aged ≥ 65 years who had a primary diagnosis of cancers and high-intensity treatment at least once in the intensive care unit (ICU) of tertiary hospitals.

MAIN OUTCOMES AND MEASURES

High-intensity treatment was defined as receiving at least one of the following treatments: cardiopulmonary resuscitation, mechanical ventilation, extracorporeal membrane oxygenation, hemodialysis, and transfusion. The EOL medical treatment costs were calculated by dividing periods 1, 2, 3, 6, and 12 months from the time of death, respectively.

RESULTS

The mean total EOL medical expense per older adult during the year before death was $33,712. The cost of EOL medical expenses for three months and one month before subjects' death accounted for 62.6% ($21,117) and 33.8% ($11,389) of total EOL costs, respectively. Among subjects who died while receiving high-intensity treatment in the ICU, the costs associated with medical treatments that occurred during the last month before death were 42.4% ($13,841) of the total EOL expenses during the year.

CONCLUSION

The findings indicate that EOL care expenditures for the older population with cancer are highly concentrated until the last month. The intensity of medical care is an important and challenging issue in terms of care quality and cost suitability. Efforts are needed to properly use medical resources and provide optimal EOL care for older adults with cancer.

Healthcare resource utilization and medical costs in patients with terminal cancer during best supportive care

Patients with terminal cancer have different physical symptoms, prognoses, emotional distress, and end-of-life care plans from those receiving aggressive chemotherapy; few studies have assessed healthcare resource use in these patients. Therefore, this study aimed to assess healthcare resource utilization and medical costs incurred during best supportive care after the last anticancer drug treatment in patients with terminal cancer. This retrospective observational study was conducted using national sample cohort data from the National Health Insurance Service in South Korea. Only patients with cancer who were treated with the last anticancer drugs from January 1, 2006, to June 30, 2015, were included in the study. The period of best supportive care was defined as the time from the date of use of the last anticancer drug to death. Healthcare resource utilization and medical costs were estimated during the best supportive care. A generalized linear model with a log-link function and gamma distribution was used to evaluate the impact of demographic and healthcare utilization factors on total medical costs. Among the 2,480 patients in the study, 93.9% were hospitalized, and hospitalization days (30.8 days) accounted for 39.7% of the surviving period (77.5 days). The proportions of intensive care unit admissions and emergency department visits were 15.8% and 18.9%, respectively. The average total medical cost per patient was $6,310, with the inpatient cost ($5,705) being approximately 9.4 times higher than the outpatient cost ($605). The length of hospitalization had the greatest impact on the total medical costs. Pancreatic cancer had the highest proportion of patients who were hospitalized (97.4%) and the highest medical cost ($7,702). Hospital-based resources were utilized by most patients with terminal cancer, and hospitalization was a major driver of the total medical cost. An alternative system for hospitalization should be developed to support patients with terminal cancer, both clinically and financially.

Disparities in healthcare expenditures according to economic status in cancer patients undergoing end-of-life care

Backgrounds

A desire for better outcome influences cancer patients’ willingness to pay. Whilst cancer-related costs are known to have a u-shaped distribution, the actual level of healthcare utilized by patients may vary depending on income and ability to pay. This study examined patterns of healthcare expenditures in the last year of life in patients with gastric, colorectal, lung, and liver cancer and analyzed whether differences exist in the level of end-of-life costs for cancer care according to economic status.

Methods

This study is a retrospective cohort study which used data from the Korean National Elderly Sampled Cohort, 2002 to 2015. End-of-life was defined as 1 year before death. Economic status was classified into three categorical variables according to the level of insurance premium (quantiles). The relationship between the dependent and independent variables were analyzed using multiple gamma regression based on the generalized estimated equation (GEE) model.

Results

This study included 3083 cancer patients, in which total healthcare expenditure was highest in the high-income group. End-of-life costs increased the most in the last 3 months of life. Compared to individuals in the ‘middle’ economic status group, those in the ‘high’ economic status group (RR 1.095, 95% CI 1.044–1.149) were likely to spend higher amounts. The percentage of individuals visiting a general hospital was highest in the ‘high’ economic status group, followed by the ‘middle’ and ‘low’ economic status groups.

Conclusion

Healthcare costs for cancer care increased at end-of-life in Korea. Patients of higher economic status tended to spender higher amounts of end-of-life costs for cancer care. Further in-depth studies are needed considering that end-of-life medical costs constitute a large proportion of overall expenditures. This study offers insight by showing that expenditures for cancer care tend to increase noticeably in the last 3 months of life and that differences exist in the amount spent according economic status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09373-y.

Projecting Lifetime Health Outcomes and Costs Associated with the Ambient Fine Particulate Matter Exposure among Adult Women in Korea

We sought to estimate the lifetime healthcare costs and outcomes associated with the exposure to the escalated concentration of fine particulate matter (particle size < 2.5 μm, PM2.5) among adult Korean women. We adapted a previously developed Markov model, and a hypothetical cohort composed of Korean women was exposed to either a standard (15 μg/m3) or increased (25 μg/m3) concentration of PM2.5. The time horizon of the analysis was 60 years, and the cycle length was 1 year. The outcomes were presented as direct healthcare costs and quality-adjusted life years (QALYs), and costs were discounted annually at 5%. Deterministic and probabilistic sensitivity analyses were performed. The model estimated that when the exposure concentration was increased by 10 μg/m3, the lifetime healthcare cost increased by USD 9309, which is an 11.3% increase compared to the standard concentration group. Women exposed to a higher concentration of PM2.5 were predicted to live 30.64 QALYs, compared to 32.08 QALYs for women who were exposed to the standard concentration of PM2.5. The tendency of a higher cost and shorter QALYs at increased exposure was consistent across a broad range of sensitivity analyses. The negative impact of PM2.5 was higher on cost than on QALYs and accelerated as the exposure time increased, emphasizing the importance of early intervention.

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.

Evolution of health care utilization and expenditure during the year before death in 2015 among people with cancer: French snds-based cohort study

BACKGROUND

Cancer patients have one of the highest health care expenditures (HCE) at the end of life. However, the growth of HCE at the end of life remains poorly documented in the literature.

OBJECTIVE

To describe monthly reimbursed expenditure during the last year of life among cancer patients, by performing detailed analysis according to type of expenditure and the person's age.

METHOD

Data were derived from the Système national des données en santé (SNDS) [national health data system], which comprises information on ambulatory and hospital care. Analyses focused on general scheme beneficiaries (77% of the French population) treated for cancer who died in 2015.

RESULTS

Average reimbursed expenditure during the last year of life was €34,300 per person in 2015, including €21,100 (62%) for hospital expenditure. "Short-stays hospital" and "rehabilitation units" stays expenditure were €14,700 and €2000, respectively. Monthly expenditure increased regularly towards the end of life, increasing from 12 months before death €2000 to €5200 1 month before death. The highest levels of expenditure did not concern the oldest people, as average reimbursed expenditure was €50,300 for people 18-59 years versus €25,600 for people 80-90 years. Out-of-pocket payments varied only slightly according to age, but increased towards the end of life.

CONCLUSION

A marked growth of HCE was observed during the last 4 months of life, mainly driven by hospital expenditure, with a more marked growth for younger people.

End-of-life cost trajectories and the trade-off between treatment costs and life-extension: Findings from the Cost and Medical Care of Patients with Advanced Serious Illness (COMPASS) cohort study

BACKGROUND

Few studies have assessed how patient preferences influence end-of-life costs.

AIM

To estimate mean monthly healthcare costs in 2019 Singapore Dollars (SGD) at five time points within the last year of life and identify how patients' preferences for the trade-off between treatment cost containment and life-extension and other factors affect these costs.

DESIGN

Mean monthly costs were quantified in the last 1, 3, 6, 9, and 12-months before death. Univariate and multivariate analyses were conducted.

SETTING/PARTICIPANTS

Billing records for 286 deceased participants in the Cost and Medical Care of Patients with Advanced Serious Illness (COMPASS) cancer cohort study in Singapore.

RESULTS

Mean monthly costs were $5140 (95% CI: $4750; $5520) in the 12-months before death and rose to $8350 (95% CI: $7110; $9590) 1-month before death. Participants preferring higher cost containment/less life-extension defied the trend of increasing costs closer to death (mean monthly costs of $4630 (95% CI: $3690; $ 5580) and $4850 (95% CI: $2850; $6850) (12-months and 1-month before death respectively). Participants preferring lower cost containment/more life-extension had costs that were $1050 (95% CI: $49; $2051) and $5220 (95% CI: $2320; $8130) higher than those preferring lower costs/less life-extension 12-months and 1-month before death respectively.

CONCLUSIONS

On average, cancer patients in Singapore can expect to spend $61,680 in the last year of life. Of broader relevance is that patient preferences and other observable factors clearly influence these costs, suggesting that policymakers and patients can better predict and budget for end-of-life costs by considering these factors.

Trends in End-of-Life Resource Utilization and Costs among Prostate Cancer Patients from 2006 to 2015: A Nationwide Population-Based Study

Purpose

The purpose of this study was to evaluate end-of-life resource utilization and costs for prostate cancer patients during the last year of life in Korea.

Materials and Methods

The study used the National Health Information Database (NHIS-2017-4-031) of the Korean National Health Insurance Service. Healthcare claim data for the years 2002 through 2015 were collected from the Korean National Health Insurance System. Among 83,173 prostate cancer patients, we enrolled 18,419 after excluding 1,082 who never claimed for the last year of life.

Results

From 2006 to 2015, there was a 3.2-fold increase the total number of prostate cancer decedents. The average cost of care during the last year of life increased over the 10-year period, from 14,420,000 Korean won to 20,300,000 Korean won, regardless of survival time. The cost of major treatments and medications, other than analgesics, was relatively high. Radiologic tests, opioids, pain control, and rehabilitation costs were relatively low. Multiple regression analysis identified age and living in rural area as negatively associated with prostate cancer care costs, whereas income level and a higher number of comorbidities were positively associated.

Conclusions

Expenditure of prostate cancer care during the last year of life varied according to patient characteristics. Average costs increased every year. However, the results suggest underutilization of support services, likely due to lack of alternative accommodation for terminal prostate cancer patients. Further examination of patterns of utilization of healthcare resources will allow policymakers to take a better approach to reducing the burden of prostate cancer care.

Cost of Care and Pattern of Medical Care Use in the Last Year of Life among Long-Term Care Insurance Beneficiaries in South Korea: Using National Claims Data

In Korea, a substantial proportion of long-term care insurance (LTCI) beneficiaries die within 1 year of seeking the benefit. This study was conducted to evaluate the pattern of medical care use and care cost during the last year of life among Korean LTCI beneficiaries between 2009 and 2013 using the national claims data. The National Health Insurance’s Senior (NHIS-Senior) cohort was used for this retrospective study. The participants were LTCI beneficiaries aged 65 or over as of 2008 who died between 2009 and 2013 (N = 30,433). Medical costs during the last year of life were highest for those who used both medical care services and long-term care (LTC) services and increased as death approached. About half of the participants were hospitalized at the time of death. The use of LTC services at the time of death increased from 13.0 to 22.8%, while those who died at home decreased from 34 to 20%. This study suggests that the use of LTC services did not reduce medical costs by substituting unnecessary inpatient hospitalization. Quality of dying should be considered one of the goals of older adult care, and provisions should be made for palliative care at home or LTC facilities.

Research on Current Curative Expenditure among Lung Cancer Patients Based on the "System of Health Accounts 2011": Insights into Influencing Factors

PURPOSE

To investigate the total current curative expenditure (CCE) of lung cancer in Hunan Province, China under the framework of the System of Health Accounts 2011 (SHA 2011) and explore the effect of insurance status, surgery and length of stay on the hospitalization expenses of patients with lung cancer.

METHODS

Through multistage stratified cluster random sampling, a total of 46,214 patients with lung cancer were enrolled from 1,072 medical institutions in Hunan Province in 2016. Under the SHA 2011 framework, the lung cancer CCE was analyzed. The relationships between hospitalization expenditure and the following factors (surgery, type of hospital, insurance status, length of stay, institution level, age and sex) were analyzed using Spearman's correlation analyses, and how these factors influenced hospital expenditure was explored through multiple stepwise regression analysis and structural equation modelling.

RESULTS

The CCE for lung cancer patients was 8063.75 million CNY. In total, 96.03% of the CCE for lung cancer occurred in hospitals and 58.88% of the expenditure flowed to general hospitals. The highest expenditures were incurred in the group aged 55-74 y, which accounted for 61.58% of the CCE. Drugs accounted for the greatest share expenditure to lung cancer patients at 34.31% of the CCE. Surgery, insurance status, institution level, sex and hospital type explained 57.5% of the variance in hospital expenses. The hospitalization expenses were related to surgery, insurance status, institution level and sex (rs = 0.033-0.688, p < 0.001). Surgery, insurance status and length of stay had direct effects on hospitalization expenses. Length of stay mediated the relationship between surgery and hospitalization expenses for lung cancer patients. Surgery mediated the relationship between insurance status and hospitalization expenses. All of these variables can explain 45% of the variance in hospitalization expenses.

CONCLUSIONS

The CCE of lung cancer is extremely high. The problems related to treatment efficiency and equity are serious for lung cancer patients in China. It is essential to expand health insurance coverage and reduce the curative expenditure of lung cancer.

National practice patterns and direct medical costs for prostate cancer in Korea across a 10 year period: a nationwide population-based study using a national health insurance database

BACKGROUND

A complete enumeration study was conducted to evaluate trends in national practice patterns and direct medical costs for prostate cancer (PCa) in Korea over a 10-year retrospective period using data from the Korean National Health Insurance Service.

METHODS

Reimbursement records for 874,924 patients diagnosed between 2002 and 2014 with primary PCa according to the International Classification of Disease (ICD) 10th revision code C61 were accessed. To assess direct medical costs for patients newly diagnosed after 2005, data from 68,596 patients managed between January 2005 and 31 December 2014 were evaluated.

RESULTS

From 2005 to 2014, the total number of PCa patients showed a 2.6-fold increase. Surgery and androgen deprivation therapy were the most common first-line treatment, alone or within the context of combined therapy. Surgery as a monotherapy was performed in 23.5% of patients in 2005, and in 39.4% of patients in 2014. From 2008, the rate of robot-assisted RP rose sharply, showing a similar rate to open RP in 2014. Average total treatment costs in the 12 months post-diagnosis were around 10 million Korean won. Average annual treatment costs thereafter were around 5 million Korean won. Out-of-pocket expenditure was highest in the first year post-diagnosis, and ranged from 12 to 17% thereafter.

CONCLUSIONS

Between 2005 and 2014, a substantial change was observed in the national practice pattern for PCa in Korea. The present data provide a reliable overview of treatment patterns and medical costs for PCa in Korea.

The Last Year Before Graft Failure Negatively Impacts Economic Outcomes and is Associated With Greater Healthcare Resource Utilization Compared With Previous Years in the United Kingdom: Results of a Retrospective Observational Study

Supplemental Digital Content is available in the text.

Background.

Kidney and liver transplantation is the standard of care for end-stage renal or liver disease. However, long-term survival of kidney and liver grafts remain suboptimal. Our study aimed to understand the healthcare resources utilized and their associated costs in the years before graft failure.

Methods.

Two noninterventional, retrospective, observational studies were conducted in cohorts of kidney or liver transplant patients. Once identified, patients were followed using the UK Clinical Practice Research Datalink linked to the Hospital Episode Statistics databases from the date of transplantation to the date of the first graft failure. Total healthcare costs in the year before graft failure (primary endpoint) and during years 2–5 before graft failure (secondary endpoint) were collected.

Results.

A total of 269 kidney and 81 liver transplant patients were analyzed. The mean total costs were highest for all resource components in the last year before graft failure, except for mean costs of immunosuppressive therapy per patient, which decreased slightly by index date (ie, graft failure). The mean total healthcare costs in the last year before graft failure were £8115 for kidney and £9988 for liver transplant patients and were significantly (P < 0.05) higher than years 2–5 before graft failure. Mean healthcare costs for years 2, 3, 4, and 5 before graft failure were £5925, £5575, £5469, and £5468, respectively, for kidney, and £6763, £7042, £6020, and £5651, respectively, for liver transplant patients.

Conclusions.

Total healthcare costs in the last year before graft failure are substantial and statistically significantly higher than years 2–5 before graft failure, in both kidney and liver transplant patients. Our findings show the economic burden placed on healthcare services in the years before graft failure.

Medical care costs of cancer in the last year of life using national health insurance data in Korea

Background

Medical care of cancer patients at the end-of-life is costly. This study aims to describe the monthly trends of EOL medical care, drug therapy, and chemotherapy costs per patient with cancer in the last year of life in the inpatients vs. outpatient setting for the 13 most prevalent cancers in Korea.

Methods

Using the Health Insurance Review and Assessment Service (HIRA) database, we identified the patients who had been treated for the primary diagnoses of one of the 13 most prevalent cancers in Korea and died between January 1, 2013 and December 31, 2015. We calculated the mean monthly costs of medical care, drug therapy, and chemotherapy per patient in the last year of life by cancer site and patient setting (inpatient vs. outpatient).

Results

For most cancers, the monthly inpatient costs per patient remain stable or increased gradually from 12 months to 3 months prior to death and then increased steeply from 2 months prior to death. The mean monthly inpatient costs per patient were highest for acute myeloid leukemia (AML) throughout the last year of life; all solid tumors had similar trends of monthly inpatient costs. The mean monthly inpatient costs for AML increased from $5,465 (SD, $5,248) in 12 months prior to death to $15,033 (SD, $11,864) in the last month. The monthly outpatient costs per patient showed similar, gradually decreasing trends for most cancers. The mean outpatient costs were highest for kidney cancer; the costs sharply decreased from $954 (SD, $1,346) in 12 months prior to death to $424 (SD, $736) in the last month. The proportion of inpatients receiving chemotherapy in the last month of life was highest for AML (77%), followed by liver cancer (67%) and breast cancer (56%).

Conclusion

The monthly inpatient medical care costs per patient with cancer increased as the patient approached death, while the monthly outpatient costs decreased. A considerable proportion of inpatient received chemotherapy in the last month of life. Efforts are needed to optimize EOL care for cancer patients.

Intensity of Care at the End of Life Among Older Adults in Korea

AIM

To examine the intensity of care at the end of life among older adults in Korea and to identify the individual and institutional factors associated with care intensity.

METHODS

This secondary data analysis included a sample of 6278 decedents aged 65 years or older who were identified from the 2009 to 2010 Korean National Health Insurance Service-National Sample Cohort Claims data. We examined the medical care received by the cohort in the last 30 days of their lives.

RESULTS

Overall, 36.5% of the sample received at least 1 intensive care procedure in the last 30 days of their lives; 26.3% of patients experienced intensive care unit admission, with an average stay of 7.45 days, 19.5% received mechanical ventilation, 12.3% received cardiopulmonary resuscitation, and 15.5% had a feeding tube placement. A statistical analysis using a multiple logistic regression model with random effects showed that younger age, higher household income, primary diagnoses of diseases (ischemic heart disease, infectious disease, chronic lung disease, or chronic heart disease), and characteristics of care setting (large hospitals and facilities located in metropolitan areas) were significantly associated with the likelihood of receiving high-intensity care at the end of life.

CONCLUSION

A substantial number of older adults in Korea experienced high-intensity end-of-life care. Both individual and institutional factors were associated with the likelihood of receiving high-intensity care. Gaining an understanding of the intensity of care at the end of life and the impact of the determinants would advance efforts to improve quality of care at the end of life for older adults in Korea.

Joint Symposium of Korean Cancer Association & UICC-ARO-Cross-boundary cancer studies: cancer and Universal Health Coverage (UHC) in Asia

On 16 June 2016, the Korean Cancer Association (KCA) and Union for International Cancer Control-Asia Regional Office (UICC-ARO) organized a joint symposium as part of the official program of the 42nd Annual Meeting of the Korean Cancer Association to discuss the topic 'Cross-boundary Cancer Studies: Cancer and Universal Health Coverage (UHC) in Asia.' Universal Health Coverage is included in the Sustainable Development Goals adopted by the United Nations as part of the 2030 Agenda for Sustainable Development. The objectives of UHC are to ensure that all people can receive high-quality medical services, are protected from public health risks, and are prevented from falling into poverty due to medical costs or loss of income arising from illness. The participants discussed the growing cost of cancer in the Asian region and the challenges that this poses to the establishment and deployment of UHC in the countries of Asia, all of which face budgetary and other systemic constraints in controlling cancer in the region. Representatives from Korea, Japan and Indonesia reported on the status of UHC in their countries and the challenges that are being faced, many of which are common to other countries in Asia. In addition to country-specific presentations about the progress of and challenges facing UHC, there were also presentations from WHO Kobe Centre concerning advancing UHC in non-communicable diseases and prospects for further collaboration and research on UHC. A presentation from the University of Tokyo also highlighted the need to focus on multidisciplinary studies in an age of globalization and digitization.

Budget impact analysis of gene expression tests to aid therapy decisions for breast cancer patients in Germany

OBJECTIVES

Many women with early-stage, hormone receptor-positive breast cancer may not benefit from adjuvant chemotherapy. Gene expression tests can reduce chemotherapy over- and undertreatment by providing prognostic information on the likelihood of recurrence and, with Oncotype DX, predictive information on chemotherapy benefit. These tests are currently not reimbursed by German healthcare payers. An analysis was conducted to evaluate the budget impact of gene expression tests in Germany.

MATERIALS AND METHODS

Costs of gene expression tests and medical and non-medical costs associated with treatment were assessed from healthcare payer and societal perspectives. Costs were estimated from data collected at a university hospital and were combined with decision impact data for Oncotype DX, MammaPrint, Prosigna and EndoPredict (EPclin). Changes in chemotherapy use and budget impact were evaluated over 1 year for 20,000 women.

RESULTS

Chemotherapy was associated with substantial annual costs of EUR 19,003 and EUR 84,412 per therapy from the healthcare payer and societal perspective, respectively. Compared with standard care, only Oncotype DX was associated with cost savings to healthcare payers and society (EUR 5.9 million and EUR 253 million, respectively). Scenario analysis showed that both women at high clinical but low genomic risk and low clinical but high genomic risk were important contributors to costs.

CONCLUSIONS

Oncotype DX was the only gene expression test that was estimated to reduce costs versus standard care in Germany. The reimbursement of Oncotype DX testing in standard clinical practice in Germany should be considered.

The Effect of Hospice Consultation on Aggressive Treatment of Lung Cancer

Purpose

The aims of this study were to investigate trends of aggressive treatment of non-small cell lung cancer (NSCLC) patients at the end-of-life (EOL) during the recent 5 years and examine the relationship between hospice consultation (HC) and aggressive care.

Materials and Methods

The medical records of 789 patients with stage IIIB-IV NSCLC at Seoul National University Hospital (SNUH) who received palliative chemotherapy and died from 2010 to 2014 were retrospectively reviewed. Indicators of aggressive treatment were evaluated, and the association of HC with these indicators was analyzed.

Results

During the last 5 years, the frequency of HC increased from 26.7% to 43.6%. The time interval from last chemotherapy to death increased, and the proportion of patients who received palliative chemotherapy, visited an emergency room, were admitted to intensive care unit, during the last month of life, and died in SNUH significantly decreased over time. Referral to HC was significantly associated with lower intensive care unit admission rates, lower out-of-hospital death rates, and less use of the chemotherapy within 1 month prior to death. Overall survival did not differ by HC.

Conclusion

The pattern of cancer care nearthe EOL has become less aggressivewhen HCwas provided. The positive association of HCwith better EOL care suggests that providing HC at the optimal time might help to avoid futile aggressive treatment.

Health care services utilization during the last 6 months of life among patients with bladder cancer who underwent radical cystectomy in Quebec, Canada

INTRODUCTION AND OBJECTIVES

Management of bladder cancer imposes a great economic challenge on the health care system; with the greatest share of this burden attributed to radical cystectomy (RC) and prolonged postoperative follow-up. Our aim was to characterize health care services utilization and evaluate associated cost predictors during the last 6 months of life in patients who had RC.

METHODS

We conducted a retrospective study within a cohort of 2,988 patients who had RC from 2000 to 2009. Data were obtained from the Quebec health insurance medical services database. We included patients who deceased during the study period, and survived at least 6 months after the first 90 postoperative days. Services billing codes were used to retrieve hospital, outpatient and imaging services. Linear regression models were used to assess predictors of costs.

RESULTS

From the 1,355 patients who deceased during the study period, we analyzed data of 799 subjects. Men formed 77.3% and 52.8% of patients were between 60 and 75 years of age at the time of RC. In their last 6 months of life, 17.2% of patients had surgery for major urinary tract complications, 25% had chemotherapy whereas 27.6% had radiotherapy. Also, 3.5% of patients had hemodialysis. Imaging was performed in 94.6% of patients. Urologist (specialist) visits ranked first where 72.3% of patients had 3,481 visits (average = 6 visits/pt) followed by medical subspecialist where 69% of patients had 10,010 visits (average = 18 visits/pt). For supportive care, 97% of patients had 25,560 family physician visits (average = 31 visits/pt) whereas only 16% of them had highly specialized care. Services utilization kept increasing with time especially during the last 2 months before death. Post-RC complications were significant predictor associated with increased costs at all assessed services (P<0.0001).

CONCLUSION

Our study results suggest that health care services utilization varies in the assessed period. Urologists involvement in the process of care tends to decrease over time, in favor of other medical specialties, however, some health care services, such as highly specialized supportive care, may be underutilized.

Evaluation of the Cost of Comprehensive Outpatient Therapies in Patients with Malignant Brain Tumors

OBJECTIVE

The aim of this study was to compare the cost of comprehensive outpatient therapy (day rehabilitation) in individuals with malignant brain tumors to those with stroke and traumatic brain injury.

DESIGN

This was a prospective, nonrandomized, longitudinal study of 49 consecutive adults with malignant brain tumors enrolled in the 6 day rehabilitation sites of 1 institution over 35 months. The control group was composed of 50 patients with brain injury and 50 patients with stroke, who were also enrolled in the day rehabilitation program during the same period. A comparison was made of the total Medicare cost and the cost per day of day rehabilitation in patients with malignant brain tumors compared with the control group.

RESULTS

The patients with malignant brain tumors had lower total cost and cost per day than did the combined traumatic brain injury and stroke group during day rehabilitation (F2,143 = 3.056 [P = 0.05] and F2,142 = 5.046 [P = 0.008], respectively).

CONCLUSIONS

The cost of comprehensive outpatient rehabilitation in patients with malignant brain tumors is less expensive than that of patients with traumatic brain injury or stroke, which are neurological diagnoses commonly seen in day rehabilitation. This study shows that cost should not be a barrier to providing outpatient therapies to this patient population.

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

BACKGROUND

No population-based longitudinal studies on end-of-life (EOL) expenditures were found for cancer decedents.

METHODS

This population-based, retrospective cohort study examined health care expenditures from 2001 to 2010 among 339,546 Taiwanese cancer decedents' last year of life. Individual patient-level data were linked from administrative datasets. Health care expenditures were converted from Taiwan dollars to U.S. dollars by health-specific purchasing power parity conversions to account for different health-purchasing powers. Associations of patient, physician, hospital, and regional factors with EOL care expenditures were evaluated by multilevel linear regression model by generalized estimating equation method.

RESULTS

Mean annual EOL care expenditures for Taiwanese cancer decedents increased from 2000 to 2010 from U.S. $49,591 to U.S. $68,773, respectively, with one third of spending occurring in the patients' last month. Increased EOL care expenditures were associated with male gender, younger age, being married, diagnosed with hematological malignancies and cancers other than lung, gastric, and hepatic-pancreatic cancers, and dying within 7-24 months of diagnosis. Patients spent less at EOL when they had higher comorbidities and metastatic disease, died within 6 months of diagnosis, were under care of oncologists, gastroenterologists, and intensivists, and received care at a teaching hospital with more terminally ill cancer patients. Higher EOL care expenditures were associated with greater EOL care intensity at the primary hospital and regional levels.

CONCLUSION

Taiwanese cancer decedents consumed considerable National Health Insurance disbursements at EOL, totaling more than was consumed in six developed non-U.S. countries surveyed in 2010. To slow increasing cost and improve EOL cancer care quality, interventions to ensure appropriate EOL care provision should target hospitals and clinicians less experienced in providing EOL care and those who tend to provide aggressive EOL care to high-risk patients. The Oncologist 2017;22:460-469Implications for Practice: Cancer-care costs are highest during the end-of-life (EOL) period for cancer decedents. This population-based study longitudinally examined EOL expenditures for cancer decedents. Mean annual EOL-care expenditures for Taiwanese cancer decedents increased from U.S. $49,591 to U.S. $68,773 from the year 2000 to 2010, with one third of spending in patients' last month and more than for six developed non-U.S. countries surveyed in 2010. To slow the increasing cost of EOL-cancer care, interventions should target hospitals/clinicians less experienced in providing EOL care, who tend to provide aggressive EOL care to high-risk patients, to avoid the physical suffering, emotional burden, and financial costs of aggressive EOL care.