Health care costs in last week of life associated with end-of-life discussions, race/ethnicity

Differences in health care costs during the final weeks of life existed among patients with advanced cancer, according to data from two studies published in The Archives of Internal Medicine. The cost discrepancies were associated with physician-patient communication about end of life and race/ethnicity, and led to worse quality of death among patients.

According to data from the Coping With Cancer study, physician-patient end-of-life discussions may help lower health care costs and physical distress during the last week of life. In contrast, higher health care costs were associated with increased physical distress and worse overall quality of death.

The longitudinal, multi-institutional study included 603 patients with advanced cancer. At baseline, patients were interviewed on such issues as whether or not they trusted their physician and whether they had discussed end of life with their physician. Patients were followed until death.

Cost discrepancies

Less than half of patients (31.2%) reported discussing their end-of-life wishes with their physicians. The researchers used propensity score matching to balance patients who reported end-of-life discussions and those who did not with all variables, such as age, race, marital status, education, health insurance status, religion, cancer type, baseline health status, recruitment site, illness acknowledgment and treatment preferences.

Mechanical ventilator use, resuscitation and admittance into or death in an intensive care unit during the final week of life were less likely among patients who reported an end-of-life discussion. Conversely, these patients were more likely to receive outpatient hospice care and to be referred to hospice sooner. Though no differences were reported between the two groups on psychological distress, quality of death or survival time, patients who reported end-of -life discussions had less physical distress than those who did not report end-of-life discussions.

The propensity score-matched cohort included 145 deceased patients. Using these patients, the researchers conducted an adjusted analysis to determine the mean aggregate medical costs for end-of-life care. Costs for patients who reported end-of-life discussions were $1,876 compared with $2,917 for patients who did not, yielding a 35.7% lower cost of care among patients who reported end-of-life discussions (P=.002).

The researchers used the deceased cohort of patients in the study sample (n=316) to determine the associations between medical costs and quality of death and survival in the final week of life. A multivariable analysis indicated that higher medical costs were associated with more physical distress and worse overall quality of death as reported by the caregiver, according to the researchers. However, health care expenses at the end of life were not associated with a difference in survival.

Racial/ethnic discrepancies

The second study was an analysis that included a random, stratified sample of 158,780 Medicare decedents, oversampled for whites. Researchers related differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions and hospice to racial and ethnic differences in expenses during the last six months of life.

Compared with white patients, black and Hispanic patients incur higher health care costs during the last six months of life. Medicare Parts A and B expenses averaged $20,166 for whites, $26,704 for blacks and $31,702 for Hispanics during the last six months of life. Cost discrepancies persisted despite stratification for age, sex, cause of death, site of death and geographic area.

The researchers attributed 53% of the higher costs for blacks and 63% of the higher costs for Hispanics to differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status and hospice use.

Though hospice use occurred most frequently among whites (26%) compared with blacks (20%) and Hispanics (23%), racial and ethnic differences in cost were not significantly affected. However, increased use of the ICU (32.5% for blacks, 39.6% for Hispanics and 27.0% for whites) and intensive procedures among blacks and Hispanics accounted for 85% of the observed higher costs.

“At life’s end, minorities often receive more expensive but not necessarily life-enhancing care,” the researchers wrote. “It is unclear how much of this was actively sought, or the extent to which racial and ethnic differences are principally driven by how choices are presented or how they are ‘heard.’ These would be fruitful questions for future research.”

Hanchate A. Arch Intern Med. 2009;169:493-501.
Zhang B. Arch Intern Med. 2009;169:480-488.