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Hospital expenditures among dying patients with cancer highest in US, Canada, Norway
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Hospital expenditures near the end of life among older patients with cancer appeared higher in the U.S., Canada and Norway than other Western countries, according to the results of a retrospective cohort study.
Although end-of-life care appeared more hospital-centric in Canada and Europe than in the U.S., ICU admissions occurred twice as frequently in the U.S. than in other countries.
Ezekiel J. Emanuel, MD, PhD
“Differences in utilization and end-of-life care among developed countries are of considerable policy interest despite scarce data to inform international comparisons,” Ezekiel J. Emanuel, MD, PhD, professor and chair of the department of medical ethics and health policy at University of Pennsylvania Perelman School of Medicine, and colleagues wrote. “In the U.S., end-of-life care is considered resource intensive, expensive, and insufficiently attentive to patients’ needs and wishes.”
Emanuel and colleagues sought to compare health care utilization, hospital expenditures and location of death among dying patients with cancer in seven European and North American nations.
To do so, they accessed administrative and registry data on patients with cancer aged older than 65 years who died in 2010 in Belgium (n = 21,054), Canada (n = 20,818), England (n = 97,099), Germany (n = 24,434), the Netherlands (n = 7,216), Norway (n = 6,636) and the U.S. (n = 211,816).
Key study outcomes included death in acute-care hospitals, hospitalization in acute-care hospitals, ICU admission, and hospital expenditures paid by insurers during the 180-day and 30-day periods preceding death. The researchers utilized country-specific methods for calculating the cost of inpatient services.
Overall, the countries with the lowest proportion of deaths occurring in acute-care hospitals included the U.S. (22.2%) and the Netherlands (29.4%). Death during hospitalization occurred more commonly in Canada (52.1%), Belgium (51.2%), Norway (44.7%), England (41.7%) and Germany (38.3%).
In the last 180 days of life, between 82.6% and 88.7% of decedents in Belgium, Canada, England and Norway experienced hospitalization. In the U.S., Germany and the Netherlands, less than 77% of patients were hospitalized in the last 180 days of life, with U.S. patients having the fewest hospital days per capita (mean, 10.7 ± 14 days).
Despite these data, U.S. decedents experienced the greatest percentage of ICU admissions during their final 180 days of life (40.3%). Similarly, the U.S. had the highest mean number of days spent in the ICU per capita (mean, 3.6 days) and the greatest use of chemotherapy within the last 180 days of life (38.7%). However, use of chemotherapy within the last 30 days of life declined to 10.6% in the U.S.
In the last 30 days of life, the majority of countries included showed intermediate hospitalization rates, ranging from 49% (England) to 62.6% (Norway). Only Germany (44.8%) and the Netherlands (43.2%) had low hospitalization rates during this period.
The highest mean per capita hospital expenditures (in U.S. dollars) in the last 180 days of life occurred in Canada ($21,840), Norway ($19,783) and the U.S. ($18,500).
Germany ($16,221) and Belgium ($15,699) had intermediate hospital expenditures during this period, with low expenditures seen in the Netherlands ($10,936) and England ($9,342).
When the researchers conducted subsequent analyses — which included a secondary analysis of decedents of any age from the six non-U.S. countries, a subset analyses of a more homogenous cohort of patients with lung cancer aged older than 65 years who died in 2012 in the U.S. and Germany, and an analysis of more recent data from patients aged older than 65 years from Germany and the U.S. — the trends from the primary analysis persisted.
The researchers acknowledged that their study included data from patients with cancer who died, which does not necessarily mean they died of cancer. Further, they acknowledged that country-specific data sources might not be comparable in their recordkeeping.
“Our findings and the limitations highlight the need for greater cross-national comparisons of end-of-life care using prospectively designed quality and cost metrics,” Emanuel and colleagues concluded.
These data demonstrate a global trend moving away from hospitalization near death, Atul Gawande, MD, MPH, professor of health policy and management at Harvard T.H. Chan School of Public Health, professor of surgery at Harvard Medical School, and general and endocrine surgeon at Brigham and Women’s Hospital, wrote in an accompanying editorial.
“All of these countries appeared to be making a radical transition away from nearly universal reliance on hospitalization at death for cancer patients, with the United States, perhaps surprisingly, having moved the farthest and fastest away from institutionalization at death,” Gawande wrote. “Other research shows the United States now has perhaps the highest level of hospice capacity and use, and the highest likelihood of death at home, in the developed world.” – by Cameron Kelsall
Disclosure: Emanuel reports stock ownership in Nuna, as well as speaking fees from numerous companies and organizations. One other study researcher reports a majority stock ownership interest in Eir Solutions, as well as fees paid to his institution from the Anamorelin Advisory Board. The other study researchers report no relevant financial disclosures. Gawande reports royalties and compensation from numerous publishers and media outlets for writing and medicine-related media.
Perspective
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Ryan D. Nipp, MD
This study addresses an important and timely issue as health care systems are striving to align care with patient preferences and to decrease utilization of unnecessary and unwanted health care services at the end of life. Prior work has demonstrated that patients with cancer often prefer not to die in the hospital, yet over one-fifth of patients from the U.S. in this study died in the inpatient setting. Notably, half of patients were hospitalized in their last month of life for an average of 5 days. Although we do not know why the patients were hospitalized, these findings underscore a compelling need for efforts to understand the reasons patients with cancer require hospitalizations at the end of life.
Patients with cancer often experience significant symptom burden, which may result in hospitalizations, but additional research is needed to understand how patients’ symptoms contribute to their hospital admissions and length of stay. Importantly, patients’ symptoms represent a potentially modifiable risk factor that, if properly addressed, can improve the quality of their care and may prevent unwanted hospitalizations.
As the researchers noted, we do not know patient preferences for end-of-life care in this study, nor the rates of hospice and palliative care utilization, all of which are important components of care for patients dying with cancer. Additionally, although we lack information about other factors that may impact cancer patients’ end-of-life care, including comorbidity, functional status, social support and prognostic understanding, findings from this manuscript should motivate future research focused on how these and other factors may influence care at the end of life.
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