Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review

Abstract

Background: Aggressive end-of-life (EOL) care is associated with lower quality of life and greater regret about treatment decisions. Higher EOL costs are also associated with lower quality EOL care. Advance care planning and goals-of-care conversations (“EOL discussions”) may influence EOL health-care utilization and costs among persons with cancer. Objective: To describe associations among EOL discussions, health-care utilization and place of death, and costs in persons with advanced cancer and explore variation in study measures. Methods: A systematic review was conducted using PubMed, Embase, and CINAHL. Twenty quantitative studies published between January 2012 and January 2019 were included. Results: End-of-life discussions are associated with lower health-care costs in the last 30 days of life (median US$1048 vs US$23482; P < .001); lower likelihood of acute care at EOL (odds ratio [(OR] ranging 0.43-0.69); lower likelihood of intensive care at EOL (ORs ranging 0.26-0.68); lower odds of chemotherapy near death (ORs 0.41, 0.57); lower odds of emergency department use and shorter length of hospital stay; greater use of hospice (ORs ranging 1.79 to 6.88); and greater likelihood of death outside the hospital. Earlier EOL discussions (30+ days before death) are more strongly associated with less aggressive care outcomes than conversations occurring near death. Conclusions: End-of-life discussions are associated with less aggressive, less costly EOL care. Clinicians should initiate these discussions with patients having cancer earlier to better align care with preferences.

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature

“…168 Finally, reviews of research manuscripts published between January 2012 and January 2019 show that end-of-life discussions with patients with advanced cancer are associated with greater use of hospice care, greater likelihood of death outside the hospital, as well as less costly end-of-life care. 21 Palliative care among non-Hispanic blacks. Published research in disparities in palliative care is limited.…”

“…(2019). 21 Between January 2012 and January 2019 Systematic Review of 12 quantitative studies Some studies found evidence that racial minorities were less likely than Whites to have EOL discussions with their health-care providers. Sanders, J. J., et al…”

Living with Metastatic Cancer: A Roadmap for Future Research

“…Providers may hesitate to initiate ACP discussions due to concern about causing distress; however, a large prospective study of patients with advanced cancer and family caregivers found that end-of-life discussions with medical providers were not associated with increased risk of depression or worry [ 182 ]. In fact, discussions between patients and providers regarding goals of care were associated with fewer hospital admissions and less aggressive treatment near end-of-life [ 183 , 184 ], which may improve quality of life and reduce financial toxicity [ 185 ]. Bereaved family members also have better psychological adjustment when patients undergo less aggressive treatments near end-of-life [ 182 ].…”

“…Bereaved family members also have better psychological adjustment when patients undergo less aggressive treatments near end-of-life [ 182 ]. The majority of research on ACP involves hospitalized patients and those near end-of-life [ 183 , 184 , 185 , 186 ]; however, goals of care can be an ongoing and evolving discussion throughout metavivorship. Further research is needed to determine the optimal timing of ACP discussions for metavivors and their family caregivers.…”

Methodological aspects of economic evaluations conducted in the palliative or end of life care settings: a systematic review protocol

“…cadth. ca/ resources/ findingevidence/ strings-attached-cadths-database-search-filters# eco, OVID Expert Searches Health [33][34][35][36][37] Different combinations of search terms and specifications have been tested in regard to their sensitivity for our research question. For each applied modification, the first 100 articles have been evaluated to decide whether the modification is applied or not.…”