End-of-Life Hospital Costs in Cancer Patients: Do Advance Directives or Routes of Hospital Admission Make a Difference?

Abstract

Objective: End-of-life cancer care is costly. The current study explored whether advance directives or route of hospital admission reduced cancer patients’ terminal hospitalization costs. Methods: This single-institution study focused on solid tumor patients who died on an inpatient oncology service in 2008 and 2009. Patients’ total costs were compared based on advance directives and route of hospitalization. Results: Among 120 patients, all except 4 had an incurable malignancy. Forty-six (38%) had an advance directive. Sixteen (13%) were admitted after an oncology clinic visit and 6 (5%) from hospice; others were admitted via other routes, most commonly from the emergency department. The median total cost for hospitalization (range) per patient was USD 12,962 (1,244–138,877). Patients with advance directives had no statistically significant difference in cost (p = 0.30), even after adjusting for age and time in the hospital. Those admitted after an oncology clinic or from hospice also had no difference in cost compared to those admitted via another route. Use of cardiopulmonary resuscitation, intensive care unit monitoring and intubation were similar between all compared groups. Conclusion: Advance directives and route of admission do not appear to impact the cost of terminal hospitalization for cancer patients.

The economic evidence for advance care planning: Systematic review of evidence

“…The quality of ADs cannot be presumed to be always high, with Tan and Jatoi (2011) noting that around a third of the 46 ADs held by patients in their study were insufficiently specific. Several studies attempt to distinguish ACP from the documenting of medical decision-making in the last weeks and days of life, with two studies specifying that ADs should have been initiated prior to the index hospital admission Tan and Jatoi, 2011). Weeks et al (1994) also gather data about when these ADs were first established, finding it to be a median of eight months prior to hospital admission.…”

“…Three studies use data from the US Health and Retirement Study, with its nationally representative sample of older people Nicholas et al, 2011;Kelley et al, 2011), while Kessler and McClellan (2004) use a large random sample of Medicare beneficiaries. The remaining studies use selective samples, defined either by patient characteristics, for example, high-cost and low-income Medicare beneficiaries , or by care setting, with seven of the studies based on hospital samples (Yoo et al, 2012;Tan and Jatoi, 2011;Zhang et al, 2008;Gade et al, 2008;Teno et al, 1997;Chambers et al, 1994). Some studies use samples defined by both patient characteristics and care setting, for example, patients admitted to an inpatient oncology unit in a US hospital (Tan and Jatoi, 2011).…”

“…The remaining studies use selective samples, defined either by patient characteristics, for example, high-cost and low-income Medicare beneficiaries , or by care setting, with seven of the studies based on hospital samples (Yoo et al, 2012;Tan and Jatoi, 2011;Zhang et al, 2008;Gade et al, 2008;Teno et al, 1997;Chambers et al, 1994). Some studies use samples defined by both patient characteristics and care setting, for example, patients admitted to an inpatient oncology unit in a US hospital (Tan and Jatoi, 2011). While selective samples are appropriate for evaluating interventions specific to these populations and settings, care needs to be taken in generalising findings to individuals beyond these groups.…”

“…These cover different types of ACP activity, operationalised for research in a range of ways (Table 2). Nicholas et al, 2014 A proxy report of a decedent having a treatment-limiting, written AD; US Health and Retirement Study Nicholas et al, 2011 A proxy report of a decedent having a treatment-limiting, written AD; US Health and Retirement Study Kelley et al, 2011 A proxy report of a decedent having a written AD or having engaged in an end of life discussion; US Health and Retirement Study Tan and Jatoi, 2011 Record of an AD completed prior to hospital admission in retrospectively reviewed medical records Zhang et al, 2008 Self-report during baseline interview of having had a prior discussion with their doctor about end of life preferences.…”

“…Rather, included studies can mostly be characterised as cost-savings studies, focused on identifying potential healthcare, and particularly hospital-based, cost savings. Healthcare costs, however, are defined and measured in a wide range of different ways (Table 3) ing costs, using a range of different accounting systems, assumptions and approaches, and either covering hospital services alone Abel et al, 2013;Baker et al, 2012;Tan and Jatoi, 2011) or a wider set of healthcare costs Gade et al, 2008;Engelhardt et al, 2006). Teo et al (2014), additionally include nursing home costs, which they define as healthcare costs and are funded by the Singapore Ministry of Health.…”